The NHS: not back to Era 1 but forward to Era 3--policy challenges for labour.
| Author | Iliffe, Steve |
| Position | AGAINST NOSTALGIA - National Health Service - Essay |
Labour is the creator and defender of the NHS. But the party should not be aiming to return the NHS to 'Era 1'. Rather, we need to have a coherent plan for how to get healthcare from Era 2 into Era 3--to a state that addresses the service's current problems and is appropriate to the kind of culture and society we now live in. Don Berwick's ideas, if translated properly, offer ways to do this.
Don Berwick, a North American fan of Britain's National Health Service and critic of the wasteful US healthcare system, urges us to enter 'Era 3' of modern medicine. In a paper in the Journal of the American Medical Association, (1) and in a presentation to the King's Fund on improving the quality of NHS care, in February 2016, (2) he offers a manifesto for the NHS which differs from the usual tired exhortations to integrate, collaborate and become patient centred. The ideas he puts forward could be combined with the work on policy development done by Labour before the 2015 General Election, especially Whole Person Care, expressed as 'One person supported by people acting as one team from organisations behaving as one system' (3)--but not before some serious questions are answered. This discussion paper explores the relevance of Berwick's manifesto to the NHS.
Berwick describes the history of modern health care systems in terms of three eras. Era 1 was the period of noble, beneficent, self-regulating professionalism that powered the NHS constructed by Labour in 1948. In the compromises needed to launch the new health service, the political class conceded to the professions the authority to judge the quality of their own work.
Era 2 began when the variations in the quality of care, the injustices and indignities inflicted on people because of class, gender and race, the profiteering and the sheer waste of Era 1, became inescapable. Era 2 introduced accountability, scrutiny, measurement, incentives and market mechanisms. As Berwick puts it, 'The mechanism of Era 2 is the manipulation of contingencies: rewards, punishments and pay for performance'. Labour contributed to the consolidation of Era 2 during the Blair/Brown governments, but Era 2 began in the late 1980s with the introduction of the purchaser-provider split, the imposition of contracting, the promotion of evidence based medicine and the industrialisation of the NHS.
Era 2 has promoted discomfort and defensiveness amongst NHS staff, and feelings of anger, of being misunderstood and of being over-controlled. Managers and the Department of Health in turn become suspicious, feel resisted and can become either aggressive (creating a culture of bullying) or helpless while their political superiors invest more and more in what Berwick calls 'ravenous inspection and control'. However, Era 2 is coming to an end; market mechanisms are no longer seen by senior NHS managers as useful, and the English Health & Social Care Act 2012, which promoted marketisation of the NHS, no longer drives managerial policy and practice.
The conflict between the competing and incompatible drivers of Era 1 and Era 2 diverts attention and resources away from improving and redesigning care, according to Berwick. The question for policy makers, managers and professionals is how can the conflict be resolved productively, and how can Era 3 be brought into being? In other words, what would a modern health and social care system look like?
England is not the USA
Berwick has some suggestions, but before considering them we should think about three things that are specific to our situation.
First, the NHS is a success which compares well with other countries' health services, providing highly equitable care and performing well on measures of experience and access, but could do better on key health outcomes (such as deaths that could be prevented by effective health care). (4) Whilst the NHS and social care are currently in a politically-induced funding 'trough' international comparisons and national projections show that a modern care system care based on the NHS is both effective and affordable. Funding shortfalls aside, the tough problem is health inequalities, which the NHS fails to alter.
Second, the funding of the NHS is now so constrained that its normal functioning cannot be guaranteed. NHS providers and commissioners ended 2015-16 with a deficit of [pounds sterling]1.85 billion--the largest aggregate deficit in NHS history. The scale of the deficit signifies a system buckling under the strain of huge financial and operational pressures. The principal cause of the deficit is that funding has not kept pace with the increasing demand for services. (5) The predicted [pounds sterling]22 million budget shortfall in England by 2020 is too big to be corrected by increased productivity, new ways of working, pay restraint and reductions in expenditure on medication. The government's expectation that squeezing the budget will stimulate higher productivity and creativity in work organisation is not shared by most of those running or working in the NHS.
This is not to say that change is impossible, and some will indeed occur. Nevertheless it seems clear that the government's financial targets will not be reached. Failure to meet targets is more likely to increase the bullying that is so widespread in the NHS (see below) than to...
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