Shifting the deckchairs on the <i>NHS Titanic</i>
Authors: Alan Maynard
Journal: Journal of the Royal Society of Medicine (2010)

There is a risk that the good ship NHS Titanic will be in serious difficulties if its navigation is not improved.

After relatively balmy weather during the Blair–Brown epoch, the ship is running into choppy waters with icebergs hidden in the mists of policy-making incompetence.

The rhetoric of Whitehall village is ‘evidence-based policy-making’ but in practice policies appear to be based on the ‘re-disorganization’ of healthcare structures. Inherent in this is an innate but flawed belief that altering the structures of healthcare delivery will lead to improved processes of care for patients which in turn will improve their health outcomes.

Sadly, the history of Labour and Conservative reforms in terms of changing healthcare structures appear to have generally failed to improve performance for patients and taxpayers.

For instance, the Labour government abolished GP fund holding in 1997 and then partially reinvented it in 2005 as ‘practice-based commissioning’. They abolished hospital Trusts and then created Foundation Trusts. They abolished Health Authorities and replaced them with over 300 Primary Care Trusts, subsequently reduced to 152 in 2006. The costs of these upheavals in terms of redundancy payments, pension hand-outs and human misery among NHS staff were very high. The benefits to patients and taxpayers are noticeable by their absence. Healthcare reform is based on ‘faith’ or the often ideological and evidence-free ideas of passing Secretaries of State.

We now have a new set of political leaders who are focused on further radical reforms for which there is no evidence base. The current Secretary of State, Andrew Lansley, clearly indicated his intentions in a Conservative policy document in 2007. He intends to abolish the weak commissioners of healthcare, the 152 Primary Care Trusts created by Labour as the answer to ill-defined system problems. PCTs will be replaced by GP consortia, membership of which is to be compulsory. Each consortium will have budgets to buy healthcare for their patients. A new national NHS Board will direct NHS commissioning, supposedly independent of the Secretary of State.1

What evidence does Whitehall have that this will steer the NHS Titanic away from the icebergs that its right wing opponents would like it to strike? The answer is none. The NHS Board that was created during the early years of the Thatcher–Major NHS reforms was abandoned as ineffectual. Giving budgets to GPs was tried in the 1990s, taken up by a self-selected group of GPs and only evaluated on its abolition, which demonstrated that it appeared to have some small effects on elective admissions to hospital.

Such evidence is an inadequate basis for the whole system reform that is emerging. Clearly this view is shared in part by the Treasury who appear to be rightly anxious about GP accountability when they may be handed control of £70 billion of NHS expenditure, and by the Coalition Commission which has insisted that the White Paper is accompanied by ‘consultation papers’ which will seek to elucidate just how this untried and untested reform will be made to operate.2,3

The possibility remains of privatizing part of the remaining ‘family crown jewels’ as Harold Macmillan described the objects denationalized by Thatcher.

There are calls from the right to sell NHS hospitals and, for a government faced by a large deficit, this must be tempting. There are over 100 Foundation Trust hospitals which have been subjected to quite rigorous financial controls. These are to be transformed into social enterprise organizations and may be operated as private firms or on a co-operative partnership basis. This could potentially raise billions of pounds to ameliorate the deficit in public finance.

The NHS would survive as an organization that is tax funded and free at the point of delivery. The only change would be that the public–private mix of delivery would alter, perhaps radically. This would be ideologically challenging for the left and trade unions but attractive to the right.

But would this improve efficiency and equity? The limited empirical basis available shows little difference in the performance of public and private hospitals in mix systems of provision. However, lack of evidence never stopped reform in the past!

Are the problems associated with the good ship NHS Titanic a result of its construction or the crew that are responsible for its day-to-day operation? Those in the engine room are working hard to keep the ship afloat, but have given perhaps insufficient attention to steering. This healthcare ‘vessel’ exhibits problems very similar to public and private healthcare systems worldwide, e.g. reluctance to translate evidence of cost-effectiveness into clinical practice, variations in the delivery of care to patients and poor measurement of ‘success’, i.e. does healthcare make patients better than they otherwise would be?

To improve the safety of the NHS Titanic and to ensure it avoids ideological icebergs in its path, its staff need to improve their performance by benchmarking practices, auditing ‘outliers’ in terms of low activity, higher costs and poorer outcomes and ensuring that all practitioners, particularly doctors and nurses, are transparent in terms of their performance and accountable. The efficient governance of the NHS labour force, preferably conducted by the professions themselves, is noticeable by its absence.

Investment in standard setting and enforcement with demonstrably efficient incentive systems, non-financial and financial, would be a better investment in securing the NHS than yet another un-evidenced re-disorganization of its structure. Sadly, this is unlikely to happen as when Whitehall policymakers claim their work is evidence-based, it is usually faith-based!