Reforming the NHS: untried remedies for misdiagnosed problems?

Text of full paper submitted to NHS White Paper Consultation 11th October 2010
Authors: Professor Margaret Whitehead*, Dr Barbara Hanratty and Professor Jennie Popay
Department of Health Inequalities and Social Determinants of Health, University of Liverpool, Liverpool L69
3GB (M.Whitehead and B.Hanratty)
Division of Health Research, Lancaster University, Lancaster (J.Popay)
*Contact: mmw@liverpool.ac.uk
Introduction
On 12 July the UK‟s new Coalition Government issued a White Paper, instigating the biggest changes of the
NHS in England since its establishment in 1948.1 This comes after 3 decades of almost continuous reform of
the NHS (see Panel 1), which have caused widespread re-structuring fatigue. Both the Conservative and
Liberal Democrat election manifestos appeared to recognise this by promising to defend the NHS from further
reorganisations.2
Why, therefore, is the UK Government breaking its manifesto pledges and bringing in massive reforms just
weeks after the election and without the consultation and scrutiny such proposals demand? What is so
broken about the NHS that it requires such drastic medicine?
The aim of this paper is to raise some of the questions that need to be asked of the White Paper proposals
from a health systems and equity perspective. First, we consider the reforms on their own terms, asking:
what are the perceived problems with the NHS that necessitates urgent and profound action? What is the
rationale behind the proposed solutions and will they have the intended effect? Second, we ask what the
likely impact of the proposed remedies will be on the fundamental equity objectives of the NHS. (see Panel
2).3 As a separate public health White Paper will be issued in the Autumn the specific proposals for public
health are not touched upon here.
The White Paper identifies at least five apparent problems with the NHS to justify the radical reforms
proposed. All require careful scrutiny to distinguish rhetoric from reality and to appraise equity impact.
1. “Excessive bureaucracy and top-down control”?
One of the main reasons given for the urgency of reform is that the NHS cannot afford unnecessary
management and administrative costs at a time of widespread public sector cuts, when the NHS budget
should be focused on frontline services for patients. The proposed solution is to “radically de-layer and
simplify the number of NHS bodies” (p.5) and cut management costs by 45% of the next four years (p.5).
This will entail abolishing the 151 PCTs and replacing them with an estimated 300-
500 consortia of GP practices which will be allocated the bulk of the NHS commissioning budget of £80 billion
to commission services for their registered patients. In addition, the 10 Strategic Health Authorities which
oversee the PCTs will be abolished, but their function in regulating primary care commissioning will be
replaced by a new central NHS Commissioning Board with regional offices.
Far from “de-layering”, this is effectively the replacement of two old layers by two new ones. Each GP
Consortium will require expert commissioning support to replace that currently provided by PCTs. This
support could come from re-deployed PCT staff, or be bought in from commercial companies . The proposals
are therefore unlikely to reduce management costs, indeed they may increase as they have in the past.4,5 A
crucial difference, however, is that whilst the NHS budget will still pay, the staff may not be employed by the
NHS , and therefore not be included in the assessment of management costs.
Additionally, the cost of implementing the re-organisation itself, not least in redundancy, re-deployment and
early retirement, has been estimated as between £2 billion and £3 billion,6 over a period when the NHS will
be required to make £20 billion of efficiency savings.
Equity impact
The switch to commissioning through GP Consortia will undermine one of the fundamental mechanisms by
which the NHS strives to ensure good geographic access to a full range of services wherever people live.
Currently PCTs have responsibility for all their resident populations within defined geographic areas, not just
the patients registered with specific health services. This allows for long-term needs assessment, planning
and commissioning of services to match those needs, as well as accountability of public employees for the
use of the resources allocated for that population, measured against outcomes that are also population-
based. The proposals in the White Paper abandon the population-based principle for the first time in the
NHS‟s history. With GP Consortia, the basis of commissioning is for registered patients only, within
amorphous, ill-defined Consortia boundaries. The ability to assess needs of people living in an area and plan
for the proper geographic distribution of services for communities and local populations will be lost.
The incentive to cream-skim (invite the practices with the most profitable/easier to serve catchment areas to
be members and avoid the practices serving difficult/unprofitable catchment areas) will be greater with the
introduction of commercial commissioning support organisations seeking to make a profit. The White Paper
makes it clear that the Government intends to develop the market in these services, so this eventuality is a
real possibility. The proposal is a recipe for a breakdown in equity of geographic access. In the rush to cut
what are perceived as „unnecessary management‟ posts, essential public health input into needs
assessment and commissioning will be lost.
2. “Relatively poor health outcomes compared to other developed countries”?
The White Paper argues that the failure of the NHS in England is reflected in “relatively poor health outcomes
compared to other developed countries” including poorer survival rates from heart disease and cancer and
that the service has “much further to go in managing care more effectively” (p.8). However, this charge is not
well supported by evidence, even that cited in the White Paper.
One of the best known reviews of health system performance is conducted annually by the Commonwealth
Fund. The Fund‟s most recent report compares six countries (England, the Netherlands, Germany, Australia,
New Zealand, the USA and Canada). The NHS was ranked in the top two for eight of the eleven measures of
quality, access, efficiency and equity of care.7 It was rated particularly well for chronic disease management,
where the UK outperformed the other countries on six of the ten indicators. National population level data also
support the more positive interpretation of NHS performance suggested by the Commonwealth Fund survey.
Premature mortality from cancer has fallen, year on year since 1995-97.8 Standardised mortality rates from
acute myocardial infarction halved between 1997 and 2006 and in hospital case-fatality following stroke is
reported by the OECD to be comparatively low, at 6%.8,9
The use of survival data to compare the performance of health systems, assumes that data from different
countries are collected in a similar manner and are of comparable quality. This is rarely the case.11 The
figures from 1995-1999 did show that survival rates for some cancers were lower in the UK than in other
European countries, though wide variation in population coverage of cancer registries, and the absence of
information on stage at diagnosis or relevant socio-demographic factors affect the interpretation of these
findings. Whatever the limitations of the comparative data, the NHS has acknowledged that cancer survival
should be improved, and initiatives have already been introduced within an overall strategy (The Cancer
Plan)12 to address inequalities, such as in speed of access, staffing and monitoring.
Equity impact
The NHS should strive for continuous improvement in health outcomes that can be influenced by health care,
but the strategy for improvement needs to be based on sound understanding of the causes of the poor health
outcomes in question and how they can be influenced. Over the past decade, for example, serious concerns
have been raised about poorer survival from some cancers in more disadvantaged areas.13 The causes
include wider social determinants beyond the health sector, but also factors that the NHS should be able to
do something about –such as late presentation with symptoms and delays in diagnosis. Initiatives have been
started to try to address such causes, which is the direction in which strategies should be developed further.
The White Paper, however, proposes a different approach: the development and use of financial incentives
and penalties linked to health outcomes. Incentive schemes of this nature can increase
inequalities in health if providers focus their efforts on healthier, more affluent populations for whom improved
outcomes would be easier to achieve. The White Paper‟s proposals to shift from population to registered
patient commissioning, coupled with opening up of provision to „any willing provider‟ increase the possibilities
for this sort of inequitable selection of patients to take place.
The proposals represent a huge, untried experiment in the use of financial incentives for quality and
outcomes in a universal system such as the NHS. They follow a much more limited scheme in general
practice, the Quality and Outcome Framework (QOF), introduced as part of the 2003 GP contract. This had
the aims of increasing income of GPs, improving overall quality of care for chronic disease and reducing
variation in care between practitioners. Most of the incentivised activities were concerned with clinical
activities, rather than improved outcomes for patients, which would take much longer to materialise. Panel 3
summarises the results of an equity assessment of impacts of QOF that revealed both positive and negative
impacts on inequalities in quality of care, but also the difficulty of attributing impacts to the financial
incentives.14 The QOF initiative also revealed the need for extensive monitoring and continual adjustment of
these schemes to control the way the incentive operates in practice.
3. Disempowered health professionals?
The White Paper identifies too much regulation and “political micromanagement” (p.4), coupled with too little
competition throughout the system as problems that are stifling innovation and quality improvement. The
proposed remedy is to de-regulate and put control at arm‟s length from politicians. The mechanisms for
liberating health professionals include “freeing” GPs from PCT control by putting them in charge of the bulk of
the NHS commissioning budget, giving Foundation Trust status to all NHS hospitals, “liberating” NHS staff to
create “employee-led social enterprises” in which the staff would part-own the service they work for, and
opening up provision of services to “any willing provider” to inject a higher degree of competition into the
system.
But will all this liberate health professionals in the way that the White Paper rhetoric implies? Any idea that
GPs in Consortia will have any more freedom than they did under PCTs to prescribe and to refer patients as
they wish, without taking account of effectiveness or costs of their decisions is misguided. The Consortia will
still have to balance the books and stick to NICE guidelines on which services can be commissioned and
drugs prescribed. There is no indication that top-down control of GP Consortia by the NHS Commissioning
Board will be any lighter – arguably it should be heavier.
Making all NHS providers free-standing Foundation Trusts means that Government responsibility for them will
be withdrawn. Staff will be removed from NHS national terms and conditions and ultimately may also lose the
coverage of the NHS pension scheme. One potential effect, which would be of benefit to politicians rather
than to staff, is the removal of NHS Foundation Trusts from the public sector balance sheet – so it looks as
though public spending has been reduced. The effect of opening up provision to “any willing provider” is a
further decisive step towards privatisation of NHS provision.
Equity impact
Aggressive enforcing of a free market by the competition regulator, Monitor, coupled with the transformation
of all NHS Trust into autonomous financial organisations, will lead to fragmented services, with an uneven
geographic spread and disruption to patient pathways. GP commissioners under intense pressure to contain
spending, will not be able to favour a local NHS community or hospital trust. Commercial companies will be
vying to undercut local NHS providers, by cherry picking the most profitable aspect of the service or even
offering a loss-leader. The matching of services to population need will be lost and the disruption to local
hospitals could be terminal, with the Government under no obligation to save a hospital that gets into financial
difficulties (p.46), even if that means that a local community loses its only viable service. Allowing a pleurality
of private providers to compete for NHS business is likely to exacerbate the inverse care law, as the best
opportunities for profit are to be found amongst more affluent, healthier groups and areas of the country. The
transfer of NHS assets to “social enterprises” – owned not by all citizens as currently, but by current NHS
employees - raises further questions of staff vested interest and indeed conflict of interest, in a system that
is supposed to be national and for everyone, based on an ethos of public service, not personal gain.
4. Too little responsiveness and choice for patients?
A fourth major problem identified in the White Paper is that the “NHS scores relatively poorly on being
responsive to the patients it serves” (p.8). This conclusion could be challenged. Responsiveness has been
an on-going concern within the NHS since the early 1990s when waiting times became a focus of public
debate. Since then there has been a succession of initiatives, including responsiveness targets, with some
success. Available data suggest that access to NHS care has improved substantially since 1997.15 Waiting
times for admission to hospital, outpatient and cancer care are shorter in most specialties,8,15 and 87% of
people report being able to see a GP within two days of requesting an appointment. Responsiveness should
also encompass other aspects of health care: being treated with dignity, appropriate and sensitive
communication from professionals, the quality of facilities.16 Surveys have reported uniformly positive patient
ratings of care, but no improvement has been seen over recent years.15 The White Paper now promotes
increasing choice as a means of enhancing NHS responsiveness. This is an extension of the choice agenda
introduced by the previous government, and the potential challenges that will face GPs who are
simultaneously commissioning care, working within the NICE framework and balancing fiscal responsibilities,
will be no less daunting.
Equity impact
Prompt access to secondary care services is one way in which the NHS has become more equitable in recent
years. The proposed removal of the „two week wait‟ for people suspected of having a cancer diagnosis, and
other waiting list targets will inevitably result in longer delays. This will have the
greatest effect on people who are unable to afford a queue-jumping referral. It may also result in wider
geographical variation in waiting times, if some providers are more successful in attracting patients than
others.
The proposals on Choice are not a panacea for tackling inequalities in the NHS. The factors that influence a
patient‟s ability to exercise choice - health beliefs, knowledge, self efficacy and material resources - all vary
with socioeconomic status. Price, convenience and previous experience will affect an individual‟s ability to
make use of choice,17 all of which point towards most benefit for younger, better educated, more affluent
patients. Supporting real choice amongst poorer patients would need help with the costs of accessing care,
including transport, time off work, and caring responsibilities. Whether „choice‟ can be extended to such an
extent, or if it is desired by patients, is in doubt. In a survey by the Kings Fund, the majority of respondents
(69%) continued to choose their local provider of care,18 even when choice was available, which raises
questions over the extent to which choice will improve patients‟ experiences. In addition, only a small
proportion of NHS spend is elective care, and the overriding requirement when a patient requires non-elective
and emergency care is for good quality services available locally and promptly at the time they need them,
not the choice of some distant provider.

5. “Nothing about me without me”: disempowered patients and public

One problem the White Paper correctly identifies is that the service has failed to make significant progress in
empowering individual patients or meaningfully engaging with patients and the public at a collective level. But
the solutions proposed are unlikely to help the NHS achieve these most elusive of equity principles.

Many proposals in the White Paper have already been tried with limited success. The promised “information
revolution”, for example, is a necessary but not sufficient condition for equitable empowerment.17 This will
require more sophisticated and potentially expensive support to help patient make effective use of
information.19,20 Similarly, a multitude of policy initiatives have failed to deliver the transformation of care
through shared decision making proposed in the White Paper.21

Effective individual patient empowerment requires effective collective empowerment of patient groups and the
public – you can‟t have one without the other.21 To strengthen this collective voice the White Paper proposes
a new consumer champion, HealthWatch England (located in the national regulatory body the Care Quality
Commission). HealthWatch would work through Local Involvement Networks established in 2007 and as yet
having relatively little influence on NHS decision making. The National Commissioning Board will have
responsibility for promoting patient and carer involvement and GP commissioning consortia will have a duty to
engage with patients and the public. But many of the pre-requisites for effective empowerment revealed by
the experience of the previous regulator, the
Healthcare Commission,22 could be undermined by the White Paper proposals. The proposed increase in the
diversity of health care providers and employers, for example, will make it more difficult to develop a shared
understanding and knowledge base about empowerment amongst health care staff, whilst the abolition of a
national framework for training and severe financial constraints will impact negatively on resources for
empowerment.

Most importantly, research has repeatedly shown that health professionals resist the transfer of power to
patients and the public. Primary care-led commissioning organisations, in particular, have a poor record of
engaging patients and the public in a meaningful way.5,23 By increasing the power of health care professionals
as commissioners and providers, the White Paper proposals may therefore make the achievement of patient
and public empowerment more difficult.

Conclusions
These represent major reforms to the NHS, not just adjustments or extensions of existing practices, as they
have been portrayed in some media briefings. None of the stated reasons for the reforms provides a
justification for rushing into them without going through the normal Green Paper consultation phase and when
there is no democratic mandate for this level of upheaval to the NHS. The NHS is not broken and does not
need fixing to such an extent that the scale of these reforms implies
With even this brief examination, it is clear that these reforms will fail to meet their own stated objectives.
Even more importantly, the proposed reforms risk adverse side effects to the fundamental equity and
efficiency objectives of the NHS and the sustainability of the organisation. Rather than liberating the NHS,
these White Paper proposals look more like an exercise in liberating the NHS £100 billion budget to
commercial enterprises.
This situation demands serious scrutiny and analysis, distinguishing rhetoric from reality. The public needs to
be informed about what is happening to their NHS and involved in crucial decisions about it. The coalition
government has a democratic duty to allow this scrutiny and debate to take place now. Otherwise, the result
may be the end of the NHS as a truly national service: “the operation was a success but the patient died”.
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Panel 1: NHS reorganisations/reforms 1974-2010

1974 Establishment of Regional Health Authorities and Area Health Authorities

1982 Abolition of Area Health Authorities and restructuring 192 District Health Authorities

1984 General Managers appointed throughout the NHS

1986 NHS Management Board established

1989 NHS Management Board reorganised into NHS Policy Board and the NHS Management Executive

1990 New GP Contract

1991 Establishment of 57 NHS Trusts (eventually 270 over next 5 years); Reconfiguration of District Health
Authorities as Health Authorities; GP fund- holding – 309 practices

1996 Community fund-holding; Reorganisation of Regional Health Authorities from 14 to 8 regions

1998 Abolition of GP fund-holding

2000 Abolition of the NHS Executive;

2001 Regional Directorates of Health and Social Care set up(4) ; 303 PCTS set up

2002 Abolition of NHS Regional Offices; Reorganisation of Health Authorities, from 96 to 28 Strategic Health
Authorities in England

2003 Regional Directorates of Health and Social Care abolished

2006 SHAs reduced from 28 to 9;; PCTs reduced from 303 to 152

2010 NHS White Paper “Equity and Excellence: Liberating the NHS
Panel 2: Principles and values of equity in the NHS

 Universal entitlement – a service for the entire population with no means testing or eligibility tests

 Shared financing of the system, according to means – achieved through funding the system from general
taxation

 Free at the point of use – so that money does not stand in the way of obtaining care when sick

 Comprehensive in range of services – covering preventive, treatment and rehabilitation services, mental as
well as physical health, chronic as well as acute care

 Comprehensive in geographic coverage – residents in all parts of the country should have access to
effective health services, through planning for geographically defined populations and communities

 Selection on the basis of need, not ability to pay or other social influence

 The same high standard of care and consideration for everyone without discrimination

 Encouragement of an non-exploitative ethos - including minimising incentives for making profits from
patients

Source: Adapted from Whitehead, 1994.3

Panel 3: Impacts of financial incentives in primary care (QOF) on health inequalities, 2004-2008
Potentially positive impacts on health inequalities
 For incentivised activities, the worst performing practices – concentrated in the most deprived areas –
improved at the fasted rate.

 Gaps in the quality of primary care for conditions including coronary heart disease, asthma and diabetes
quickly narrowed under the QOF scheme.

 The provision to „exception report‟ is an important component of the scheme because it preserves the
clinical autonomy of practitioners, safeguards against inappropriate treatment of patients and ameliorates
perverse incentives to deny care to „difficult‟ patients.

Potentially negative impacts on health inequalities

 Prevalence of the QOF conditions recorded by practices is lower than prevalence estimates provided by
national surveys – this gap may be greater in more deprived areas. Quality of care for „missed‟ patients is not
known. Some practices also appear to have removed patients who are unlikely to meet a QOF target from the
relevant disease registers.
 Improvements in quality of care have not been as rapid for some ethnic minority groups.
 Quality of care was already improving prior to the introduction of the QOF, and for many QOF activities
there was only marginal and short-term improvement in quality above the underlying trend. Evidence on
whether improvements in QOF scores are associated with improved outcomes for patients is equivocal.
 Quality of care for some non-incentivised activities was improving prior to 2004, but does not appear to
have done so after the introduction of the QOF. There is also less training, education and use of guidelines
for non-QOF conditions. Gaps in quality care may therefore be developing between patients with QOF
conditions and those with non-QOF conditions, particularly in practices which had low baseline achievement
for QOF-incentivised activities.
 Primary preventive activities may have been neglected to some extent in favour of the secondary
preventive activities prioritised in the QOF.
 Practice staff behaviour and the nature of the relationship between health professional and patient has
changed under the QOF, and gathering data for quality targets has become a priority in consultations. The
nature of the QOF scheme, and the proportion of practice income that is tied to performance on the QOF
indicators, creates a risk that care will become more fragmented, efficiency will be prioritised over genuine
quality, and professionalism will be eroded.

Source: Adapted from Doran 2009, pp24-25.14