Reforming UK health care to improve health

The current debate about reforming the NHS is surprising in a number of ways. Timmins (1988) points out that it was unforeseen and not part of the Government’s main concerns after winning the election in June 1987. It is surprising in another way because it is only six years ago since there was another debate about the NHS which resulted in no radical change. This raises two questions: what was it that led to the debate emerging so quickly in late 1987, and what has happened in the last six years which could lead to the current debate producing proposals for change in contrast to the debate of six years ago? Timmins (1988) supplies a clear guide to the first question, and it is not our purpose to add to his account. What matters for this paper is that the way the debate was forced onto the political agenda has understandably largely determined the initial focus of the Government’s secret Review, and the wider-public debate which has sought to influence that Review. The Review was a response to an alleged financial crisis in the NHS and closures of acute hospital beds. These may be seen as inevitable consequences of policies of giving priority to services other than acute within a total constrained by cash planning with cumulative underfunding of inflation since 1982-83 (Timmins, 1989). A purpose of the financial squeeze of cash planning was to create incentives for more efficient use of health care resources: DHSS performance indicators suggest considerable variations between districts in the intensity with which resources are used. Unfortunately, using resources more intensively commonly increases total costs, and does not therefore necessarily ease financial pressures. To set the context for a different approach, new values were taken to be important for a service created in a time of rationing: the need to regard patients as “consumers” and to provide choice to enable those who are able to pay more to get benefits from doing so. Introducing choice implies ending the virtual monopoly of the state over finance and delivery of service. Greater pluralism in finance has been seen as one way of easing financial pressures on health care, because private finance of health care in the UK is much lower than in the other OECD countries (OECD, 1987). The context of the Review has thus resulted in concerns with finance, acute medicine and introducing consumerism. It is assumed that providing more acute care in response to consumers’ choices will be beneficial. Introducing choice into the finance and provision of health care means that individuals can buy convenience and luxury privately and it is intended that hospitals through competing in a market will become more “efficient” 9i.e. reduce costs). Some changes may not, however, be without problems: they may lead to dual standards of care; and will the “efficient” hospital actually be more attractive to patients – another supposed benefit of choice? Thus attempting to introduce consumer choice may threaten other values which are the concern of this paper: promoting equity of access according to health care according to need; and improving the impact on health outcomes from the limited budget available for health care in the UK. The primary questions considered by this paper are: how effective are different types of health care, is the current balance between these types appropriate, and how could this balance be altered to improve cost-effectiveness and equity? This paper argues that answers to these primary questions require research into health care rather than the imposition of generalised solutions which are deemed to work in organising the production and distribution of other economic commodities. Health care differs from other economic commodities in three important respects. Firstly, as is explained below, there is consensus that those in need of care ought not to be denied access on ground of ability to pay, hence equity is a fundamental objective. Secondly, “consumers” of health care do not know how ill they are, what methods of diagnosis and treatment are available, their likely costs and outcomes. And indeed an important part of the relationship established between “consumers” and their physicians may include passing the burden of making decisions on diagnosis and treatment to physicians (McGuire et al, 1985). Thirdly, little is known about the effectiveness of most health care. Fuchs (1985) suggested, as a plausible hypothesis, that 80% of secondary care improves individual patients’ health, 10% has no effect, and 10% reduces health status, but that we do not know for much of health care the category to which different components belong. This paper examines below the current fashion for introducing a provider (or “internal” market) into UK health care. Without research to illuminate further what such change might lead to, the UK would be repeating mistakes of previous reorganisations of health care. The NHS was reorganised in the 1970s on the basis of a belief in planning, and in the mid 1980s on a belief in management. These reorganisations have been based on passing fashions, rather than a well-researched argument about how to optimise the use of scarce resources available for health care for improved health. Although the organisation of health care needs to take account of changing views about the most effective ways of organising enterprises, it is also necessary to recognise the elusive nature of assessing effectiveness in health care and the little we know about the cost-effectiveness of these activities.