Sir Alan Langlands
Principal and Vice-Chancellor of Dundee Univeristy
SMJ 2006 51(1): 13-16
A new dawn
As 2006 dawns, the Scottish Medical Journal celebrates its 50th anniversary and a new era of collaboration with the Royal College of Physicians and Surgeons of Glasgow, the NHS moves inexorably towards its 60th birthday in 2008 and the world continues to live with the risks of war, nuclear brinkmanship, climate change, bird 'flu and a slowing global economy. Health care is a key issue in every country, with the developed world focused on cost control as the poorer countries strive with minimal resources to reduce child mortality, improve maternal health and combat HIV/AIDS, malaria and other infectious diseases. I always find that it pays to keep the problems of the NHS in perspective.
In Scotland, 2006
heralds the implementation of legislation to secure smoke-free, enclosed public
spaces from 26 March and other initiatives on smoking cessation, healthier
eating in schools and alcohol abuse. These policies systematically carried
through in partnership with the Scottish people, are more likely to improve
health than decades of experimentation with structures, processes, targets and
incentives. The Scottish Parliament's stance on smoking is without doubt the
single most important achievement of devolution. And the policy fudge at
Westminster simply strengthens this claim. There is some evidence that the NHS
in England is outperforming Scotland in terms of growth in investment and
improvement in waiting times but Scotland's resolve on health improvement and
its willingness to play a long game in tackling deep seated health problems
seems stronger.
Politics, policies and performance
The Labour Party swept to power in 1997 on a manifesto pledge to 'save the NHS' which translated into a series of policy interventions, structural changes and higher levels of investment on both sides of the border. 'Investment for reform' was the mantra and the Blair government delivered real terms growth of 4.8% p.a. in its first term and 7.4% p.a. in its second, compared to 2.6% p.a. in the Major government which covered the period 1992 - 1997. These historic levels of growth will be sustained until 2007/8 by which time the Prime Minister's commitment, made in January 2000, to match European levels of spending on health will have been exceeded and the patience of HM Treasury will be wearing thin.
Insiders know that much of the growth money in the NHS has been swallowed up by changes to staff contracts and pay increases, clinical negligence claims and reducing junior doctors' hours in line with the European Working Time Directive. But the Treasury hawks who finally conceded the need for investment following the Wanless review of NHS spending will note that productivity has been falling and that only a small proportion of NHS growth translates into new patient services. The Wanless Report also called for faster development of information and communications technology in support of patient care, progress on workforce development and skill mix and action to streamline NHS management and these issues will have to be included in the health departments' report cards to the Treasury in the next spending review. We are probably living through the tail end of the good times - the NHS should be bracing itself for growth closer to the historic averages of about 3% p.a.
I find it impossible to disentangle the financial fortunes of the NHS north and south of the border - they essentially operate within the same parameters - but the different approaches to the organisation and management of the NHS have become very pronounced since devolution.
Partnership for Care: Scotland's Health White Paper focused on promoting health and set out ways in which "the redesign, integration and quality of services can be systematically progressed". As the title suggests it laid strong emphasis on partnership working including a central role for primary care teams in new Community Health Partnerships and a determined effort to build stronger bridges at community level between the NHS and local authorities. Whilst the emphasis on redesign and the greater involvement of professional staff and patients in shaping change follows the approach being adopted in England, the quasi-market model was firmly rejected in favour of a planned approach to managed clinical networks and shifts in the balance of care. The objectives of reducing health inequalities and tackling "lifestyles and circumstances which damage health" were centre stage.
These themes were echoed in David Kerr's report Building a health service fit for the future: a national framework for service change in the NHS in Scotland which promotes a decisive shift in the balance of care within the NHS with a strong emphasis on supporting the growing number of older people who live with long term conditions and the need to balance investment in local diagnostic and treatment services with the ongoing requirement for prompt access to specialised services. The Scottish Executive's response to the Kerr Report - Delivering for Health - sets out a detailed implementation plan which is both comprehensive and aspirational. With more than 100 complex actions to be taken over the next couple of years in pursuit of more than 50 very specific outcomes it will also be difficult to deliver, especially if the high level of real terms growth experienced in recent years was suddenly to drop to 3% or less. The hard choices implicit in shifting the balance of care would become even harder.
The last vestiges of the Conservative Government's internal market have been swept away in Scotland but the position is very different in England. GP fundholders became Primary Care Groups and then Primary Care Trusts and NHS Trusts remained with some becoming Foundation Trusts under the auspices of an independent regulator. The basic purchaser-provider split has been maintained and by introducing 'payment by results' and new rights for patients to choose where they are treated, the government is relying on a cocktail of market style incentives and centrally determined targets, price tariffs and regulation to drive change and improvement. The commissioning of public services from a wider base of suppliers in the private sector simply adds to the complexity.
In its Independent Audit of the NHS under Labour (1997-2005) the King's Fund refers to the NHS Plan as the "apotheosis" of central planning. From these centralist beginnings, it will be interesting to see if the UK government keeps its nerve as the consequences (intended and otherwise) of devolving responsibility to foundation trusts and other quasi-market reforms begin to surface. Many of the successes of the past few years have been the result of top down intervention during a period of high spending and even then 25% of NHS trusts in England are reporting significant financial deficits. Market style reforms and a return to average or low growth is a volatile mix.
Nicholas Timmins' biography of the welfare state is a tour de force. Timmins follows Beveridge's crusade to slay the five giants of want, ignorance, disease, squalor and idleness and traces the ups and downs of British welfare policy - including NHS policy - from the 1940s. He methodically works through the expansion of the 1950s and 1960s, the doubts of the 1970s, the rhetorical, financial and organisational assaults of the 1980s and the mid-life crisis of the 1990s. He stops short of a descriptor for the first decade of the new millennium but words like frenetic, diverse and complex spring to mind.
Making sense of all this change and complexity is one of the key issues facing the people who work in the NHS and the people who use the NHS. Reaching a balanced judgement about the progress of the NHS across the UK and in a devolved Scotland is not easy. Inputs - money, staffing levels, buildings and equipment - have all improved in the past eight years and the numbers of people waiting for treatment and the time they wait have reduced. Some progress has also been made in the priority areas of cancer, heart disease and mental health although mortality in these areas has been falling for some time and it remains difficult to measure the effects of wider social and economic influences on population health. Comparative studies between Scotland and key regions in England will be of interest in the future but it will also be important to benchmark progress against other countries which we still lag behind in terms of key health measures, access to diagnostic services, provision of critical care beds and the incidence of hospital acquired infections.
Constancy of purpose
Faced with unrelenting change and a plethora of policy announcements, action plans and targets, I find that it helps to reflect on the purpose of the NHS, the enduring challenges facing the service and the key results that the service is trying to achieve. One purpose, six enduring challenges and three key results is a reasonable set of issues for most of us to deal with.
For nearly sixty
years, the real strength of the NHS has been clarity and constancy of purpose.
The fundamental purpose has wide public acceptance and has been restated in
legislation by successive governments. In essence it is to secure through the
resources available the greatest possible improvement in the physical and mental
health of people by:
· promoting health
· preventing ill health
· diagnosing and treating injury and disease, and
· caring for those with long term illness and disability who need the services
of the NHS.
The aim is still to provide services on the basis of equal access for equal need, not the ability to pay and there is political consensus on this principle north and south of the border.
Enduring challenges
Despite this consensus the NHS, like every other health system in the world is under pressure. Change is endemic and six key challenges remain:
(1) The swing
from the collective to the individual
Some analysts such as Uwe Reinhardt believe that the erosion of collective
values in society will occur to such a degree that all health systems might
eventually have the same three-tier structure: a top tier of fee-for-service
medicine for the very rich; a middle tier of insurance-based managed care
covering the middle classes; and a third tier of publicly funded 'rough and
ready' care for the poor. UK government policy is to avoid this route and
Scotland's collectivist credentials remain intact but the challenge of
sustaining the best of the NHS model should not be underestimated. As some
people become wealthier and want faster one-to-one attention and government
spending is constrained, strange things might happen. The changes in long term
care for the elderly and NHS dentistry over the past 10-15 years may provide
early warning of change which will affect other NHS services in time.
(2) Harnessing
innovation in science and technology
The NHS provides a unique test bed for biomedical research which is
resulting in new forms of diagnosis and treatment. Research funders are
committed to promoting basic science, translational research and large scale
population studies. The science base in Scotland is particularly strong and
current attempts to develop the clinical research capacity in Scotland through
the provision of new facilities and incentives for the recruitment and retention
of clinical scientists should be strongly supported. To maintain our
competitiveness in this area, securing both economic and patient care benefits,
the Scottish Executive needs to follow the example set in England in response to
the Walport Report by financing career pathways for students and junior doctors
who wish to work in clinical academic medicine. Innovation in information
technology and communications also has the potential to revolutionalise patient
care and work on electronic patient records and improving the efficiency of
clinical trials should continue apace.
(3) Changes in
the media and increasing political involvement
Changes in the media mean that the public are seeking out and becoming more
familiar with research based information - sometimes in a controlled manner
(like NHS direct and NHS 24) - sometimes not. One recent paper from the US
estimated that more than 70,000 websites disseminate health information and more
than 50 million people seek health information online. We are only beginning to
understand the long term consequences of this for health systems.
Political interest in the NHS is more intense than ever and as media scrutiny increases, the public are increasingly making the link between the performance of domestic public services and the competence of government. The temptation for politicians to get involved in the detail of health care is irresistible and it remains to be seen whether more recent talk of standing back will be followed through. A range of public services, including higher education, housing and the BBC are funded, delivered and regulated through agencies working at arms length to government and a serious debate about distancing the NHS from direct political control might well be timely. There must be a way of maintaining proper public accountability whilst liberating the system from constant political intervention.
(4) The
imbalance between demand and supply
Regardless of the actual level of supply and demand in the NHS (which cannot
be measured very easily), the perceived difference will grow as expectations
rise. The answer cannot just be more of everything. A 2002 British Medical
Journal article aimed to show in a comparative study of the NHS and Kaiser that,
though the per capita costs of the two systems are broadly the same, there are
significant differences in some aspects of performance including access to
specialists and waiting times. Although some of the data can be questioned, the
article laid out legitimate challenges for the NHS in relation to integration,
cost effective care, choice and the use of information technology. The most
telling finding of all was that the NHS uses three times as many days of
hospital admission per capita as Kaiser. Using increases in the number of acute
beds as a measure of improvement is therefore a misjudgement. As Wanless pointed
out, people, systems and the interrelationship between the two matters just as
much and, of course, the Kerr report signals significant shifts in the balance
of care in Scotland.
There will be a premium on managing these perceptions and, an unstoppable requirement to give people the information they need to make choices about their own treatment and care and to influence the development of the services they are funding. The need to balance, for each individual, the desire to provide care at home or in the community with safe, high quality, cost effective care will continue to be a significant tension.
(5) Changes in
the burden of disease
Attention will continue to focus on the impact of ageing and the continuing
inequalities in health between rich and poor - two of the strongest themes in
the Kerr report. There will also be changes in the nature and prevalence of
diseases like AIDS, tuberculosis, increased resistance to antibiotics and
threats from changes in the physical environment. Global travel is increasing
the risk of transmission of infection and it is not so long ago that the spread
of the severe acute respiratory syndrome (SARS) virus was posing a major public
health challenge to governments around the world. The long awaited 'flu pandemic
may be brewing and the threat of bioterrorism has also cast a shadow. Risky
behaviour particularly amongst the young, may also have profound effects in the
future. Maintaining an effective nationwide 'health intelligence' capacity will
be a key priority.
(6) The new professionalism
Professional careers in the 21st century are tough and challenging. In most professions the essential elements of a recognisable code of ethics, a system of self regulation and a sense of vocation remain but many aspects of professional life are subject to fundamental change.
There is now a much stronger emphasis on professional accountability shaped by third party regulation, market forces and a tough regime of standards, performance monitoring and mandatory continuing professional development. For many there is also a greater dependence on new technologies, changes at the boundaries between different professions requiring new approaches to teamwork and an overriding imperative to take account of changing public attitudes. Bristol, Shipman and Alder Hey knocked the stuffing out of many NHS professionals particularly doctors but public trust and support for the people working in the NHS remains strong and it is time to assimilate the new professionalism and the lessons from these difficulties and to move on in a positive way.
Key results
The NHS and other health professionals across the world face these six challenges now. The ethos, funding and tradition of the NHS means that progress has to be measured in a balanced way against three key results - equity, efficiency and responsiveness - which are defined as follows:
equity - improving the health of the whole population and reducing variations in health status by targeting resources where needs are greatest
efficiency - providing patients with treatment and care that is both
effective and good value for money
responsiveness - meeting the needs and wishes of individual people who
use the NHS.
Achieving progress in each of these areas is a huge challenge in itself, with the health gap between rich and poor in Scotland proving particularly stubborn, but these three results are interlinked - a great deal of NHS decision making from the clinic to the board room is about finding trade-offs and compromises between the three.
Conclusion
The challenges facing the NHS in a devolved Scotland cannot be seen in isolation from other parts of the UK and other parts of the world which are striving to deal with many of the same issues. 2006 is a landmark year in terms of smoking policy and an important time in beginning to implement the changes set out in the Kerr Report and Delivering for Health. This task will require effective leadership, the understanding and support of the Scottish people and the continued commitment of staff in the NHS. It may well be made more difficult by a return to lower levels of real terms growth in the NHS.
Nearly 60 years
on, the ideal of a publicly funded NHS, available to all and free at the point
of delivery lives on with the aim of keeping people healthy and independent. The
responsibility of providing the people of Scotland with high standards of care;
quick, effective and convenient treatment and good information about health and
health services is something to be nurtured, something that deserves every ounce
of professionalism and commitment we can muster.
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