Features: April 28th, 2006

The Fall and Rise of the NHS

By David J Hunter

This article was first published in Public Management and Policy and is reproduced by permission of the Association. http://www.cipfa.org.uk/pmpa/index.cfm 

The National Health service has been overhauled at least a dozen times in the past 25 years. By any standards – public or private – this amounts to a great deal of turbulence and upheaval. More worrying, it is by no means self-evident that any of the changes has benefited the public’s health or that the significant costs accompanying major change have been outweighed by any gains.

Pointing to the ‘worldwide epidemic of health care reform’ , Reinhardt (1997) claims that ‘permanent unhappiness with the health system is part and parcel of the human condition as are the periodic calls for bold reforms’ that are followed by incipient implementation of change, prompting yet further calls for reform. While it is true that successive reorganisations often follow familiar cyclical patterns, for example from centralization to decentralization and back again, there are also important distinguishing features (see Public Money & Management, Vol. 25, No. 4, August 2005 on the National Health Service 1980–2005).

The changes the NHS will undergo over the next couple of years or so amount to its most disruptive ‘redisorganization’ since its inception. It will be disruptive for two main reasons: the loss of a large number of authorities and the jobs that go with them, and the changing ethos and shape of the NHS. For the purposes of this article, the focus is on the NHS in England since the changes are confined to here. Following political devolution in 1998, the NHS has begun to diverge in the four countries making up the UK. This is especially apparent in Wales and Scotland.

In 1997, so the official line goes, the incoming Labour government inherited an ailing NHS which, thanks to the medicine being administered, is slowly regaining full health. But the problem for many analysts is the nature of the medicine, the degree to which it is evidence based, and a concern that the cure seriously risks killing the patient.

The thesis advanced here is that the NHS, far from being rescued, is being transformed (some would say hollowed out), essentially by stealth with virtually no public debate, into something very different and, in the view of many observers, not particularly attractive, that risks fatally undermining the public service ethos that inspired the

original vision for the NHS. But it need not be that way. Reform is necessary but an alternative approach is available.

The Fall of the NHS

New Labour’s modernization programme will not axiomatically produce a rejuvenated NHS. For a start, there is little that is either new or modern about any of the policies and drivers for change favoured by the government. Hard-line, mechanistic, neo-Taylorist managerialism was a feature of the 1970s, and a focus on markets characterized much of the NHS’s development in the first half of the 1990s. Yet, despite them being largely bankrupt currencies, the government and its advisers are endlessly fascinated by, if not fixated on them. Why, if we know such currencies to be flawed?

A long-standing observer and analyst of international health care systems, Bob Evans (2005), believes that the persistence of such currencies reflects fundamental conflicts of interest that cannot be resolved by fact and argument. He writes: ‘these conflicts may go into remission, but they never disappear’. They are what he terms ‘intellectual zombies, constantly brought back to life by those whose interests they promote’.

Market mechanisms are the refuge of all those, but principally economists, who consider public planning to have failed and who continue naively to believe that the market is a more effective and efficient deliverer of quality care that is responsive to user preferences.

But why are we intent on dismantling those institutions, like the NHS, under the guise of the incessant rhetoric about progress? Few deny that these institutions need to adapt to face new challenges, but are they as moribund or beyond renewal as the government seems to believe, or wants us to believe? The official historian of the NHS, Charles Webster (2002), claims that ‘it is entirely misleading to caricature Bevan’s health service as some kind of obsolete soviet-style command and control system’.

But if the move to markets is a consequence of ‘intellectual zombies’, there are also other forces at work. Many have their origins in globalization and the Anglo-Saxon response to this in terms of remaining competitive and ‘progressive’. Bobbitt (2002) analyses the emergence of the market state as a direct response to global economic trends and fiscal pressures.

But this does not refute the argument that markets and medicine do not mix well. Reforms based on markets or market-like mechanisms, and relying on competitive incentives to change provider or patient behaviour, have a particular tendency to generate inequities in access or regressive patterns of payment as well as greater fragmentation in the delivery of care. A fundamental characteristic of markets is that participants do whatever pays best— need is irrelevant. Defeating the inherent and natural tendency of such market-type reforms requires a strong and sophisticated regulatory environment. But as Evans wryly observes, ‘structuring such an environment is like riding north on a southbound horse’. There are powerful incentives for participants to erode or circumvent regulatory controls and move in the natural direction.

The Rise of the NHS

Is there another way which both avoids retreating into a misplaced faith that all has been well in the NHS if only governments would stop meddling with it on the one hand, and maintaining a naive, yet highrisk, belief that simply handing the delivery of health care over to the market-place will achieve the desired goals on the other?

There is another way. But first we should recall what John Stewart and Michael Clarke (1987) termed ‘the essential rationale of public service’. The public service orientation and consumerism, conflated by the government, are not one and the same thing. Services and functions have been placed in the public sector to be run on a different basis from those in the private sector. In particular, considerations determined by the political process rather than considerations of the market place are critical. All this may be blindingly obvious but there is a real danger of losing sight of it amidst the rhetoric of ‘modernization’.

What is required, and is conspicuously absent from current discussions, is a reconceptualization of what it means to provide a public service in the 21st century and the nature of professionalism in this endeavour. We need a ‘third way’ between old-style public services on the one hand, and free market provision on the other. Whether this means going down the route of setting up new publicly-owned companies or encouraging the emergence of mutuals or cooperatives is less clear. However, there does not appear to be a huge hunger among the public for running complex undertakings like hospitals.

Whatever appeal they may hold, we should remain sceptical about the scope and potential of such organizational forms.

But perhaps there is another way that seeks to build on the systems and traditions already established in the NHS, but which recent and future changes have largely ignored. Before abandoning the structures, systems and patterns of behaviour that have evolved over the life of the NHS, devoting greater attention to how they might be reconfigured or redirected without resorting to wholesale structural changes and market-style lures that amount to a distraction could reap higher rewards.

The rise of the NHS requires a modified conception of public service in the 21st century and one that embraces notions of public participation through citizenship and a refreshed conception of professionalism which is best described as ‘responsible autonomy’. The locus of control in the NHS should be placed where it needs to be—locally with those on the front line who need to change and assume responsibility for such change. Such an approach demands a new working relationship between clinicians and managers, and the public to whom both groups are accountable. Indeed, it requires clinicians (including doctors and nurses) to be at the centre of the management task.

Clinical governance may be the key to achieving this goal. If it is to mean anything, then it has to be linked to structures and processes that integrate financial control, service performance and clinical quality in ways that will both engage clinicians and generate service improvements. Only through such means can ‘responsible autonomy’ be re-established as a founding principle in the performance and organization of clinical work. None of this is novel or startling. Yet it has not happened in a consistent or mainstreamed way as the research by colleagues at Durham University, led by Pieter Degeling (2004), amply shows.

The focus of the team’s work on clinical governance as a development tool is critical to the solution they propose. It requires the implementation of a model that, first, is based on the centrality of clinician involvement in the design, provision and improvement of care, and, second, is structured to change how clinical work is conceived, performed and organized. System redesign and management action to engage clinicians can bring clinical objectives closer to those of society. This is likely to be a more fruitful path to follow than a reliance on competitive markets. Indeed, it is difficult to see how the introduction of a competitive market will help the move towards a more effective professional culture.

Conclusion

If the NHS is not to be reinvented in years to come, having in the meantime withered away in all but name, then there is an urgent need not only to articulate this alternative direction but to embed it locally. Then we would be witnessing not the prospect of the NHS’s demise but its genuine renewal.n

References

Bobbitt, P. (2002), The Shield of Achilles (Penguin Books, London).

Degeling, P., Maxwell, S., Iedema, R. and Hunter, D. J. (2004), Making clinical governance work. British Medical Journal, 329, pp. 679–68 1.

Evans, R. G. (2005), Fellow travelers on a contested path: Power, purpose, and the evolution of European health care systems. Journal of Health Politics, Policy and Law, 30, 1-2, pp. 277–293. Reinhardt, U. (1997), Accountable Health Care: Is it Compatible with Social Solidarity? (Office of Health Economics, London).

Stewart, J. and Clarke, M. (1987), The public service orientation: Issues and Dilemmas. Public Administration, 65,2.