Do NHS services have to be provided by the NHS?

Abstract

After 18 months of political trench warfare over the health bill, the Westminster bandwagon is moving on. However, for the NHS, this is the beginning not the end. Leaders in the NHS need to make sense of the hand they have been dealt and start turning the Health and Social Care Act 2012 into a workable system that delivers better care for patients. At times like these, it is useful to look back on the past decade or so of policy-making in healthcare – in the NHS and further afield. A constant issue that governments have faced has been finding a balance between centralisation and localism. Advocates of centralism stress and place value on ‘the need to standardise’ and emphasise ‘equitable access’. Meanwhile, advocates of localism prize the importance of ‘clinical freedom’ and ‘encouraging innovation’. Behind such ideas lies a recurrent, fundamental and often unhelpfully polemical debate about the best way to ensure that equitable, high-quality healthcare is available to all of a country’s citizens rather than an elite few, with no wide gulf in citizens’ quality of care. It is therefore well worth reflecting on the way policy makers and senior leaders in the UK have responded to the question over the past 15 years to see what that tells us about the future. To begin, one should recognise the ideological factors in play; for example, people in the UK fundamentally believe that access to healthcare is a universal right and have strongly supported this principle since the inception of the NHS. However, in recent years, the policy development of using choice and competition to move from a universally available, average system to a higher quality, more-personalised and individually tailored system has begun to challenge these fundamental assumptions. In light of this, the issue of centralism versus localism has often and misleadingly equated the centralist view with a predominant desire for equity, while the non-centralist view has been equated to a less-managed, deregulated world in which a market philosophy sits more comfortably. This has led to decentralisation policy becoming a political question and, unhelpfully, has turned what should have been an evidence-based debate about policy into a hotly contested political debate. In 1997, the incoming Labour government did not hesitate to declare its preference on the spectrum, moving immediately to centralise and standardise the offer for patients. It abolished the previous Conservative government’s flagship GP fundholding programme, which was perceived to be highly partial and, after eight rounds of applications, had only just managed to cover more than 50% of the nation. The Labour government put in place primary care trusts to commission services with universal coverage, the National Institute for Health and Clinical Excellence (NICE) to standardise decision making on treatment, and performance-managed national targets. Interestingly, there was an opportunity to decentralise in 2000 when the Labour government set out the NHS plan – a ‘national framework within which they could have encouraged local freedom’ – and backed this with a huge increase in resources. However, the desire of ministers to account for the use of these resources to improve waiting times led to centralised performance management – not empowerment of frontline organisations. In their defence, policy makers of that time might point to the creation of foundation trusts, arguing that the decentralisation of power was focused on provider side policy rather than commissioning. However, many – including some former ministers – would say that the aspirations to liberate foundation trusts to act as real local agents were frustrated – first by political concessions and then by an overzealous regulatory regime. To this day, many foundation trusts question the notion of having thousands of members as part of their governance arrangements. A second big opportunity for decentralisation came three or four years later. The NHS was performing well against central targets, with dramatic reductions in waiting times across the country, new money was coming on stream and understanding