President Obama’s battle to get his healthcare bill through Congress was big news on this side of the Atlantic last year, not least for the way our own National Health Service (NHS) was used as a reference point in the debate. Now though, it is Britain’s (or, to be specific, England’s) turn to be consumed by arguments about healthcare reform, and if you were to listen to some critics, you’d imagine just as much was at stake. The reform in question is the British Government’s Health and Social Care Bill, which is currently the subject of some fairly furious wrangling in the House of Lords. The bill entered committee stage last week after the Government won a key Lords vote, but although it now looks almost certain to become law in some form, there’s still fierce debate about many of the details.
Depending on where you stand, the health bill will either drag Britain’s creaking NHS into the 21st century, or it marks the first stage in the dismantling of a national institution. Actually though, some of this rhetoric is a little overblown. The bill represents a wide-ranging and pretty dramatic package of reforms, but it’s still some way short of an Obama moment. One thing it does not do is challenge the fundamental tenet on which the NHS was founded, which is that everyone in Britain has access to universal healthcare ‘free at the point of use’, funded through taxation. That tenet is rather less perfectly applied than is sometimes admitted – many people do have to pay prescription charges, and NHS coverage of dentistry is pretty patchy – but it’s nevertheless an article of faith for the British public, and no mainstream political party would dare to challenge it (overtly at least).
Still, the bill does make two very substantial changes to the way the NHS is organised across England (although it has been brought by the UK government, it does not apply to Scotland, Wales or Northern Ireland, all of which have devolved powers for their own parts of the NHS). The two key changes are both designed to make the NHS more efficient in the face of Britain’s financial crisis, both could have far-reaching implications and both have been hugely controversial. Firstly, it abolishes a whole tier of NHS management and hands its powers instead to the family doctors at the frontline – the general practitioners, or GPs, as they are known here. Secondly, it loosens the constraints on the NHS’s internal market, providing scope for private companies to compete to run many more NHS services. The two reforms are intended to work together to drive efficiency across the health service, and the efficiencies required are pretty frightening – 4% a year for the next four years.
During the years of Labour government, spending on the NHS rose very substantially – by almost 7% a year in real terms over a decade. That spending did bring some concrete improvements – greatly reduced waiting times for operations and improvements in survival for heart disease and cancer – but it probably didn’t bring enough benefits to justify the cash spent. Certainly, NHS productivity dropped by more than 3% during the Labour years. The current health secretary believes part of the answer to the need for greater efficiency is to align ‘clinical and financial responsibility’ to use the buzz phrase. It is GPs who control the demands placed upon the health service, through the number of (very costly) referrals they make to hospital. It should therefore also be GPs, so the argument goes, who should take responsibility for the costs generated by those demands – by managing the budget of the whole healthcare system. Mr Lansley wants to underline the level of responsibility taken by GPs by linking a proportion of their pay to their ability to control their portion of the budget. He calls it a quality premium, but the phrases used by some GPs to describe it have been rather less polite. For many doctors it is an incentive to act against their clinical instinct by not referring patients to hospital, even when they might benefit from specialist treatment.
But the second part of Mr Lansley’s grand plan is even more contentious. He doesn’t want GPs to be buying in patient care simply from the local NHS hospital… whenever a GP discusses with a patient where they should be treated, he wants them to be shopping around among a range of different providers, public and private. The policy is called Any Qualified Provider, although that name is itself a response to the controversy it has caused – it was once called Any Willing Provider, until someone pointed out to the health secretary that simply being willing to provide a health service wasn’t necessarily enough to assure the public you were qualified to do so. Whatever its name though, the plan was always going to be labelled as a ruse to ‘privatise the NHS’ – as emotive a phrase here as the suggestion of creating ‘socialized medicine’ has been in some quarters in the US. The NHS in fact already has an internal market, and about 5% of primary care for instance is provided by private companies, but opponents of the health bill fear that figure will rise steeply once the new legislation is passed.
Britain’s Government is of course a coalition, between the Conservatives and the Liberal Democrats, and that has made it particularly sensitive to the criticism it has received over the health bill, which has been especially strong from the doctors and nurses working in the NHS. Earlier this year, Prime Minister David Cameron was forced into an intricate dance of apology and supplication over the way the health bill had been handled, which involved ordering a six-week listening exercise and a number of reasonably substantial concessions to critics, such as slowing down the market-led reforms. The PM has played the politics with characteristic dexterity, and it now looks like he will get his bill. Just as with President Obama’s legislation, however, the real question will be whether it can achieve, in rather diluted form, what it was intended to do.
Richard Hoey is editor of Pulse, a weekly magazine for UK primary care professionals and physicians. He writes Pulse’s editorials and muses on general practice in his weekly blog. You can follow him and read other news about the NHS at pulsetoday.co.uk.