Transcript Radical Reform of the National Health Service in the UK: Proposals

National Research University Higher School of Economics
Masters in Management and Economics of Health Services
Seminar Presentation 21 March 2011
Radical Reform of the National
Health Service in the UK in 2011:
Background, Proposals, Prospects,
and Lessons for Russia
Dr. Christopher Davis
Department of Economics and School of Interdisciplinary Area Studies
University of Oxford
Motivations for Medical System Reform
• Control rising cost of medical care, reflected in
increasing health shares of GDP, driven by ageing
populations and technological progress
• Improvement in access to medical care and reductions
in health inequalities
• Improvement of quality of medical care
• Reductions in inefficiencies, duplication in the medical
system
• Improvements in health outcomes (survival rates, raising
life expectancy)
• Reducing public dissatisfaction with medical care and
increasing patients’ choice of treatment
Health Reform Waves: 1990-2000s
[Toth (2010) review of reforms in France, Germany, Netherlands,
New Zealand, Sweden and UK]
• Early 1990s: Introduce market-style mechanisms,
greater competition, purchaser-provider split, patients’
choice.
• Mid 1990s: Criticism of market mechanisms, unclear
impact on efficiency but worse equity and access.
Emphasis on improving integration of components of
medical system. UK abolishes fund-holding and adopts
Primary Care Trusts.
• 2000s: Emphasis on quality of care and patients’ rights.
Patients in NHS can choose provider and funds follow.
Unexpected Health Reforms During
Global Financial Economic Crisis
• Russia 2008: “Priority Health Project” and
“Conception of Health RF to 2020”
• China 2009: “Implementation Plan for the
Recent Priorities of the Health Care System
Reform (2009-2011)”.
• USA 2010: Senate Bill 3590 “Patient
Protection and Affordable Care Act”
• UK 2011: “Health and Social Care Bill”
4
Questions to be Answered
• What are the main problems in the UK
health system?
• Have past health reforms worked?
• What are the features of the announced
2010-11 UK health reforms?
• What are the criticisms of the new
health reforms and the prospects for
their adoption ?
Structure of Presentation
• Concepts used in Analysis of Health Reforms
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Health in Political and Economic Systems
Governance in Health Systems
Health Production and Health Outcomes
Priority of the Health Sector and Health Financing
Measurement of Health System Coverage of Population,
Benefits and Cost-Sharing
Sources of Data
Principles and Development of the UK NHS
Health Reforms in UK and Russia 1990-2010
2010-11 Proposals for Radical Reform of the UK
NHS and Criticisms of Them
Political System, State Priorities and Health
• Importance of politics in health reform
– Sheiman & Shishkin 2009: “After an unsuccessful start of the
programme of monetization of benefits in early 2005
discussion of health reform legislation was minimized
..Transformations in organization, management and financing
of the health service were moved to the back burner.”
• Political system
– influences health sector (State bureaucracy, political
parties, legislature, interest groups, voters, public
opinion and expressions of discontent)
• State priorities
– influence allocations of resources, protection of
health sector in a crisis, and degree of inequalities
Political Actors Influencing Health Reform
Executive Government
Legislature
Political Opposition
Non-Governmental
(UK Shadow Government)
Media
Leader
(Prime, Minister,
President
Party Leader
Opposition Party
Leader
Cabinet
Cabinet, Council
of Ministers
Professional
Groups
Parliament, Duma
Ministries
(including Health)
Ministries
(including Health)
Committees,
Commissions
(including Health)
Defence
Health
Think Tanks
Education
NGOs
Public
Regions
Districts
Medical Units
Davis 2011
Governance in Health Services
• Health systems made up of many institutions
(central and regional government, regulators,
boards, medical facilities) that need to achieve
objectives while maintaining standards and
controlling costs.
• To achieve this requires good governance
(Strategy, Leadership, Vision, Assurance, Probity)
[2011 Governing the New NHS]
• Governance different from, but related to,
operational management
• Many UK NHS reforms aimed at improving health
governance
RUSSIA
Public Concern
about Health in
Russia, China,
USA
USA
CHINA
USA
CHINA
RUSSIA
10
Health Sector in an Economic System
Economic Policies
Fiscal, Monetary, Industrial, Foreign Trade, Exchange Rate
Economic System
Health Sector
Household
Medical System
Medical Supply
Medical Industry
Biomedical R & D
Medical Foreign Trade
Health Bureaucracy
Economic Environment
Natural Resources, Population, Integrity of Economic Space,
External Economic Factors,
Performance of Health Institutions
Quantity of Medical Services
Quality of Medical Services
Medical System Efficiency
Sufficiency of Medical Inputs
Effectiveness of Supply System
Production of Medicines and
Medical Equipment
Medical Technology Innovation
Imports of Medicines and
Medical Equipment
Health Sector Production Process
Demography
Household Health
Production
Consumption
Illness Pattern
Environment
Medical
Treatment
Health Output
(Mortality, Invalidity)
Central Health Bureaucracy
Preventive Services
Curative Services
Allocation of Resources
1
Medical System
2
Medical Supply System
2
3
4
5
6
1
Medical Industry
Biomedical R & D
Medical Foreign Trade
12
Impacts of Reforms on Health System Coverage
of Population, Benefits and Cost-Sharing
WHO 2008, Fig. 2.2
Sources of Data for Presentation
• Data for Empirical Assessments
– Official Russian sources
– OECD databank and reports
• Data for Diagram of Health Coverage, Benefits
and Cost-Sharing
• Information about Current UK Health Reforms
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–
–
–
Official documents (White Paper and Parliament Bill)
Think Tanks (Kings Fund, Nuffield Foundation)
Academic Journals
Newspapers
Empirical Estimation of Trends in Axis
Variables in Health Diagram
• X Axis: Coverage of Population (% of population covered by a
national health service (NHS) or health insurance (100% public,
mixed public-private, or subsidized private)). Government
statistics and reports. Reliable estimation of trends.
• Y Axis: Coverage of Benefits (% of potential benefits in a country
provided to the population). Measurement more problematic .
Identify maximum standard in a country and evaluate how
provision of the average citizen deviated.
• Z Axis: Coverage of Costs (% of health costs covered by public
sources). Estimates of this indicator based on government
statistics and independent reports. Measurement reliable.
15
Establishment of UK NHS in 1948
• First national health service in democratic system not based
on insurance. Established in July 1948 with principles
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–
–
–
–
–
Universal coverage
Free of direct charge
General taxation source of finance for NHS
Pooling of financial risk at centre
Collective provision
Promotion of advances in medical science
• Political struggle over the reform
– Government and medical professional in favour of reform
– Opposition by Interest groups (hospital doctors, GPs, other
medical workers, trade unions, patients, NGOs)
– Local government opposed to centralisation
– Groups fights to maintain “freedom of choice” (patients have
right to choose doctors, doctors have right to choose
treatments)
Compromises and Actual Arrangements in
Establishing the UK NHS
• More a national hospital service than a national health
service
• Compromises
– Teaching hospitals subordinate to centre whereas other
hospitals under local government
– Doctors (but not other medical professionals) have key
management roles
– Local government keeps control of district nurses, child
welfare, public health
– GPs not salaried or employed by government. Sign
contracts with Executive Committee run by GPs. Paid on
capitation basis (related to patient list)
– Groups of GPs encouraged but not mandatory
– Private practice by hospital doctors allowed
Structure of UK NHS in 1948
NHS Developments and Reforms
1948 – 1980s
• Substantial growth of NHS and quantities of services
provided
• Significant increase in medical technology in NHS and in
quality of care
• Continuing increase in the cost of the NHS (HE % GDP rises
from 3.5 % to 5.6 %)
• Improvements in almost all measures of health outcomes
(e.g. life expectancy)
• But shortages, queuing, rationing
• Reforms introduced to improve performance
– 1950 – 73 Technocratic change (planning, management)
– 1974 Unification/integration, Regional Health Authorities,
Community Care Councils
– 1982 Introduce general management, outsourcing (contracting
out to private sector of non-essential services)
UK Elections, Parties in Power and
Health Reforms: 1945-1989
Election
1945, 1950
Party in Power
Labour 1945-1951
Major Health Reforms
1948 Establishment of NHS, technocratic changes to improve
planning and management
1951, 1955, 1959 Conservative 1951-1964
More technocratic reforms, greater attempts to reduce regional
inequalities through planning and re-distribution
1964, 1966
Labour 1964-1970
More technocratic reforms, greater attempts to reduce regional
inequalities through planning and re-distribution
1970
Conservative 1970-1974
More technocratic reforms, greater attempts to reduce regional
inequalities through planning and re-distribution
Labour 1974-1979
1974 focus on unification and integration. Establishment of
Regional Health Authorities (15), Area HA (90), and 200 District
Mangement Teams and Community Health Councils (voice of
consumers). 1976 Resource Allocation Working Party (RAWP)
to re-distribute funds across regions.
Conservative 1979-1987
1979 Royal Commission on NHS criticises 1974 reforms for
increasing bureaucracy. 1982 reform promotes simplification
and decentralisation. Elimination of Area Health Authorities.
Family Practitioner Councils become independent. Encourages
local fund-raising and private sector involvement.
1974
1979, 1983
C. Davis 2011
Structure of UK NHS: 1974 and 1982
Comparison of the UK and USSR
NHS in the 1980s
Political system
UK
Emphasis on individual rights
Multiple political parties
Contested elections
Free press
Firm party discipline
Strong popular support for the NHS
Popular dissatisfaction with performance of NHS an
important political issue
USSR
Emphasis on the collective and the state
Single Communist Party
Uncontested elections
Censored press
Rigid party discipline
Strong popular support for the NHS
Popular dissatisfaction with performance of NHS an
insignificant political issue
Economic system
UK
Most property in private sector
Market regulation of the economy
Consumers have strong market power relative to suppliers
(buyers' market)
Weak government control of income and consumption
Economy open to world competition (private control of
foreign trade)
High consumption share of national income
Chronic excess supply in consumption markets
Unequal distribution of income and wealth
State-owned NHS an anomaly in market economy
USSR
Most property in state sector
Central plan regulation of the economy
Consumers have weak market power relative to suppliers
(sellers' market)
Strong government control of income and consumption
Economy closed to world competition (state monopoly of
foreign trade)
Low consumption share of national income
Chronic excess demand in consumption markets
Unequal distribution of income and privileges
State-owned NHS typical component of centrally
planned economy
Davis 1990
Performance of the UK and USSR NHS
[Davis 1990 chapter in Social Policy Review]
• Rising demand for medical care
• Successful cost containment in both countries
[1984 The Painful Prescription]
• Shortages in both health services, but more acute
in USSR
• Pervasive rationing of medical care in both health
services
• UK lags behind most EC countries in availability of
medical technology (71 % average MRI), but is
substantially more advanced than USSR
• Almost all health outcome indicators better in UK
than in USSR
Russia Health System Coverage of Population,
Benefits and Costs in 1990
Total Health Expenditure
100
80.0 %
Height:
% of Costs
Covered by
Public
Russia Health 1990
State
Guarantee
100
80.0 %
Universal Coverage in 1990
100
0
Depth:
% of Benefits
Covered by
Public
Width: % of Population Covered
Davis 2010 (Concept from WHO 2008, Fig. 2.2)
Male Life Expectancy 1980-2008:
UK, USA, China, Russia
80.0
75.0
USA
65.0
China
60.0
Russia
UK
55.0
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
50.0
1980
Years
70.0
Objectives of Health Reforms in UK
• Control cost of medical care
• Improve efficiency so that health spending has
greater impact
• Reduce bureaucracy, strengthen purchaserprovider split, increase competition
• Devolve decision making and resource
allocation to consortia of GPs
• Give patients greater choice of treatment
paths
Health Reforms in the UK in the 1990s
• 1990 NHS and Community Care Act of Conservative
government
• 1991 Introduction of the “internal market”. Purchaserprovider split. Two models of purchasing: health
authorities and GP fundholders (non-urgent elective
and community care for patients).
• 1994 Total Purchasing Pilot Scheme allows GPs to
commission all services
• 1997 GP fundholders abolished in favour of Primary
Care Groups and Trusts (PCG, PCT) that maintain
Purchaser-Provider split
UK Elections, Parties in Power and
Health Reforms: 1990-2010
Election
1987, 1992
1997, 2001, 2005
Source: C. Davis 2011
Party in Power
Major Health Reforms
1990 NHS and Community Care Act introduces "internal
market" and general management, creates Hospital Trusts
("sellers"), health authorities become "commissioners"
Conservative 1987-1997
(buyers). 1992 Private Finance Initiative for mixed funding of
NHS facilities. 1997 White Paper The New NHS. Modern,
Dependable establishes Primary Care Trusts (PCTs).
Labour 1997-2010
1997 Devolution of UK NHS to England, Scotland, Wales,
Northern Ireland. 2000 The NHS Plan creates Care Trusts.
2001 Creat National Patient Safety Agency. 2002 Create
Strategic Health Authorities. 2004 Create Create Commission
for Healthcare Audit and Inspection (CHAI). 2005 Create
National Institute for Health and Clinical Excellence (NICE)
from old NICE. 2006 Commissioning a Patient-Led NHS
establishes GP Practice-Based Commissioning.
Evolution of Purchaser-Provider
Relationships in UK NHS
Purchaser-Provider Arrangements in
the UK NHS in the 1990s
Health Reforms in Russia 1990-2008
• 1991-1993 Introduction of CMI and other health reforms
• Deterioration of economic performance, weak state, overambition means most health reforms fail in 1990s
• In 2000s more emphasis on health education, prevention
• Intensified reforms related to management and incentives
in the medical system
• Improvements of CMI system
• Adoption of Federal Goal Programs in health for 2002-06
to supplement normal activities
• Priority National Project in Health 2006-10
• Adoption in December 2008 of Conception of Health RF
to 2020
• Real health expenditures from state budget, CMI and
private sector increase substantially
Medical Systems in China, USA, Russia, UK
Indicators
Doctors
Hospital Beds
Middle Medical per doctor
Doctors
Hospital Beds
Middle Medical per doctor
Doctors
Hospital Beds
Middle Medical per doctor
Doctors
Hospital Beds
Middle Medical per doctor
Units
China
Per 1,000 population
Per 1,000 population
Number
USA
Per 1,000 population
Per 1,000 population
Number
Russia
Per 1,000 population
Per 1,000 population
Number
UK
Per 1,000 population
Per 1,000 population
Number
2000
2007
1.7
2.4
2.8
1.5
2.7
3.1
2.3
3.5
4.6
2.4
3.1
4.6
4.7
11.6
2.3
5.0
10.7
2.2
2.0
4.1
4.4
2.5
3.4
3.8
Russia Health System Coverage of Population,
Benefits and Costs in 1990, 2007
Total Health Expenditure
100
80.0 %
65.0 %
Height:
% of Costs
Covered by
Public
Russia Health 1990
State
Guarantee
100
Russia Health 2007
80.0 %
60.0 %
Universal Coverage in 1990, 2007
100
0
Depth:
% of Benefits
Covered by
Public
Width: % of Population Covered
Davis 2010 (Concept from WHO 2008, Fig. 2.2)
Male Life Expectancy 1980-2008:
UK, USA, China, Russia
80.0
75.0
USA
65.0
China
60.0
Russia
UK
55.0
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
50.0
1980
Years
70.0
ДЕМОГРАФИЧЕСКАЯ ПОЛИТИКА В
РОССИЙСКОЙ ФЕДЕРАЦИИ
ИЗМЕНЕНИЕ ЧИСЛЕННОСТИ НАСЕЛЕНИЯ
МЛН. ЧЕЛОВЕК
Population: 142 million
Area: 17 million км2
Birth Rate: 11.3 per 1,000
Crude Death Rate: 14.6 per 1,000
150
Цель
145 млн
Россия
146
142
142 млн
138
2020
2015
2010
1990
1995
2000
2005
ДИНАМИКА ОЖИДАЕМОЙ ПРОДОЛЖИТЕЛЬНОСТИ ЖИЗНИ В
РОССИИ И В СТРАНАХ ЕВРОСОЮЗА
ОБЩИЙ КОЭФФИЦИЕНТ СМЕРТНОСТИ
НА 1 ТЫС. ЧЕЛОВЕК
СМЕРТНОСТЬ НАСЕЛЕНИЯ РФ
17
15
13
Россия
ВОЗРАСТ
«Старые» страны ЕС
80
Цель
75 лет
76
«Новые» страны ЕС
72
«Новые» страны ЕС
10
11
«Старые» страны ЕС
Россия
68
67,5 лет
9
1980
1985
1990
1995
2000
2005
2010
2015
2020
64
1980
1985
1990
1995
2000
2005
2010
2015
2020
1
Russia Health System Coverage of Population,
Benefits and Costs in 2007, 2020
Total Health Expenditure
100
65.0 %
60.0 %
Height:
% of Costs
Covered by
Public
Russia Health 2020
State
Guarantee
100
70.0 %
Russia Health 2007
60.0 %
Universal Coverage in 2007, 2020
100
0
Depth:
% of Benefits
Covered by
Public
Width: % of Population Covered
Davis 2010 (Concept from WHO 2008, Fig. 2.2)
Developments of Health in the UK
in the 2000s
• In 2002 Phasing out of Health Authorities,
move to 152 PCTs with ave pop of 300,000
and responsibility for £ 80 b (80% NHS)
• 2004 new form of commissioning PracticeBased Commissioning (PBC): GP practices
given indicative budget by PCT and
encouraged to make savings while achieving
quality targets
• 2007 World Class Commissioning. Set
standards for PCTs and PBCs
UK NHS Structure Late 2000s
2010 UK NHS Governance
Patient Contacts in NHS
NHS Expenditure Early 2000s
Primary Care Trusts
• 300 (reduced to 150) Primary Care Trusts are subordinate to
the Strategic Health Authority and represent the local
Primary Care community (GPs, dentists, public health).
• Objectives are to improve the health of the community,
engage in partnership work and community-based health
and care initiatives, implement population screening
programmes, develop and integrate family health services,
medical (primary care), dental and optical
• Have assumed responsibility from district health authorities
of commissioning (purchasing) of community, secondary
care and tertiary/specialised services
• Also responsible for mental health, emergency ambulance
and patient transport services, NHS Direct and walk-in
centres
NHS Trusts and Foundation Trusts
• NHS Hospital Trusts
– Hospital trusts subordinate to Strategic Health Authorities
and need to satisfy annual accountability agreements
– More freedom of activities than previously
– Provide services to PCTs
– Must satisfy standards set by Care Quality Commission
• Foundation Trusts
– NHS Trusts that are promoted by Monitor because they
satisfy stringent criteria concerning financial viability
– Greater autonomy in medical and financial activities
– Provide medical services to PCTs in accordance with
contracts
– Must satisfy Monitor and Care Quality Commission
Foundation Trusts
Monitor
• Monitory established in 2004. Executive nondepartmental public body
• Oversees performance of NHS Trusts (primarily on
financial grounds) and grants selected ones licences to
operate as Foundation Trusts.
• Has sole responsibility for overseeing Foundation
Trusts to ensure their financial viability while
maintaining agreed safety and medical quality
standards
• Assigns each FT risk ratings on an annual basis, which
influences detail of supervision
• Can intervene to direct activities of failing FTs
NICE
• In 1999 National Institute for Clinical Excellence
established to provide information to patients, the public
and medical professionals on evidence-based practice in
the prevention and treatment of illness. Carried out costeffectiveness studies of diagnostics, medicines, medical
devices, clinical management of illnesses, and public
health interventions.
• In 2005 old NICE merged with Health Development
Agency to form the National Institute for Health and
Clinical Excellence, but has kept the acronym NICE.
• Produces clinical guidelines concerning treatment,
appraisal guidance on drugs and techniques, and guidance
on safety and efficacy of curative and preventive
interventions.
• Developing 150 new standards of treatment for specific
diseases that will be used in National Service Frameworks
Care Quality Commission (CQC)
• In 2009 CQC established as new “superregulator” to supervise and inspect the quality
of all providers of secondary/tertiary medical
care and social care
• Ensures that all organisations adhere to
detailed Essential Standards.
• Promotes achievement of outcome measures.
• Rates the performance of NHS Hospital Trusts
UK Total Health Expenditure as % of
GDP: 1980 - 2008
10
9
8
7
6
5
4
3
2
1
0
Health Expenditure Shares of GDP in
International Perspective
Russia
UK
Economic Significance of Health
Sectors in UK and Russia
USA
Health and GDP 2008
% Global
HE % Global
US HE %
GDP in PPP HE % GDP
GDP
Country GDP
20.6
16.5
3.4
16.5
China
11.4
5.5
0.6
29.8
UK
3.2
8.4
0.3
106.3
Russia
3.3
6.0
0.2
103.0
50
Mortality and Life Expectancy:
China, USA, Russia, UK
Indicators (2009)
Infant Mortality Rate
Units
Deaths per 1,000
live births
Deaths/1,000
General Mortality Rate
Life Expectancy at
Years
Birth, Total Population
Sources: CIA World Factbook 2010
China
USA
Russia
UK
20.3
6.2
10.6
4.6
7.1
8.4
16.1
9.3
73.5
78.1
66.0
80.1
UK Health System Coverage of Population,
Benefits and Costs in 1990, 2007
Total Health Expenditure
100
90.0 %
85.0 %
UK Health 2007
Height:
% of Costs
Covered by
Public
UK Health 1990
100
85.0 %
80.0 %
Universal Coverage in 1990, 2007
100
0
Depth:
% of Benefits
Covered by
Public
Width: % of Population Covered
Davis 2011 (Concept from WHO 2008, Fig. 2.2)
Parliamentary Report on Commissioning
(Purchasing) in the UK NHS in March 2010
Conclusions from House of Commons
March 2010 Report on Commissioning
• Expensive: rise in share of NHS administration from 5 %
pre-reform to 14 % (lack of transparency)
• PCTs lack necessary skills (analysis, clinical knowledge,
management), do ineffective job in commissioning
• Weaknesses of PCTs force them to make extensive use
of expensive outside consultants
• PCTs remain weak relative to providers and do not
insist on hospitals using evidence-based procedures
• Adversarial system without benefits. “After 20 years of
costly failure, the purchaser/provider split may need to
be abolished.”
Pre-Election 2010 Proposals for
Change in NHS Structure
Parliamentary Election, July 2010 White
Paper, December 2010 Health Reform Bill
• May 2010 parliamentary elections in UK. A
government formed from a coalition of
Conservative and Liberal Democrat parties.
• Neither party had radical reform of the NHS in its
election manifesto
• July 2010 government published White Paper on
Equity and Excellence: Liberating the NHS
• Proposes radical reforms to organisation and
functioning of the NHS
Health and Social Care Bill: January 2011
• Abolish all 150 Primary Care Trusts and 10
Strategic Health Authorities
• Establish GP Commissioning Consortia
– GP practices to continue to offer community based
services as independent contractors
– But groups of GPs to form Commissioning Consortia
that will be NHS organisations and to be given £ 70-80
billion to purchase services
• Create new NHS Commissioning Board
• All NHS Hospital Trusts will become Foundation
Trusts and be regulated by Monitor according to
financial criteria
Proposed Changes in NHS
Governance 2011
White Paper and Parliament Bill
Proposals for 2013 NHS Governance
Political Actors Influencing 2011 Health Reform
Government
CoalitionExecutive
government
proposes radical reforms
Legislature
Political Opposition
Non-Governmental
(UK Shadow Government)
Media
Prime Minister
Cameron, Deputy
Clegg
Party Leader
Opposition Party
Leader
Think Tanks
Cabinet
Cabinet
Professional
Groups
Parliament
Ministries
(including Health)
Ministry of Health
(Minister Lansley)
Defence
Health
Regions
Districts
Medical Units
Committees,
Commissions
(including Health)
NGOs
Shadow government
Public
strongly opposed to
Conservative party in reforms
favour, labour opposed,
Almost all comments
and Liberal Democrats
from non-governmental
divided over reforms
groups hostile to
reforms
Many professionals within
Davis 2011
HS critical of reforms
Education
Opposition in Parliament and Among
Members of Political Parties
• Labour Party official position is strong opposition
to the radical health reforms. All relevant
members of the shadow government have
publicly criticised the proposals and members of
the parliamentary party will vote against it.
• Liberal Democrat party is divided. 12 March 2011
LD party conference supported resolution
condemning the reforms and putting forward
alternative proposals (restrict power of GP
consortia, limit private sector involvement,
reduce use of market mechanisms)
Coverage of Health Reforms in Media
• Most recent television reports and articles in
printed media have been critical of the health
reforms
• 7 March “The non-national health service”
• 10 March “Lib-Dems from top to bottom are in
revolt over NHS reforms”
• 15 March “Doctors gunning for Lansley over
reforms”
• 20 March “David Cameron's health reforms risk
destroying the NHS, says Tory doctor”
Opposition by Groups of
Medical Professionals
• 15 March Special Conference of British Medical
Association to discuss reforms. Almost all motions
before conference are negative.
• Most doctors opposed to reform and believe it will
result in a worsening of the quality of patient care
and increased inequality
• 7 March Chairman of BMA Consultants’ Committee
argues that reforms will damage management of
the NHS, waste resources, and give the private
sector the most lucrative components of treatment,
with the NHS responsible for the unprofitable
residual care
“David Cameron's health reforms risk destroying
the NHS”: GP in Conservative Party
• "It is one thing to rapidly dismantle the entire middle layer of NHS
management but it is completely unrealistic to assume that this
vast organisation can be managed by a Commissioning Board in
London with nothing in between it and several hundred
inexperienced commissioning consortia.
• New commissioning consortia are "doomed to fail and will have to
hand over their commissioning to the private sector".
• “An organisation responsible for £100 billion needs people who
seriously understand accountancy and, trust me, GPs do not.“
• "It is no use 'liberating' the NHS from top down political control
only to shackle it to an unelected economic regulator. If Monitor,
the new regulator, is filled with competition economists with a
zeal for imposing competition at every opportunity, then the NHS
could be changed beyond recognition.“
Critical Analyses of Health Reform Proposals
by Think Tanks (Nuffield, Kings Fund)
• Financial environment of reforms
– Tight constraints on real health spending in NHS. PCTs facing 2% cuts in
real health spending. Need efficiency savings of £ 20 billion 2011-14.
– UK health spending (8.7 % GDP) low by OECD standards.
– Difficult to keep financial control during time of reorganisation
– Reforms require better management, but overall NHS target of 45% cut
in management costs over next several years.
• GP Consortia
– Past experience with GP fund-holding reveals many deficiencies. Years
needed to develop necessary expertise. GP Consortia won’t have
necessary competence in commissioning and planning.
– GP Consortia should be subjected to same critical evaluation as NHS
Trusts currently receive. Should have to prove themselves.
– Need safeguards to prevent conflicts of interests of GP Consortia
Critical Analyses II
• NHS Commissioning Board
– New Board will play important role. Will be able to intervene in
work of GP Consortia.
– But lack of clarity of functions and accountability of Board.
Experience from New Zealand reforms not positive.
– Unclear if Board can ensure high standards in both GP
commissioning and provision of medical care.
• Abolition of Strategic Health Authority
– Huge reorganisation will distract management and entail
substantial additional costs
– Will result in loss of experience leadership with long-term vision
because not many managers will transfer to GP Consortia
• NICE
– New freedoms to GP Consortia raise possibility that they will not
adhere to standards developed by NICE
– Conservative government not supportive of quasi-governmental
organisations
Conclusions
• UK NHS has been performing well over past several
decades given tight financial constraints
• NHS has been subjected to many reforms, not all
of which have been successful
• New radical health reforms promise to reduce
bureaucracy, improving efficiency and quality of
care, providing more choice for patients
• But most independent analysts highly critical or
reforms and most political forces against it
• Modified version of bill is likely to be adopted, but
the reforms will not deliver promised results