NHS reforms have produced “only limited benefits so far”

The government’s ambitious programme of reform for the NHS has delivered only limited benefits for patients, says a report from two healthcare watchdogs.

Unless GPs are given the support to take forward commissioning in the community “the reform programme will not provide the necessary balance of power between primary and secondary care” to succeed, says the report from the Healthcare Commission and the Audit Commission.

In 2000 the then prime minister, Tony Blair, announced a range of sweeping reforms in the NHS plan for England to deliver a more devolved health service with improved services for patients (BMJ 2000;321:317; doi: 10.1136/bmj.321.7257.317). The reforms were accompanied by the largest ever investment in the NHS, with spending for England doubling from £43.7bn (€55bn; $86bn) in 2000-1 to £90.7bn in 2007-8.

The report, which is based on work carried out between May and November 2007, examines the impact on improving care for patients of foundation trusts, the system of payment by results, practice based commissioning, the choice agenda, and new workforce contracts for hospital and community staff.

It says that several factors have hampered implementation of the reforms. These include two structural reorganisations in the NHS, underdeveloped commissioning capacity, and a lack of support to implement and monitor the reforms.

In addition, many people involved in implementing the reforms did not fully understand the aims of the reform programme, how the individual elements contributed, and how they could best be made to work.

Some positive effects were evident although these were limited, says the report. Competition is improving services in some areas and payment by results and foundation trust status has led to better financial management.

But overall the reforms are so far failing to deliver the desired change. Commissioning and contracting skills are still too weak to have any noteworthy impact on moving care out of hospitals and into primary care; few patients are being offered real choice about the services available to them; and new patient care pathways have not been created.

Michael O’Higgins, chairman of the Audit Commission, said, “We don’t underestimate the scale of the challenge of reforming the NHS. It employs four times more people than Tesco and is a much more complex organisation, so it will take time to deliver such major changes.

“But given the massive investment in the NHS in recent years, taxpayers and patients rightly expect that their money is spent as efficiently as possible and that services are improving. The NHS must keep the pressure on to make these reforms work for patients.”

The report calls for “a prolonged moratorium on any further national top down reorganisation of NHS commissioners” and “stronger working relationships” in primary care trusts to engage GPs in commissioning.

It also recommends that the Department of Health considers redesigning the incentive scheme for GPs to ensure that choice reaches patients. If the policy of choice is going to have an impact on activity, primary care trusts should also monitor the situation more robustly with spot checks, says the report.