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Health Policy Review - Volume 1, Issue 4

Setting strategic priorities for service development in England
Spring 2007

This journal is produced by the Health Policy and Economic Research Unit and is designed to stimulate debate. The views expressed do not necessarily represent BMA policy.

Editorial - Tom Smith
Setting strategic priorities for the future of the NHS
Since it became known that Tony Blair was stepping down, policy analysts have scoured Gordon Brown’s speeches as chancellor for some indication of the approach he will take to health service reform. They have found his comments difficult to decipher. Some reports say he will not shy away from reform while others say he is set to ‘curb privatisation’.

Amid all the interest in his political position, it is worth noting a graph from Ipsos MORI from a set showing trends in polls over the Blair years. It shows a growing aversion to political parties policies on health.

Growing support among professionals for distancing politicians from the day-to-day management of the NHS is reflected among the recommendations the BMA published in early May. A rational way forward for the NHS in England covers a whole range of issues and offers 24 recommendations to develop reform. It is based on a wide-ranging nine-month review by a working group elected by BMA’s council.

The group gathered evidence from doctors in a range of settings as well as from a range of policy experts. This issue of health policy review contains four papers that formed part of their review. They were prepared by the BMA’s health policy and economic research unit in January 2007 as part of the review.

The papers in this issue were written to generate discussion on the strategic priorities for health reform in England. The four papers explore: the founding values of the NHS and their continuing relevance; patient and public involvement in the NHS; clinical engagement and service change; and changing financial flows in healthcare reform.

In the first paper Thomas Frusher explores the concepts held as the core values of the NHS, that it is comprehensive and universal, funded through general taxation, and free at the point of use. He asks whether these are sustainable in the light of an ongoing debate about whether the health service is financially sustainable. He notes that safeguarding these values requires the constant management of tensions.

In our present situation, with a commitment from all political parties to universal and comprehensive care, Frusher makes the point that sustaining this position will require an open acknowledgement from politicians that these values are not completely absolute. There are trade-offs between them. Maintaining universality, for example, involves a trade-off with how comprehensive the service can be. If the founding values of the NHS are to remain core there is a need for politicians to acknowledge the cost pressures that have to be managed. It demands openness in the setting of priorities.

In the run up to the end of the financial year in April, there were reports of PCTs changing the criteria for which services could be accessed. Rationing was reported to be taking place implicitly. The implication of the paper is that if these decisions are to be made, because society has to trade off the funds it wishes to devote and what it demands of this investment, then this should be an explicit and clinically informed decision. As the NHS distributes social resources, politicians need to find a transparent and open approach to doing so.

Open acknowledgement of the need for such an approach would create an environment more conducive to an open debate with the public about service change. In a paper examining public and patient involvement, Juliet Dunmur, Barbara Wood and Simon Young note at a time of great change there has never been a greater need for the NHS to actively engage the public in discussion about plans to change services.

The government has tried to promote a national debate on service reconfiguration at a difficult time. The public do not trust that it is unrelated to an apparent financial crisis. The government needs to go further in explaining that service change should not be a response to short-term pressures, but may be an appropriate response to medium-term ones. There are opportunities to improve the sustainability of the NHS by better managing those living with long-term conditions. As well as improving care it could save the NHS money by preventing an expensive admission.

The challenge facing the government is how to transform a financially tainted debate on service reconfiguration – where it has not previously been trusted into a positive discussion about service redesign, and changing patient pathways.

Although doctors are sometimes portrayed as opponents of change they very often support the overarching aims of policy. It is the means they question. Doctors have resisted service change that is driven by short-term financial pressures, resulting from the volatility that new policy has created.

Sally Al-Zaidy’s paper examines the recent experience of clinical engagement in efforts to redesign services. She finds evidence of adversarial tensions exacerbating the divide between clinicians in primary and secondary care when ambitions to redesign care pathways and prevent emergencies depend upon it.

A key challenge is finding ways to manage healthcare across these boundaries. Funding, organisation, management and culture all need to change and models of working need to be adopted to support collaboration across institutional boundaries and the spectrum of care. Forums are needed to bring together professionals from different parts of the system to discuss service development.

Jon Ford’s paper outlines the economics that support an integrated infrastructure for the NHS. It points to the productivity gains to be made by enhancing the capacity for local health economies to manage their health system as a whole. Current reform contains incentives that fragment the care system. Ford’s paper suggests that more sophisticated financial approaches are needed to drive improvement and the development of integrated care.

At a time when there is tension between the health service and the government, a change in leadership offers the potential for some reflection on the direction of reform. There is a critical need to depoliticise the reform process. The NHS is desperate to avoid a new set of political initiatives, but crying out for a set of clear and consistent strategic priorities.

In mid-May Gordon Brown told BBC Radio 4's Today programme that listening to people’s views on the future of the healthcare system was an ‘immediate priority’ for his government. He will find that professionals have a lot to say on reform, but feel that they have thus far not been listened to.

Contributors
Sally Al-Zaidy, Senior Policy Executive, General Practitioners Committe
Juliet Dunmur, Deputy Chair, Patient Liaison Group
Tania Fisher, Research Analyst, Health Policy and Economic Research Unit
Jon Ford, Head, Health Policy and Economic Research Unit
Thomas Frusher, Policy Analyst, Health Policy and Economic Research Unit
Eleanor Gray, Research Analyst, Health Policy and Economic Research Unit
Tom Smith, Senior Policy Analyst, Health Policy and Economic Research Unit
Barbara Wood, Chair, Patient Liaison Group