Demand for a new era: the future of health

The forthcoming 60th birthday of the NHS presents an opportunity to review the Service’s readiness for coming years. The Department of Health’s current NHS review, led by Lord Darzi, gives a particular focus.

One key theme facing health policy makers is an increase in demand for better health services. This is due to a number of positive trends in both society and medicine:

-Greater access to medical information;

-greater consumerism, particularly among younger people;

-innovation in drugs and technologies;

-population increase and ageing;

-improved survival at birth and later in life;

-greater incidence of chronic conditions;

-greater incidence of stroke, cancer and dementia; and

-lifestyle changes, in particular an increase in obesity.

-Yet the major funding increases for the NHS have already taken place.

As a result a better service has to be achieved under much greater financial constraints. What is needed amounts to structural reform of the service, comprising:

-a transition away from monopoly;

-comprehensive service redesign and innovation; and a new focus on patient engagement and empowerment.

Some of the social and medical changes outlined above will support this kind of change, notably greater consumerism and access to information.

Current government policy accepts the idea of increasing demand but resists the need for structural reform.

The idea that more empowered patients will require a new kind of NHS has been part of government thinking since the 2000 NHS Plan. The idea that changes in lifestyle will require new thinking on public health and service redesign has been a consistent theme since the 2004 NHS Improvement Plan.

Given this, it is striking that the interim report of the Darzi Review concluded that it was “not about changing the way the NHS is funded or structured”. The resistance to structural reform can also be seen in the recommendations to manage the delivery of primary care from the centre, via 150 “new health centres in easily accessible locations” and longer opening hours for GPs, and to create a new central agency to support innovation.

In the autumn of 2006, structural reform of the NHS seemed like a real possibility. It was reported that the then Chancellor, Gordon Brown, was considering making the NHS “independent” by devolving day-to-day control of the NHS to an independent board, should he become Prime Minister. The Conservative Party launched a Bill to make the NHS independent.

Since then the focus on radical change has receded as the Government’s interest has moved from “independence” to a “constitution”. Statements by the new Prime Minister and the Secretary of State for Health have suggested that a constitution will set out the “values” of the NHS – such as taxpayer-financing for the most part. It is likely to include a sense (but not a definition) of the entitlements and responsibilities of patients.

A statement of values and of desired goals in partnership is not to be deprecated. But it needs to be accompanied by an initiative which makes it more possible for people to achieve these values in practice and to bring about structural change. What are needed are some practical steps which will promote greater integration of care, ensure better use of the time of experienced staff and achieve a greater margin of investment for local decision makers.

An essential first step is an economic constitution which will promote a new drive for value. The commitment to “public value” in the BBC charter could be an interesting model for the NHS.

The constitution will specify new duties for commissioners. It will enable use of modern financial reporting and comprehensive service redesign. It will be the vital step in the move from a provider-dominated service to one in which there is more choice, personalisation of services and improved outcomes.

The NHS is close – frustratingly so- to a very positive future. The key step is to empower people to get value from the vast amount of funds already in the system. There are already some local moves towards low cost programmes to bring about better services and better communication quickly. But currently these initiatives remain small, due to the massive financial commitment to traditional types of care. An economic constitution would drive them forward. It would give full rein to innovation in each of the clinical areas highlighted in the Darzi Review.