Introduction
The publication of The New NHS White Paper in the autumn of 1997 set the framework for the new government’s approach to the NHS in England. This included six key principles for the NHS: to ensure that the NHS remains a genuinely national service and ensure that all people had equal access to high-quality healthcare services; to ensure that the standards set in healthcare are made a priority at the local level; to get the NHS to work in partnership with local authorities; to drive efficiency through a rigorous approach to performance by cutting bureaucracy; to shift focus onto the quality of care so that excellence is guaranteed to all patients and finally to rebuild public confidence in the NHS as a public service accountable to patients and shaped by their views (Watkins et al 2003, p. 6).
This plan by the government of Tony Blair in 1997 radically reformed the health service in England, the NHS, since its establishment in 1948. The plan ensured “improved standards of care, an end to the “postcode lottery” of care, more investment in staff development, increased partnership working between the NHS and social care and a renewed commitment to improving the health of the nation” (Butler 2003, p. 1). These goals were sought to be achieved through an ambitious “modernization” program that would involve recruiting thousands of more medical personnel and investing heavily in building new hospitals, GP surgeries, and medical equipment. Thesis: The current NHS reforms of New Labor though implemented with the best of intentions have met only with partial success and are facing a lot of opposition from many quarters on various issues.
Main Elements of the NHS Reforms
In the new NHS reforms introduced by the New Labor Party, internal competition within the NHS was averted and the focus was on cooperation between the purchasers and providers (QMUL 2009, p. 1). Moreover, it was ensured there would be only one type of purchaser – the primary care groups and trusts. These groups and trusts were led by a team of GPs and community nurses with about 50 GPs for a population of about 100,000 (QMUL 2009, p. 1). All GPs must be members of primary care groups. The groups and trusts managed their own finances and retained profits and when a primary care group was able to manage its own budgets and services, it will be transformed into a trust. The only difference between the primary care groups and trusts was that the former were operated by the government health authorities, the latter were self-governing (QMUL 2009, p. 1). The main advantage of these primary care groups and trusts was that they enabled the central administration to reach all levels of service including GPs. There was the provision in the new reforms for the creation of new institutions – to encourage efficiency such as The National Institute for Clinical Effectiveness (NICE) to review key areas of treatment and make recommendations and The Commission for Health Improvement (CHIMP) to review the plans made by health authorities for optimal distribution of services (Jones 2006, p. 205). As part of these reforms, the NHS direct scheme allowed patients direct telephone access to a nurse. Trusts that met the performance standards set by the NHS were rewarded by being made NHS Beacons.
There were some important benefits from these reforms. By creating a sense of awareness of capital costs, these reforms improved the efficiency of the assets used, and by separating purchasers from providers it allowed health authorities to focus more on the health care needs of the people instead of just maintaining their facilities (Wiley et al. 1995, p. 53).
However, there have been some problems in the implementation of these reforms. As a result of the splitting of all sectors of the health service into purchases and providers, the NHS has been restructured into a business enterprise allowing private health institutions to tender their services competing with NHS provider units. Apart from this, when financial controls are not adequate there is confusion as to what will happen when Trusts fail to generate enough income. It has been pointed out by Wiley et al. (1995, p. 53) that the performance measures suggested by the new NHS reforms need not necessarily reflect the actual volumes of services delivered; they could just be reflecting the changes in the recording of work. Ultimately, health reforms have increased the costs of administration of the NHS.
Government investment in hospitals
Many key recommendations were made by an independent inquiry to the NHS after a scandal rocked the Bristol children’s heart surgery department in July 2001 (Butler 2003, p. 1). The government adopted those recommendations to get patients more involved in treatment decisions and later, the government made plans to include patients at all levels of healthcare (Butler, 2003, p. 1). These government plans included building foundation hospitals and called for a new system of financing hospitals called financial flows. However, there was a lot of opposition to foundation trusts from many important people including former health secretary Frank Dobson, the biggest health union, Unison, and a number of backbench Labour MPs. Their main concern was that trusts will be divisive in nature and would create a two-tier system in the NHS where the rich people get more resources at the expense of failing hospitals and this, they predicted would widen health inequalities. Moreover, they speculated that as foundations hospitals can pay more to their staff, they are likely to “poach” staff from other local hospitals (Butler, 2003, p. 1). The general opinion is that though the foundation status for NHS hospitals did not directly mean privatization, it implied to some extent denationalization. Moreover, it is widely felt that foundation hospitals are likely to be transformed into individual public benefit corporations that are independent and unaccountable.
NHS reforms for Staff
In the context of staff treatment, the NHS reforms of New Labour aimed at providing “improved pay for staff, plus better working conditions that would include changes to working patterns, on-site childcare provision, career development opportunities and zero tolerance on violence against the workforce” (Butler 2003, p. 1). Though the plan was received well initially, very soon, the staff opposed it as they realized that the government wanted radical changes to working practices in return. According to the NHS plan, consultants were offered more money in return for more flexible working patterns and this was rejected by the consultants (Butler 2003, p. 1). GPs were not very happy with the proposed ‘modernization’ of their job. Patrick Butler, in 2003, reported that though the Royal College of Nursing had voted to accept the Agenda for Change reform of NHS national pay structures, the support of Unison, the largest health union was very uncertain. This underlines the difficulties associated with the NHS reforms.
NHS reforms and the patients
The NHS plan of the New Labour Party promised “fast and convenient” care designed around the needs of the patient and accordingly, it promised that waiting times for treatment will be cut, and there would be improvements in three key areas: cancer, heart disease and mental health (Butler, 2003, p. 1). For the patients, the government introduced many significantly innovative measures. About 90 NHS walk-in centers have been set up in England, managed by primary care trusts, offering a wide range of NHS services and equipped to deal with minor illnesses and injuries (NHS 2009, p. 1). These centers provide nurse-led medical services for everyone and do not require patients to make an appointment or register. Most centers are open 365 days a year and are situated in convenient locations that give patients access to services even beyond regular office hours. In the year 2002 – primary care trusts were launched to oversee 29,000 GPs and 21,000 NHS dentists (NHS 2009, p. 1). These primary care trusts are responsible for vaccination administration, control of epidemics and 80 percent of the total NHS budget (NHS 2009, p. 1). They have the powers to deal with the private sector whenever needed. However, from the perspective of the new reforms, they are just local organizations that are best positioned to understand the needs of the community and make sure that the organizations providing health and social care services are working effectively. Ministers have recently stepped up their focus on giving patients more choice and now patients can get treated from any hospital that meets the standards set by the NHS. This has proven to be a great breakthrough in providing the best healthcare for all people. In 2007, a technological breakthrough happened in the NHS with the introduction of a robotic arm leading to groundbreaking heart operations. This technological revolution is being used at St Mary’s Hospital, London, where it is used to treat patients for a fast or irregular heartbeat in a relatively safe manner. These are new measures taken in line with the principles of the New Labour Party and which are very successful from the patient’s point of view.
Service standards
One of the measures introduced as part of the reforms in the NHS by the New Labour included the enforcement of service standards. This created a lot of problems for doctors and managers. Due to targets such as a 4-hour limit on waits in emergency departments, there have been inappropriate admissions, withdrawal of care from serious cases so that the less needy may be attended to within the time limit, and several other negative effects in other services (Davidson 2004, p. 1). The reform to reduce hospital waiting lists has been criticized by Kathleen Jones who says that this measure has brought considerable pressure to bear on hospitals to achieve it. In the words of Kathleen Jones, “New hospitals take years to build and skilled physicians and surgeons take years to train. Overall waiting lists….are virtually meaningless” (Jones 2006, p. 205). Due to a great deal of opposition in implementing service standards, the government was forced to backtrack on some targets in 2008. In early November 2008, the problem of patients being held in ambulances in hospital parking lots was attributed to unreasonable targets and enforcement of new government standards. The press wrote that some hospitals with the aim of meeting their emergency care targets were thinking of setting up inflatable tents outside their doors. This accusation was particularly aimed at the foundation trusts who used emergency care tents as part of their efforts to meet performance targets and thereby become eligible for foundation status.
Private surgeries
With the aim of meeting targets for elective surgery waiting times, Labour launched the diagnostic treatment center initiative (DTC) by seeking proposals from foreign healthcare agencies and professionals to deliver elective surgical procedures in specialized high-volume clinics (Davidson 2004, p 1). The government’s goal was to increase the number of surgeries performed in the realm of cataracts, join replacements and minor surgical procedures. American, South African and English private companies and Calgary’s Anglo-Canadian Clinics Ltd. sent in their bids. According to the new reforms, it was expected that the bidders would provide the facilities and the staff, mostly foreign professionals, and it was expected that the NHS payments per service would be lower. But very soon, it was reported in the media that private DTC facilities would be allowed to hire up to 70% of their professional staff from the NHS (Davidson, 2004, p. 1). This raised a huge uproar among the public as it meant poaching of NHS staff. Moreover, the government confessed that they had to pay the DTCs a premium of up to 15% over NHS rates. This raised the question of why the money was not utilized to build specialized units in existing hospitals. Further, hospital trusts, especially those seeking foundation status felt that shifting elective surgical patients to private parties would reduce the value of their hospitals’ clinical and educational programs and distort cost profiles. Thus there was a lot of opposition when the Oxford Eye Hospital was ordered by the government to give up 1000 eye patients to the planned private DTC (Davidson, 2003, p. 1).
Criticism of the NHS reforms
According to Rob Baggott (1994, p. 263), the NHS reforms have to lead to greater centralization and the government is finding itself getting more and more involved in the detailed operations of health services. Though the reforms may be lauded for focusing on community care, primary care, and public health, the primary care reforms are found to be too narrow and too closely shaped to the needs of the GPS and too managerialism (268). The government by introducing the possibility of using foreign doctors through new contracts has failed to pay attention to the implications for remuneration, workload and quality of services. Moreover, according to Rob Baggott, the primary care reforms are not properly integrated with other key reforms in community care and public health. Rob Baggott says that it is difficult to implement a good health strategy within the planning process because the health system is fragmented. He says the fragmentation is due to the purchases and providers who ‘have a degree of freedom and independence to enter into contracts” – thus blaming the NHS reforms that created the divisions and gave them the freedom. According to Allsop (1995), the healthcare reforms have redistributed and disseminated the power within the medical profession. Consultants in the new environment were made accountable to managers who increasingly controlled consultants’ work and remuneration. In the broader community context, though the GPs were increased in status in relation to hospital consultants, they were made subservient to the Family Health Service Authority (FHSA) (Allsop 1995, p. 171). This reorientation of power shifted the financial resources and hence the power away from the hospital and into the community. The dominance of the medical profession has been thus undermined as a result of the NHS reforms (Allsop 1995, p. 171) The government perceives it as community empowerment and as a way to cut spiraling hospital costs and specialist power.
Conclusion
The NHS reforms introduced by the New Labour government have noble goals of improving the healthcare industry in England but it has been launched without a clear plan or a clear study regarding its possible side effects. The whole set of reforms seem to have been the outcome of a need to control and this need comes in the way of allowing able managers and clinicians to take direct charge and provide the best services on their own motivation. Despite the fact that these reforms are bringing in new funds for the NHS and enabling the NHS to expand the clinical and medical education infrastructure in the country, NHS reforms need a great deal of improvisation in order to be truly effective.
References
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