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This is the last of six related articles, commencing with a piece by Professor Marsland in MSN Volume 14, Issue 2 in April 1989, and concluding with this report in MSN Volume 19, Issue 1 in December 1993, which are published here, together, for the first time.


Implementing Health Care Reform: From Policy To Practice

Professor David Marsland
Department of Health Studies
West London Institute, UK


A paper presented to the Panel on Progress in Health Care Reform at the 25
th Annual Conference of the BSA Medical Sociology Group, York University, September 1993.

The other members of the Panel were Dr David Armstrong (Department of General Practice, UMDS Guy’s Hospital); Professor Robert Dingwall (School of Social Studies, University of Nottingham); and Dr Jennie Popay (PHRRC, Salford). The Chairman was Dr Nicholas Mays (Director, Health & Health Care Research Unit, Queen’s University of Belfast).


Originally published in MSN Volume 19, Issue 1, December 1993



In the three decades between the establishment of the NHS and 1979, expenditure on health care expanded dramatically and the size of its staff grew explosively, while the number of patients treated and the amount of actual health care work accomplished stood more or less still (Gammon, 1987).

This is a typical picture of any nationalised industry: squandered investment, a manpower budget out of control and poor productivity. All this is despite the exceptional calibre of our medical research, the international reputation of our doctors and the traditions, discipline, commitment and high quality of British nursing.

The founding intelligentsia of the NHS proclaimed and promised – implausibly enough, one might have thought, even in the innocently idealistic climate of the nineteen forties – that, after high initial costs, future expenditure on health care would be reduced in absolute terms, as people were brought into a healthy condition by the new system. As it has turned out, costs and expenditure have consistently escalated to a level which both major political parties and most sensible people agree must be controlled.

Widespread dissatisfaction with the NHS

On top of all these objective problems with the NHS, there was also by the nineteen eighties considerable dissatisfaction with its performance:-

  • On the part of professional staff objecting to irrational resource constraints and bureaucratic interference in their day-to-day work by the health authorities;

  • On the part of innovators and radicals who found it resistant to new ideas and new challenges and fixated on outmoded objectives, methods and procedures;

  • On the part of Governments, of whichever party, for whom the NHS seemed to comprise a reliable source of unexpected and embarrassing difficulties;

  • And not least, on the part of the general population, on account of its negligent paternalism, its impersonal lack of attention to patients as people and their growing feeling that standards of health care were not rising in parallel with improvement in other aspects of the standard of living and the quality of life in modern Britain.

By the mid-eighties, it was evident that, despite continuing ritual acclaim of the NHS as a potent symbol of politically correct aspirations, the objective quality of health care in Britain had been overtaken in many other countries. It was widely acknowledged that radical reform was essential (Scrivens, 1991 and 1993).

Reporting progress

Since the reforms were inaugurated, their progress has been reported by the media and by most social scientists of health as if by the peace party in a period of war – with every next military disaster gleefully exaggerated and imminent surrender enthusiastically anticipated. Weaknesses and failure going back years, some of them apparent since the inception of the NHS, are routinely mis-attributed, with cavalier inattention to the evidence, to the reforms and to the Government.

My view is different. So far, so good. We must press on in the face of predictable resistance. I enter two caveats:-

  • First, it is still too early to make definitive judgement about the overall success or failure of the reforms. Critics and proponents alike are eager to find confirmation of their prejudices. But these are wide-ranging, radical reforms of a massive, complex, entrenched system. It will take at least as long to establish fully and reliably their negative and their beneficial impacts as with comprehensive schooling, nationalisation, the nineteen sixties transformation of the criminal justice system or the nineteen eighties reform of trades unions.

  • Secondly, as these examples suggest, the interface between objective evaluative judgement and ideological commitment – where matters are properly adjudicated by the people at elections rather than by the advancing knowledge of experts – is treacherously difficult terrain.


It seems to me that the relevant criteria for evaluating Government reforms, at least in a liberal democracy, are the Government’s own objectives – not the Opposition’s, still less the utopian dreams or irrational worries of agents and agencies privileged to avoid reality-testing entirely.

In these terms, my assessment is of mixed but fair success so far. I will mention the successes as I see them on the basis of the evidence so far in and some remaining difficulties.

The Trusts

The Trusts have grown at a rate which their enemies claimed was impossible – almost 300 already, and a further large tranche anticipated in 1994, bringing coverage to more than 90%. They have become already normalised. The intended effects of their new status, of their autonomy, and of their enforced self-reliance in a competitive environment are coming through rapidly (Times, 21 August, 1992).

They are shaping up organisationally, sorting out their budgets and their manpower, addressing purchasers confidently and orienting to patients as people and as consumers. Most are improving their standard all round. Some may need new leadership. A few will go the wall. Overall, the Trusts are proving a triumphant success.

The morale problem – which is hardly new in the hospitals – will take time to solve. The trades unions and the professional associations, whose reactions to change powerfully influence staff morale, may need yet another Conservative electoral victory before they yield. The BMA stood out longer and more toughly, we should remember, against contraception and indeed against the NHS as such. The Trusts will not in the end be sabotaged and the productive impact of competitive autonomy will continue.

GP fund-holders

Here, the movement has been slower and resistance more organised. But the trend is set and the numbers will expand until this second key element of the reforms is as normalised as the Trusts. Already more than 6,000 GPs are involved, covering one in four of the population. A fourth wave from April 1994 will increase this substantially.

The beneficial impact of GP fund-holding is even more evident than with the Trusts – as the clamorous complaints about a two-tier system demonstrate (survey in
Doctor magazine, 7 October, 1993). Enforced equalisation of standard guarantees levelling down and the lowest common denominator. Competitive autonomy is creating a dynamic multi-tiered system, with standards of care, expertise, management, facilities and attention to patients as people improving across the board, and inadequates squeezed out.

Purchasing

Purchasing, other than by doctors, is still inchoate and inadequate. I would not expect otherwise at this stage. Purchasing in general is a more difficult art within the market enterprise than selling. The forms of organisation and the personnel involved in the Authorities were designed for a command economy of health care, rather than for the subtleties of an internal market.

More structural changes, more learning and more changes in personnel will be needed. Dr Mawhinney’s recent speeches on purchasing are having a powerful effect. “Purchasing”, he has said, “is the engine which drives the reforms”. “From first to last”, Mrs Bottomley argued at a recent NAHAT conference, “it is purchasers who should be in control. They pay the piper. They must call the tune”.

If this ambitious claim is to be fulfilled, the activities of the health authorities as agencies of state purchasing may require some independent competitive stimulus. Why not introduce incentives for big companies, which have the experience, skills and systems required for effective purchasing, to purchase health care for their employees and their families through the workplace?

Funding and the market

Until the purchasing component of the market equation is brought up to the strength of the new provider element, it is difficult to judge the dynamics of the whole system fairly. I would expect Government to relax central and regional controls gradually, to restrict its interventions to serious crises and to release the internal market to operate much more freely.

This will no doubt provoke problems and protests from time to time – the London situation being a peculiarly awkward and difficult example. But the process will continue to go forward, until even a Labour Government would not be able, or in the end willing, to reverse the process and return to centralised planning. Nostalgic pleas by academics and by health correspondents in the media for “tighter management” – i.e. subversion and sabotage – of the market should be ignored (Conservative Research Department, 1993).

Public expectations

The reforms have already had a dramatic effect on public expectations in relation to health care. Among politicians, in the media and among the people, expectations have risen, and deferential tolerance of inadequacies has fallen away. This was intended; the Charter is designed to strengthen it and is unarguably a positive gain (Department of Health, 1991).

But it has to be steered responsibly if we are to avoid what one might call “post-communist syndrome”, where unrealistic demands, combined with unwillingness to take on individual responsibility, produce a neurotic reaction into antique authoritarianism. Thus, independent health care should grow gradually and in positive collaboration with the NHS as the effects of the reforms on expectations and demand unfold. Journalists and social scientists should draw attention just occasionally to the responsibilities of individuals for their own and their families’ health care in terms of life-style decisions and spending priorities.

Sources of concern

In concluding, I will mention two concerns of mine.

The concept underlying “The Health of the Nation” seems to me valuable and timely (HMSO, 1992). It portends a long overdue shift from treatment to prevention and health promotion and from the hospital to the community as the centre of gravity in health care. However, the implementation of its message worries me.

It might provide the ground on which forces antagonistic to health care reform can re-group and work for the restoration of levelling paternalism. Rather than risk a growing army of missionary zealots to the general population, primed with generalised health promotion formulae dreamed up in Alma Ata of all places, I would prefer a less ambitious, more sharply targeted, more local, more practical approach aimed at clearing up the concrete health problems of the genuinely disadvantaged (Le Fanu, 1993).

My second worry is on information. The reforms require a massive upgrading in the quantity, quality and transparency of information of all sorts. Reliable financial epidemiological and evaluative information will be needed for operational management purposes, to steer the internal market and to apprise the public of variations in offerings and standards. Improvements are being made, but there is a long way to go (Marsland 1993).

Conclusion

Radical reform is inherently difficult, which is why it is usually avoided (Marsland, 1992). The reforms of health care seem to me courageous and broadly correct. In a remarkably short period, their implementation has gone forward strongly. I think this will continue, despite resistance and problems, until the overall thrust of reform is positively accepted by everyone except incorrigible recidivists in the collectivist lobby. Within ten years, efficiency and equity alike in the provision of health care can be substantially improved.

In his introduction, the Chairman was kind enough to say how pleased he was to welcome “a varied and distinguished Panel”. I suspect I was invited to represent the variation rather than the distinction. As a dissident among social scientists involved in research into health and health care in supporting the Government’s NHS reforms, I urge the research community to practice the open-minded, dispassionate stance which we preach to our students. The reform programme is working.

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