UK government must stop making heroic promises, report says

Labour's first five years of health policy have left “an overwhelming impression of relentless, almost hyperactive intervention,” says an in-depth review by the King's Fund, an independent health charity.

In the report, published last week, the King's Fund accused the government of unleashing a torrent of new policies since 1997, which have distracted the chief executives of trusts from more pressing issues of staffing, resources, and low morale.

The report gave its verdict on 10 key policy areas—from funding to waiting times, rationing, and private sector involvement. Sometimes policies have been sound, but their implementation has foundered, the authors say—for example, waiting list initiatives, workforce expansion, and the move to make primary care organisations responsible for public health.

In January 2000, Prime Minister Tony Blair outlined Labour's manifesto pledge to spend enough money on the NHS to match the rest of the European Union, measured as a percentage of the gross domestic product (BMJ 2000;320:205). But the report said that this target would be missed unless significantly more money was pumped into the health service—because the rest of Europe is hiking up its health contributions too.

UK spending on public and private health care will reach 8% of the gross domestic product by 2005-6, but by then the rest of Europe is likely to be spending about 10.7% based on a weighted average excluding the United Kingdom. This implies that the NHS will need about £30bn ($43bn; €49bn) more in real terms by 2005-6 than currently pledged.

The 137 page dossier claimed that decades of underinvestment have created under-resourced primary care trusts so overloaded with instructions that they cannot meet all their targets or address local priorities.

“Primary care trusts are bowing under the weight of the Government's good intentions,” said the report. They are beginning to get to grips with managing budgets and influencing hospital services, but many lack the information and financial management to commission health care and deliver on health improvement. In 2000, over 1 in 10 primary care groups still thought they had no impact at all on hospital services, according to the national tracker survey conducted by the National Primary Care Research and Development Centre and the King's Fund.

Labour's efforts to improve workforce issues have yet to make a real difference to staff, who are often unaware of the opportunities available to them, the report said. Many chief executives of trusts are being distracted from crucial staffing issues by numerous other targets they must meet. Under the NHS Plan, the government promised to recruit 7500 more consultants and 2000 more GPs by 2004, but progress towards this is slow. Upstream, the number of applicants to medical school is falling, and the supply of overseas doctors is tailing off.

Although the authors pointed out that it is still too early to expect tangible results halfway through the 10 year health plan, they berate government for making exuberant promises that could end up backfiring on the health service.

But the NHS Confederation, which represents NHS trusts across the United Kingdom, believes that the Labour government's commitment and direction of travel is “fantastic.” “We had a brand new government full of energy. What do you expect?” said Dr Gill Morgan, chief executive of the NHS Confederation. “If they stood around doing nothing, they would be criticised—they're stuck between a rock and a hard place.”

Dr Morgan thinks the biggest challenge facing the NHS is getting enough staff, resources, and beds to run the service properly, which is why the government should prioritise its targets so they can be achieved realistically.

“The anxiety is about the timing of some of the targets and the practicalities of delivering them locally,” said Dr Morgan.

The report's authors recommended that the government adjust the style and emphasis of its policies in five areas to consolidate the progress made so far. They called for the money to keep flowing, for the centre to let go—to “curb the incessant flow of orders from the centre” to improve morale.

The plethora of targets should be streamlined into fewer, broader targets that are costed and funded appropriately. A better balance should be achieved between health and health care, to give more emphasis to measures that keep people healthy and reduce health inequalities.

Finally the government must prepare for the long haul and “stop making heroic promises and buckle down to the unglamorous detail of building a good-enough health system for the 21st century.”