Abstract
There is only one reasonably confident conclusion that can be drawn from the history of the successive waves of reform that have swept over the National Health Service in England in recent decades. This is that both the (few) proponents of Secretary of State for Health, Andrew Lansley's package and the (many) opponents may well be disappointed in their predictions. Neither Lansley's vision of a transformed NHS, nor his critics' nightmare of a service stumbling towards collapse is likely to materialize. For evidence in support of this contention, there is no need to look further than the Journal of Health Services Research and Policy's latest supplement.
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This brings together the results of the research, commissioned by the Department of Health's Health Reform Evaluation Programme (HREP), that explored the impact of Labour's market reforms in the years from 2002 to 2010. The evidence, as summarized in the introduction to the collection
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shows that:
“ The changes broadly had the effects that proponents had predicted but the effects were mostly modest. Most of the undesirable impacts feared by the critics appeared not to have materialised to any discernible extent, at least by early 2010.”
Interestingly, this echoes the conclusion of an earlier exercise in evaluation; a review of the effects of the internal market introduced by the Conservative Government in the 1990s.
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This concluded:
“Overall, despite some changes in culture measurable changes were small and perhaps not as great as was predicted (or feared )”.
The fact that the wave of reform has twice swept over the NHS in England without the dramatic effects predicted by either advocates or critics in past decades does not, of itself, necessarily tell us anything about the future. There might be any number of explanations for that. It could be that change takes time to work itself through, while impatient Governments cannot resist playing with the policy levers, so never allowing new initiatives to show their full potential. It could even be that past changes were not radical enough in design and too timid in implementation, as enthusiasts for market notions 4 and presumably Lansley believe. This time it could be different; the new initiatives will be allowed sufficient time to settle down, politicians will not start playing with the organizational bricks even if there is a change of government and there will be no compromises in implementation or direction.
To believe that these conditions will apply in future, requires a heroic leap of faith. Even a leap of faith cannot, however, dispel evidence about why the institutional and professional marble of the NHS is resistant to the efforts of political sculptors to re-shape it. To varying degrees the policies of the Thatcher and Labour Governments, and now of the Coalition Government, have been driven by the belief that a combination of competition and choice, plus a diversity of providers, would deliver both greater efficiency and higher quality. But the JHSRP papers, like the overlapping, more comprehensive analysis of the research evidence published by the King's Fund 5 demonstrate why elegantly simple theories about the dynamics of change may not work as expected when they encounter the complex reality of the NHS or ignore the conditions necessary for their successful implementation.
Thus the research evidence underlines the importance of existing networks and bonds of loyalty to local institutions as constraints on competition. Patients and GPs tend to be loyal to existing providers; in turn, providers often make both formal and informal agreements limiting competition between them, possibly in defiance of the competition rules. Again, the evidence suggests the importance of context; not all geographical areas and services are equally amenable to market-led developments. The notion of consumer choice as the driving force for improving quality, crumbles under scrutiny; consumers tend to rely largely on the judgment of their GPs and make relatively little use of the available information about the performance of providers. Entry costs for new providers are high, and there may be special problems for Third Sector Organizations.
To catalogue the obstacles to transformative policies is not to suggest that all the research findings were negative or that little changed in the NHS in the years under review. Encouragingly, an analysis carried out as part of the research programme showed that socioeconomic equity did not get worse in the Blair/Brown years and may even have improved, dispelling fears that competition between providers would lead to cream-skimming and that choice would favour better-off, better educated patients. There was also some evidence that competition improves patient outcomes econometric studies comparing hospitals operating in concentrated markets (i.e. with limited competition) with those operating in more diffuse markets (i.e. with more competitors), found that the latter scored better on case-mix adjusted mortality following emergency heart attack admissions.
It was, in some respects, a puzzling finding; why the difference in quality following emergency cardiac surgery, as distinct from elective surgery where competition and choice might be expected to have the most impact? One explanation offered is that greater competition is associated with better management, which in turn improves all round performance – including cardiac surgery. But this is clearly an area where more research is needed, perhaps combining econometric analysis with qualitative studies as proposed by Nicholas Mays, the programme's scientific coordinator, in his introductory paper. Statistical correlation does not necessarily illuminate causal paths, while qualitative studies struggle to achieve generalizability.
The methodological challenge of evaluative research – and therefore the problems also of evidence informed policy making – do not end there, of course. Policy making is best seen as an experimental enterprise; 6 testing theories and instruments to see what works. Unfortunately, the experiments are carried out in a contaminated laboratory. The laboratory is crowded with policy bric-a-brac, survivors of previous experiments. In the case of the NHS, competition and choice went hand in hand with a highly centralized, command and control regime, the legacy of the early years of the Blair Government; disentangling the attribution of any improvements in performance is therefore complicated. Compounding the problem of interpretation, the market reforms were introduced at a time of unprecedented financial bounty for the NHS; it is not self-evident that the relationship between policy instruments and policy effects will remain the same in a period of financial stringency.
Ingenious research design can overcome some problems. For example, by comparing the NHS in England with the service in Scotland and Wales, both of which have decided against introducing either market mechanisms or command and control regimes, it is possible to draw some tentative inferences about the comparative performance of what are now increasingly different systems. The comparison shows that the NHS in England has higher levels of productivity and lower waiting times. 7 Lack of comparative data about other dimensions of performance, limits the scope of this conclusion, however.
Whatever the difficulties of evaluative research, it is nevertheless important that it should continue. Evidence about the difficulties of bridging the gap between policy aspirations and policy achievements may not have deterred Lansley from incurring the costs and risks – financial, organizational and political – of attempting transformative change in one great leap. But it might – just might – deter a successor from following his example.
DECLARATIONS
Competing interests
None declared
Funding
None
Ethical approval
Not applicable
Guarantor
RK
Contributorship
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Acknowledgments
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