Never again? A retrospective and prospective view of English health reforms

This chapter takes retrospective and prospective perspectives on health reforms in English NHS. Retrospectively, we offer a precis of the preceding chapters, taking stock of the cumulative lessons from the significant body of evidence that has been presented in this book. Moreover, we seek to explain the ‘how and why’ of these reforms, using a specific conceptual model (multiple streams approach (MSA)). Prospectively, we consider the direction of health policy in the English NHS, and the research agenda which might inform this process.

A view from abroad: a New Zealand perspective on the English NHS health reforms

The English NHS is of significance among health policy observers around the globe for various reasons. The NHS is particularly noteworthy for the fact that, for many, it represents the high-income world’s best attempt to have built and maintained a ‘national’ health system with a focus on universal access to care that is free at point of service. The NHS has been in transition for several years. Many commentators have highlighted the role and influence of US market ideals in this transition, with various UK governments clearly pushing this agenda. However, is often useful to look to countries more closely comparable to England, such as New Zealand, for comparison with a view to improvement. This chapter takes such an approach in looking at the NHS from abroad. It draws upon the case of NZ which, in many ways, is very similar to England when it comes to health policy and the healthcare system. In doing so, it aims to provide a critique of the NHS reforms and demonstrate that there are alternatives to the policies and structures being pursued for the English NHS by the Coalition government.

Public health: unchained or shackled?

As in the case of other parts of the UK wider health system, it has been a turbulent time for public health since 2010. Not only has the function undergone major structural and cultural change following its return to local government from the NHS, where it had been located since 1974, but it has had to confront new challenges in public health arising from lifestyle behaviours and a widening health gap between social groups. All of this has occurred during a period of unprecedented financial austerity affecting public services in general but local government in particular. This chapter reviews the state of public health in the lead up to the changes announced by the Coalition government in 2010. It then summarises the reforms before offering an interim assessment of their impact. Finally, it discusses the evidence to date concerning the reforms and speculates on likely prospects in the years ahead.

UK-wide health policy under the Coalition

A volume on health reforms under the Coalition must necessarily expand its focus beyond Westminster to consider the larger UK policy context. Legislation enacted in 1998 established devolved assemblies in Scotland, Wales and Northern Ireland with power to make law or issue executive orders in certain specified areas, including health services. This meant that an English NHS overseen by the Westminster Parliament now existed alongside separate NHS systems accountable to devolved governments in the other UK countries. Thus, the major Coalition health reforms heralded by the Health and Social Care Act 2012 applied in the main to England only. However, devolved administrations needed to formulate appropriate policy responses that either maintained differences or moved closer to the English policies. This chapter describes the divergent approaches between the four UK NHS systems, but also sheds light on the nature of coalition policy making.

Did NHS productivity increase under the Coalition government?

This chapter introduces the political focus on the productivity of the NHS. Productivity is a conceptually simple construct, relating the amount of output produced to the amount of inputs used in the production process. Productivity growth can also be calculated by comparing the change in outputs produced to the change in inputs utilised from one period to the next. Political interest is focused primarily on productivity growth. However, assessing productivity or efficiency is somewhat problematic in the context of a free-at-the-point-of-use health system service such as the NHS. The authors discuss some of the issues they face in attempting such an evaluation. With these issues in mind, the authors describe the growth in outputs, inputs and productivity between 2004/05 and 2013/14. The chapter concludes by discussing whether or not the key political measures highlighted in the first section appear to have had an influence on NHS productivity growth.

An argument lost by both sides? The Parliamentary debate over the 2010 NHS White Paper

This chapter examines the rhetoric of government and opposition in the Parliamentary debate over the 2010 NHS White Paper ‘Equity and Excellence.’ It treats the debate as a process of deliberative argument in which Secretary of State Andrew Lansley justifies his reorganisation and explores the extent to which his policy argument was scrutinised by both the opposition and by members of his own Coalition government. The chapter suggests that Lansley offered an unjustified reorganisation based on market-based governance and decentralised accountability, which would at the same time generate substantial savings in a time of financial austerity. This is contrasted with the often fragmented arguments offered by voices in the opposition. The authors ask questions about the extent to which parliamentary debate is able to adequately scrutinise governmental proposals of the complexity of healthcare reorganisation, especially at the beginning of a new term in office.

Blowin’ in the wind: The involvement of people who use services, carers and the public in health and social care

Patient and public involvement (PPI) is often framed in terms of addressing the democratic deficit in the NHS but in England, since 2000, it has become increasingly aligned with the reform of the NHS to become patient centred by enabling people to exercise choice as a right and responsibility across all aspects of healthcare. Since then, there has been a rapid diversification of approaches to and methods for PPI, which experienced organisational turbulence under the Labour administration. This chapter discusses the evolution of PPI in England before 2010, and it examines the Coalition’s reforms of PPI, and the implications of these reforms.

Orders of change in the ordered changes in the NHS

The author introduces the difficulty in conceptualising or measuring change in health systems. The author states that in this chapter draws on the account of Hall which differentiates between first, second and third order change. It views policymaking as a process that usually involves three central variables: the overarching goals that guide policy in a particular field, the techniques or policy instruments used to attain those goals, and the precise settings of those instruments. Hall regards change in settings as first order change; changes in instruments and settings as second order change; and changes in all three components – instrument settings, the instruments themselves and the goals – as third order or paradigm change. Implementing some aspects of this approach, this chapter tracks the main policy measures introduced by the Coalition’s Health and Social Care Act of 2012 backwards to the Conservative government of 1979.

Clinically led commissioning: past, present and future?

One of the key elements of the Health and Social Care Act 2010 (HSCA 2012) was the transfer of responsibility for commissioning healthcare services from managerially led Primary Care Trusts (PCTs) to newly established Clinical Commissioning Groups (CCGs), led by General Practitioners. In this chapter, the authors explore what can be learned from previous attempts to involve GPs in commissioning care. They then apply that learning to the provisions of the HSCA 2012, highlighting the correspondences and discontinuities between what is known from history and what was proposed. They then present evidence from their research on CCGs, exploring what happened in practice when CCGs were established. Finally, the authors discuss the continuing evolution of health policy in the UK in the light of both historical evidence and their current findings.

Health and Wellbeing Boards: The new system stewards?

Health and Wellbeing Boards (HWBs) emerged from debates about the Health and Social Care Bill (2011) as a key coordinating mechanism or steward for local health and social care systems. For many this is yet a further attempt to improve coordination between health and social care services which historically has been a mixed experience. The rationale for HWBs, however, includes a broader coordinating function across local authority services with a role in addressing the wider social determinants of health such as housing, education and planning, as well as social care. This chapter examines the development of HWBs and draws on the findings of studies conducted by the authors and considers whether or not HWBs are emerging as system stewards. By this the authors mean HWBs acting at a strategic level to coordinate and set the direction of health and social care developments at the local level, as well as encouraging integrated working.