A “common sense revolution” for UK health care?BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7253.63 (Published 08 July 2000) Cite this as: BMJ 2000;321:63
The Conservatives unveil their latest plans
For the NHS, just like English football, it's been a salutary month. At home some of us might just convince ourselves that the NHS is the envy of the world. But playing away, where we are compared directly with other nations, our performance is found wanting. Ranked 18th overall in the World Health Organization's worldwide league of healthcare systems, we can argue with the referee about the rules.1 But the sneaking suspicion must be that the result is about right; indeed it could have been much worse. Other countries may spend more, be less fair and less efficient, have more trouble containing costs, and have messier organisations than the NHS, but somehow they provide a better overall standard of health care. How do they do it?
At a macro level, the difference between the United Kingdom and other European countries is obvious: the United Kingdom spends less on health care and there is far less private financing and private provision. The benefits of more expenditure are comparatively clear: more and better paid staff, more and newer equipment, and better access to the latest treatments. In this respect, the government's plans to boost spending on health care to 7.6% of the gross domestic product by 2004 will be a big help. In contrast, the link between improved performance and either a mixed economy of financing or greater private provision is less clear and, in so far as it exists, highly complex.
Not so in the mind of the Conservative party, as shown in the plans for health care sketched last week in a speech by Dr Liam Fox, shadow health minister.2 So much for a Trojan horse smuggling in privatisation by stealth: privatisation is there in bold print. The Conservative party plans to encourage employers and trades unions to provide private health insurance cover for employees and to boost the number of private providers of care. The public will be given a “patient's guarantee” that on the NHS there will be maximum waiting times for patients with “the most serious conditions” and “in defined clinical areas.” If treatment cannot be carried out within the patient's own health authority within the guaranteed time, it must be provided in another health authority or in the private sector. The Conservatives claim that because the NHS will be taking care of the most seriously ill patients the insurers be able to offer more affordable insurance to the rest. Employers would be encouraged, not mandated, to offer insurance through new tax incentives.
Ideology aside, these proposals raise more questions than they answer. A recent report by the Institute of Directors suggests that employers would be reluctant to pay for extra benefits even in a buoyant economy.3 Could the definition of “the most serious conditions” be broad enough to make a dent in the rising costs of insurance premiums? How will it be possible to define “the most serious conditions” and enforce maximum waiting times?
The Conservative's second big theme is the desire to “depoliticise” the NHS to reduce the effect of politicians on the management of the NHS and to allow greater freedoms locally. The ideal role for the secretary of state for health is sketched out as a regulator, and more discretion is advocated for local budget holders. These are worthy aims, but there are no new ideas which might have some bite, for example by putting the NHS at arm's length from national government. 4 5 Good intentions, as has been amply shown in the past, are not enough to keep politicians from attempting to micromanage the NHS.
The other proposals, while of interest, would only make incremental changes to existing arrangements. In primary care, no major changes are proposed except possibly ending single handed practice and encouraging general practitioners to specialise in paediatrics and gynaecology. The number of health authorities is to be reduced to cut costs. The Conservatives also propose establishing an “exceptional medical fund,” which would be overseen by a national multidisciplinary committee, to allocate funds for treatments evaluated by the National Institute for Clinical Excellence. The supposed advantage of these arrangements is that postcode rationing would end, but rationing would still occur and politicians, who determine the size of the fund, would still be blamed. More outcome targets, extended screening programmes, and mandatory training of juniors doctors in accident and emergency and primary care complete the plan.
That the Conservatives are focusing on the terrain that divides health care in the United Kingdom from that provided in other European countries—for example, the United Kingdom's low proportion of private financing and provision of health care and the byproduct, a high level of control by national politicians—is welcome. But the plans look more like a tired abdication of responsibility for change to the market than a serious attempt to understand and promote performance in health care through more effective public-private partnerships. There is no recognition of what the NHS does well compared with other countries, in particular in offering equitable health care, and how the proposals would affect this. 1 6 Aside from questions of workability there are large gaps—for example, there is no mention of the potential to expand the roles of nurses and other non-clinical staff and of the huge future benefits of information and communications technologies. To get into the European premier league, we'll have to do better than this.