What does the future hold for the NHS at 60?

Abstract

Flux and conflict constrained by consensus as in the past

When the NHS celebrated its 50th anniversary with much pomp, commemorative stamps, and a service in Westminster Abbey, a new Labour government was busy reversing many of the policies of its Conservative predecessor. The internal market was abolished, as was general practitioner fundholding. The NHS would indeed be modernised, but it would be on the basis of cooperation not competition.

Who then—in the euphoria of the celebrations when Frank Dobson, the secretary of state for health, could claim that “the NHS remains the envy of the world”¹—would have anticipated that within a couple of years policy would go into reverse gear? Who then would have predicted the emergence of a new model for the NHS based on choice, competition, payment by results, and a plurality of providers, let alone the emergence of institutions like foundation trusts? To ask these questions is to underline the perils of prediction. It is easy to list the demographic, technological, and other challenges that will face the NHS as it moves towards its 70th anniversary, but quite another matter to be confident about likely policy responses.

But if the past carries a warning, it also provides some reassurance. From one perspective the history of the NHS is one of flux and conflict. Its 60 years have from the start been marked by conflicts between the medical profession and governments of both parties, while the political parties in turn take every opportunity to attack each other’s policies.

Meanwhile, the structure of the NHS has been in a constant state of flux, as organisational maps and nomenclatures change to the accompaniment of talk of crisis and prophecies of impending collapse. Yet from another perspective, the NHS is a remarkable monument to institutional stability and political consensus. The old building has been massively remodelled, but the basic architecture remains intact. The principles of the founding fathers—as ministers remind us constantly—have been preserved: the NHS is a universal service, funded by taxes, which provides care on the basis of need, not the capacity to pay.²

Moreover, political parties now compete about which one is most committed to the NHS. The critics of 1948, like the BMA and even the Conservative Party, have become the NHS’s advocates. And underpinning this consensus is the fact that the NHS remains the UK’s most popular institution with iconic status. This suggests in turn that future pressures on, and tensions within, the NHS will be worked out within the existing framework. As in the past 60 years, calls will doubtlessly be made for radical change—such as the adoption of a social insurance funding model—which will probably be ignored. As in the past, again, adaptive changes will occur in policy instruments rather than policy goals.

The main reason why flux and conflict have characterised the past 60 years and will probably continue to do so is that the tensions within the NHS (and in all healthcare systems) cannot be neatly resolved by heroic policy initiatives. For they involve balancing desirable goals and values that conflict with each other. The values of the NHS do not necessarily point in the same direction, and the weight attached to individual values may vary between different groups.³

The subject of whether patients should be able to top up treatment by buying drugs not available in the NHS is a case in point.^{4 5} To permit this would clearly offend against the equity principle—that patients with equal need should receive equal treatment irrespective of their ability to pay. But to prohibit it would offend against the autonomy principle—that the decisions and preferences of patients should be respected. Or consider opposition to reconfiguration proposals. Many factors are involved, but the different weights attached to different policy goals by different groups is prominent among them. Clinical safety and excellence (the professional aspiration), efficient and economic use of resources (the managerial imperative), and local accessibility (the public preference) are all worthy goals, but they are not necessarily and invariably consistent with each other.

Many examples of complex problems that involve difficult trade offs are available. It is now conventional wisdom that the NHS has become excessively centralised and the time has come to devolve decision making to the periphery. Yet postcode rationing—different health economies making different decisions about their priorities—is also unacceptable. So are uniform national standards to be brought about without central direction?

Again, although everyone agrees that competition is a spur to efficiency, services need to be integrated. So how can these challenges be met? One suggested option is to allow patients to choose between integrated systems rather than between individual providers of one-off treatments.⁶ In effect, primary care trusts would become redundant and replaced by “health maintenance organisations.” But if they were to disappear, so would the NHS’s capacity to plan for geographically defined populations. Once again, competing and desirable policy goals seem to be incompatible. Most importantly, perhaps, there is dissonance between the rhetoric of a consumer driven NHS and the reality of a model for allocating (and rationing) resources that is based on professional need: what would happen if consumer demands were to trump judgments of professional need?

The list of such incompatibilities goes on, but the point has been made. And it has an implication not only for the future but also for the present. As far as the future is concerned, it means—as argued—that flux and conflict are inevitable. For the present, it suggests that flux and conflict can be reduced, but not eradicated, to the degree that the policy making process acknowledges the complexities involved. It underlines the danger of rushes of blood to the head of policy makers—the search for instant fixes.

The warning is perhaps all the more appropriate with the publication of the Darzi review of the NHS. The Department of Health is now dominated by former NHS managers who have brought with them a “can do” culture that has scant tolerance for the civil service tradition of putting policy proposals on the rack of analysis, examining inconsistencies, and identifying possible perverse outcomes.⁷ Analysis has too often been farmed out to management consultants who do not have to live with the consequences of their work. The civil service tradition was much derided by Margaret Thatcher and Tony Blair, who saw it as a recipe for delay and obstruction. But given the policy turmoil and fiascos of recent decades, the time may have come to revive it.

Cite this as: BMJ 2008;337:a549