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The future of the NHS


The future of the NHS is looming as a critical election issue in 2015. Is the UK’s health system in danger of collapse, as some commentators claim, or is it just media hype?

Like the millions of baby boomers who make up a large proportion of its patient base, the NHS| is turning 66 this year. But there’s little cause for celebration in the world’s largest publicly funded healthcare service.

There are a number of pressures threatening to overwhelm it: an ageing population; significant increases in people with long-term chronic conditions; rising costs; constrained financial resources; and greater public expectations.

Current forecasts estimate that by 2021 the NHS will need to generate £30 billion of ‘efficiency savings’ to enable it to cope with cost pressures.

So, how can the NHS meet this challenge? According to Professor Gwyn Bevan|, a policy analyst from LSE’s Department of Management|, resource constraints coupled with the controversial reforms introduced by the Coalition Government in 2010 to extend competition within the English NHS, threaten the quality of the health service.

“The big idea is that the NHS shifts from being an integrated monopoly insurer and provider of healthcare into just an insurer. This partial privatisation of England’s National Health Service is creating massive challenges, Professor Bevan argues.

“The NHS in Scotland offers a better model as the government there has abandoned competition to enable integration between primary and secondary care.”

Under the English reforms, small organisations known as Clinical Commissioning Groups| - made up of doctors, nurses and other professionals - have been established to buy healthcare services for their local communities from competing providers from the NHS and private sector.

“Contracting for a health service to receive the best value for your population is a formidably complicated thing to do,” he says.

“The Clinical Commissioning Groups lack the resources, scale and expertise to do the job well,” he adds.

“Controlling quality is very problematic because the need to include the numerous private sector providers means that there are vast numbers of providers to inspect and regulate."

Professor Bevan says the Coalition Government broke an election promise to “stop the top-down reorganisation of the NHS that had got in the way of patient care”. 

The changes, described by the former chief executive of the NHS, Sir David Nicholson as “so big you could probably see them from space”, have created an unwieldy set of disparate organisations, he says.

 “The future of the healthcare sector is going to be a huge issue in the 2015 general election. For political parties seeking election, two of the most salient public services are schools and hospitals. The public has to make up its mind which party is best able to deliver good services.”

On a global scale, he says the NHS fulfils two of three core objectives that all health services aspire to: cost control and equity of access. It falls down on the third measure – quality.

“That’s the issue we have to address and it gets more and more difficult in a period of financial constraint. The combined pressures of austerity and the problems of managing competition could result in serious failures in the NHS.”

Curtailing services such as gastric banding, breast enlargement and tattoo removals are not the answer to alleviating these pressures, he argues.

“In the overall scheme of things, the cost of these services is really small beer. The pressures that the NHS faces come from a combination of an ageing population and developments in technology in its broadest sense.

“Ageing of the population in itself doesn’t do much to increase the demands on healthcare; what really causes the problem is the fact we can now do far more for an ageing population, which is driving the demand for additional services.”

Likewise, he dismisses calls to charge EU and foreign patients and any shift away from the free medical services currently provided by the NHS.

“There’s been an ongoing debate about user charges in healthcare but it’s a complex area.

“The idea that by charging for health services you will make people more responsible about their health and value the NHS more is counterproductive. For that to happen it would have to be a significant charge, which hits the most vulnerable in our society, where sickness is greatest.

“The other argument about user charges as a means of raising money for the NHS is redundant. We already have a very fair and effective system called taxation,” he says.

Professor Bevan co-authored two reports earlier this year on the performance of the NHS. They can be found on his website|.

Additional notes

Gwyn Bevan is Professor of Policy Analysis in the Department of Management at LSE. His current research includes analysing government health and education policies. He has been working on healthcare issues for more than 30 years and was a Director of the Commission for Health Improvement, which regulated quality of health care in England and Wales.

Posted 20 August 2014