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Health policy review

Summer 2006

Issue 2: Different approaches to reforming health services

This journal is produced by the health policy and economic research unit and is designed to stimulate debate. The views expressed do not necessarily represent BMA policy.

Editorial - Tom Smith
At first glance the contents of this issue may seem totally disconnected. There are papers on the extent of divergence within UK health policy following devolution, the management of long-term conditions in England, the economics of health service productivity, and the role of patient voice in the English reform programme. The common thread is that the UK nations are each seeking to redesign health services, but approaching this aim in quite distinct ways.

Scholars of devolution now see four health systems in the UK. Scott Greer, an expert on devolution and health based at University College London, says that fundamentally differing philosophies have driven ‘different bets’ on the best way to redesign health services. The reasons for these different philosophies are expanded upon in a paper charting divergence since devolution and its implications for professionals.

In England, the provider-purchaser split, first introduced in the early 1990s, has been reinforced and accentuated with the aim of consolidating acute care and developing more community based services. In Scotland, the purchaser-provider split has been reversed and single-system working has been introduced. While market forces apply in England, regional planning and collaboration are emphasised in Scotland.

Drawing on terms used in Professor Julian Le Grand’s recent book on motivation in public services, professionals in England are increasingly seen as ‘knaves’, with incentives accordingly aligned, while in Scotland professionals are seen more as ‘knights’ and afforded a key role in the strengthening of clinical networks and development of clinical pathways.

Already critics of the market-orientated approach in England are pointing north of the border where ambitions to improve selfmanagement and the management of long-term conditions seem more intune with the rest of the reform agenda.

A paper looking at ambitions to improve the management of longterm conditions notes its centrality to both English and Scottish policy. Differing philosophies, however, result in significantly divergent paths to achieving it. Since 1998 and the UK-wide purchaser-provider split, England is seeking to further exploit its tensions by strengthening incentives to consolidate acute care and develop community-based facilities, which may be provided by the independent sector. By contrast, Scotland has spent many years untangling the purchaserprovider split in order to establish a ‘single system’ way of working which is seen as affording the clinical collaboration seen as integral to the development of more integrated care.

Part of the aim of concentrating on long-term conditions is to increase productivity within the system. A paper explores the economics behind this increasingly debated concept. Across the UK, money for health services comes from the same pot, which has significantly expanded in recent years but stops in 2008. At that point, when funding is at the EU average, it will be difficult to argue for further increases. Instead, attention is shifting to how money is spent and achieving improved value-for-money.

In contrast to England and Scotland, Wales has chosen to focus on health more than health services and on the reduction of health inequalities. Local authorities and health authority boundaries have been aligned, free breakfasts provided for schoolchildren, and the Assembly has voted to abolish prescription charges. However, health services design is moving to the top of the policy agenda. Last year’s policy document, Designed for Life, suggests service reconfiguration is a key priority. In Northern Ireland, following a long period of relative inactivity, over the last year there has been a flurry of activity and plans set in motion to completely change the management of the health system, reducing the number of hospital trusts and strengthening commissioning. As elsewhere, policy suggests that major reconfiguration is on the cards.

The phrases ‘service reconfiguration’ and ‘redesign’ are easier to say than ‘service closures’ or ‘downgrades’ and it is not clear that the public, in England at least, fully understands the implications of phrases now regularly used by political leaders.

A paper notes that ‘patient voice’ in the English NHS is less developed than at any other time in this government’s term of office. It outlines some challenges to overcome if ‘voice’ is to become an integral part of the reform programme. It is argued that the lack of space to meaningfully discuss service changes may come to derail English health reform. Without any such forum or an engaging process, consultation on service redesign could be banner-based and politically tense.

It is worth noting that voters in Scotland, England and Northern Ireland have each elected representatives who pledged to defend a local service. It is likely that doctors across the UK will be drawn into a debate about the design of local services and there may be lessons to share across the UK on ways to achieve meaningful local debates about the future of health services.


Contributors
Eleanor Babbington, Research Analyst, Health Policy and Economic Research Unit
Tania Fisher, Research Analyst, Health Policy and Economic Research Unit
Jon Ford, Head, Health Policy and Economic Research Unit
Helena McKeown, Chairman of the Committee on Community Care and General Practitioner
Helen Smith, Research Analyst, Health Policy and Economic Research Unit
Tom Smith, Senior Policy Analyst, Health Policy and Economic Research Unit
Barbara Wood, Chair, BMA Patient Liaison group