08 June 2007
It seems the NHS is now safe in everyone's hands. But while its founding principles remain intact it will have to undergo radical surgery to keep up with twenty-first century demands, argues former Number 10 adviser Paul Corrigan
The NHS can face up to its sixtieth birthday next year, safe in the knowledge that no serious political party would now dare challenge its defining principles – of a health system paid for out of national taxation with equal access to care free at the point of delivery.
In the past, most discussion was about whether the service as it is could possibly fit the life of the twenty-first century. A few assumed that its national mutualist principles were in some way intrinsically old fashioned. But just as it emerged as the triumphant model of health care in the UK in the last half of the twentieth-century, so it will be in the twenty-first century.
However, while the principles of the NHS will continue, they will do so in a time of ever more rapid change. Every few weeks we all thrill to a new medical discovery that will save many lives and stop much distress. Yet if we are to relieve all the distress that science could allow us to, then the way the health service principles are applied will have to be radically changed again and again.
The first principle for an NHS in the twenty-first century is that if the NHS wants to be successful it will not only have to get used to change, but welcome it with a passion.
How it deals with the quickening pace of modernity and new technologies will define how successful it will be at relieving distress. This is not simply a matter of applying new technologies but of decommissioning old ones. All health care systems in the world, whether they are funded by the state, individual payments or private or social insurance, recognise that they have a resource problem because of the speed of development of new technologies. They look at the next 15 years with fear, since they believe that the twin pressures of the application of new technologies and an ageing population could bankrupt them. Unless they can create more value from the resources that are invested in health care, they will all find it difficult to survive and thrive.
It is this drive to improve value that is behind the main themes of the NHS reform package.
First, it is necessary to improve the way in which demand for health care is expressed. Again, every system suffers because those that provide health care seem to have so much more power than those who pay for it. Whether individual payers or private insurers, all are disadvantaged when faced with hospitals or doctors.
In the NHS context this is why the development of commissioning is vital for the future. We need to get much better at buying the health care that is needed. Practice-based commissioning ties together the clinical decisions made by the GP with the economic decisions about the distribution of resources.
At the moment, insufficient care is given to helping the 18 million people with long-term health problems to manage their conditions. Yet greater self-management, backed by more accessible community medicine, allows people to live their lives as normal and cuts the number of emergency admissions to hospital. Giving GPs the incentive to enable much more self and local care creates better lives, better medicine and greater value for the NHS.
The same is true for Patient Choice. Giving patients much more and better information, and allowing them to choose where they want to be treated, makes institutions more receptive. Patients already obtain much more knowledge about their conditions than they had previously, now they need to gain much more knowledge about their health service.
Alongside the demand, supply is also being developed. In secondary care, the creation of NHS foundation trusts has given publicly owned hospitals more control of their own destiny. They are learning what it is like to earn money and to reduce costs, and to recognise the importance of patients choosing their hospital over others. The independent sector treatment centres have also had an impact on how NHS patients are treated, although they provide only a very small proportion of all NHS elective treatments.
This is also true of the development of new providers in GP services. How GPs organise themselves in the small business partnership role is now under competition from other models. And there is evidence that the introduction of just a very small amount of new supply can change the way that GPs as a whole operate.
In developing demand and supply it has also proved essential to improve transactions between patients and health providers. The finances of the NHS have traditionally been opaque. Indeed, there was rarely, if ever, any relationship between the amount of work done by an institution and the amount of revenue obtained. This has begun to change and the concept of earning money, rather than just receiving it, is becoming the norm among NHS providers. This more than anything else has caused the turbulence in NHS institutions. Having to work out why a procedure costs twice as much in one health provider as in another is a painful activity – but increasingly that is the norm in financial discussions in the NHS.
It is impossible to see how the NHS as a whole or its constituent parts can make the increase in value that will be necessary to take on board all those new life-saving technologies without understanding what things cost. Of course, there is a long way to go. The introduction of the tariff is just the start in a process of understanding the relationship between cost, remuneration and value.
But that hard work is now happening. Health service providers in primary and secondary care are looking at their cost base and comparing it with those of other providers. They are looking at the value to patients of developing care in a better way, and are acting on that new knowledge. All this is based on the idea that a pound wasted in their institution is a pound that could have been better spent on relieving distress.
Alongside the development of demand and supply and the transactions between them, the N in the NHS is also being reformed. National Frameworks have been developed for all the major disease patterns, to spread best practice. The frameworks for coronary heart disease and cancer have had a dramatic impact on patterns of treatment and survival rates. The National Institute for Health and Clinical Excellence is a world-beating institution and is developing an understanding of the worth of drugs and technologies. All these are reforms of the NHS nationally.
They also provide the basis for increasing value in health care. Of course, there is a long way to go but we need to recognise the progress the NHS is making compared with other health care systems. An international study by the Commonwealth Fund, Mirror, mirror on the wall: An international update on the comparative performance of American health care, published in May, placed the NHS first alongside Germany, New Zealand, Australia and the US, not only in equity of provision but also in quality of care and efficiency.
The twenty-first century future for all health care systems will be a difficult one, but the NHS moves into these improvements with a strong set of moral values and a growing recognition that the issue of value itself will be at the core of improvement.
Paul Corrigan is director of strategy and commissioning at NHS London. He will be speaking on 'An NHS for the twenty-first century' at the CIPFA conference in Bournemouth on Thursday, June 14
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