Steadying the NHS

We believe, and refuse to be dissuaded, that the National Health Service, with its moral intent, commitment to equity, and store of knowledge, has the inherent capability to become the greatest healthcare system of any nation. Yet, lately, it seems like a boxer on the ropes, not the champion it should be.

Laudable goals

Fiona Godlee has raised a critical question about governance at the right time.¹ The vision of modernisation of the NHS that emerged in the first year of the labour government was, and remains, compelling.² Tony Blair personally led the articulation of an ambitious set of goals for reinvestment in and improvement of care, and he put his money—lots of money—where his mouth was.

Figure 1.

Tony Blair put his money where his mouth was

Credit: OWEN HUMPHRIES/PA/EMPICS

The national service frameworks that early on defined targets for better care in areas including cancer, coronary heart disease, and mental health were scientifically grounded and patient focused. Infrastructure for catalysing change grew rapidly, including the concept of clinical governance embedded in law, new regulatory organisations, new forms of accountability for NHS management and the medical professions, and growing transparency through publicly reported data. Before this, no nation had undertaken such ambitious large scale improvement in health care.³

Dr Godlee may give too little credit for the successes over the past few years—better access, reduced mortality, more reliable care for heart disease, better coordination of cancer care, and improved ratings by patients, to name a few.⁴ But the growing distress and the failure to capitalise fully on the vast new investments are evident, and the current financial crisis in the NHS renders even the best reforms increasingly vulnerable.

Shifting strategies

Surely some of this gap is due to unceasing shifts of structures and strategies since the NHS Plan was published in 2000. In barely six years, four people have been secretary of state, and several of the government's most senior healthcare advisors—none clinicians—have come and gone. Fundamental institutions such as the strategic health authorities and primary care trusts have been through two reorganisations. Foundation trusts have been promulgated, with major changes in hospital incentives.⁵ The world's largest investment in healthcare information technology is underway, implemented through complex contracts with multiple vendors.⁶ New contracts are in place for general practitioners and specialists, with unexpected soaring payments to clinicians who, at the same time, are dropping night time and weekend surgeries.

Policy has focused on market forces and choice. Private companies with values far different from those of the NHS are being invited into delivery and commissioning. As Americans, we know dependence on market forces for constructive change is playing with fire.⁷

Each of these steps makes sense to someone. However, collectively, they do not cohere. The panoply of changes, the sudden policy corrections, and the impatience that makes plans end before gaining traction create confusion and cynicism for even a willing workforce. If the NHS was a publicly traded company, stockholders would flee because of its unsteadiness of course. Dr Godlee attributes this inconsistency to the whims of politics and politicians. We do not know the cause; we have too much respect for the many thoughtful leaders we have come to know in the NHS and the government to attribute the inconsistency to either lack of caring or lack of competence. We applaud Labour's original plan for “modernisation.” But like Dr Godlee, we wonder whether something big should change to steady the NHS on its worthy, inspiring journey.

Perhaps it is time for a national review of the NHS governance and managerial structure, rather than another restructuring of the organisation within the NHS. Our bias would be not to remove NHS leadership too far from government power; it might prove unwise to trade the constructive role of engagement for independence. Politicisation is one side of a coin with involvement on its obverse. The key question, however, is: “How should an NHS fit for the 21st century be governed and managed as a whole?” And, most importantly, “How can the proper set of non-negotiable social and ethical commitments the NHS began with—equity, access for all, free at the point of care, and public funding, etc—be preserved and enhanced within a structure more consistent in its directions and plans?”

The NHS is not just a national treasure; it is a global treasure. As unabashed fans, we urge a dialogue on possible forms of stabilisation to better provide the NHS with the time, space, and constancy of purpose to realise its enormous promise.