The National Health Service (NHS) is still, some 60 years after its founding, considered one of my country’s greatest strengths. It promises healthcare “free at the point of delivery,” funded from general taxation and providing access to necessary services for everyone, independent of income and means. There is a continuing attachment to this notion across the political spectrum and the relative credence given to promises to maintain this concept has been similar among political parties at every general election.
NHS Today
Reading the tabloid press, one would be forgiven for believing that the basic tenets underlying the NHS are under severe threat. In truth, they are not—but there are seismic changes in the way healthcare will be delivered in the future. History will judge whether reforms will deliver the quality and efficiency politicians desire. What is certain is that these changes will affect U.K. rheumatologists; their concerns and anxiety are palpable at every level. Some see nothing but doom and gloom (and early retirement as leading to some form of salvation), while there are the entrepreneurs who see the opportunities to deliver a level of service to which they have always aspired.
What is the nature of this revolution? Since its inception, the NHS has been both purchaser and provider of both primary and secondary healthcare. Whereas hospital doctors were salaried full-time employees, primary care physicians (or general practitioners—GPs) secured themselves “independent contractor” status. The GPs provided primary care within the NHS, but as a delivery and business model they had some freedom to develop. Access to hospitals was channeled via GP gatekeepers. A geographically devolved system decided what secondary care was needed and aimed to ensure that there were services to meet these demands. In comparison with their GP colleagues, hospital consultants had nationally fixed salaries that were (apart from various extra merit award schemes) independent of performance. In this model, the salaries of hospital consultants mirrored the situation of U.K. hospitals as institutions because their funding was determined from a historical baseline and incentives to improve were limited.
During the 1980s and 1990s the conservative governments of Margaret Thatcher and subsequent prime ministers attempted to stimulate improvement by marking the difference between purchasers and providers of secondary care. They achieved this goal by putting GPs in a pivotal position to purchase healthcare for their patients from the available secondary care providers. As a result, patients found themselves having their hip replacements performed at the other end of the country as hospitals began to compete on price and waiting time.
Despite the hype, the effect on healthcare was only modest because acute care was excluded and GPs predominantly purchased care from their traditional, geographically based hospitals. Waiting times for the first outpatient appointment (ambulatory care) following GP referral and for admission to hospital rose. Election campaigns focused on a few high-profile and probably totally atypical cases such as “Jennifer’s ear,” where a young girl whose grommet surgery had been unreasonably delayed was wheeled out to the media to highlight the inadequacies of the NHS. Spending on healthcare was historically low compared with our European comparators.
Increased Funding—and Performance Targets
In 1997 the return of the Labour Party with Tony Blair brought new hopes and a vast increase in spending with an almost two-fold increase of the proportion of GDP devoted to healthcare. Salaries at all levels increased with an expansion in all groups of health professionals (including a 30% to 40% increase in the number of rheumatologists). There was also a massive hospital-building program, funded by public-private partnerships. The fact that such initiatives will be paid by future generations is ignored, but for politicians seeking a quick fix, the sight of giant cranes in every major hospital in the land showed “something was happening.”
The creed of Blair’s “New Labour” was that there had to be “delivery.” The problem was how to measure it. In the past 10 years, we have been faced with an ever growing list of targets for performance, with published league tables of the good guys and the bad guys (whether it is waiting times for cataracts or response times to dealing with complaints). The job security and rewards for the new breed of hospital chief executives depended on their meeting the latest bunch of targets. Professional activity started being managed to meet these targets in the teeth of great opposition and some incentives.
One new feature of this landscape was the waiting-list initiatives. In order to meet targets of specific waiting times for new (but not follow-up) outpatient appointments, hospital managers required extra evening or weekend clinics, paid for at premium rates. The incentive to see extra patients during the working day declined and paradoxically (though predictably) waiting times for new patients rose as many providers had to increase the number of slots for the follow-ups of these extra referrals.
The crude data for the past 10 years are clear: massive expansion in funding, many new hospitals, reduction in waiting times, and increases in salaries. The problem is that everyone is unhappy. The government’s solution has been to relinquish control of the hospitals, freeing them to become independent businesses (but remaining within the NHS) and encouraging those responsible in primary care for the purchase of secondary care to choose from a range of providers—both within and without the NHS.
Americanization of Healthcare
“Patient choice” has become the slogan of New Labour, and automatic referral to your local hospital confined to previous generations. As a consequence, some hospitals with established reputations are losing money and face a downward spiral of staff loss, low morale, and decline in service. These self-governing hospitals are staring bankruptcy in the face and may wither despite the political fallout even if alternative providers can fill the gap. A Mayo Clinic in London or a Scripps Clinic in Manchester could provide the NHS-funded healthcare of the future. This “Americanization” of healthcare in theory should not lead to a two-tier service. The goal is to ensure uniform quality and, possibly in contrast to the U.S. situation, British public opinion across the social divide still supports equality of access to the best care.
Surgical colleagues are leaving NHS management in droves and establishing groups of independent contractors to provide the operations the NHS needs at a price and quality all accept as being an improvement. Interestingly, the consequence of this situation is that the parallel system of private healthcare funded by the wealthier middle classes is in decline, as the private providers see higher profits and greater business opportunities in satisfying the NHS.
Of Rheumatology and Research
Where does this leave rheumatology? Primary care purchasers of rheumatology services are looking for other models of healthcare provision. Intermediate referral centers are being established where GPs with a Special Interest in rheumatology (GyPSIes) screen referrals from GP colleagues and undertake the necessary investigations (including MRIs) before either referring the patients back to primary care or selecting the few for specialist referral. Inflammatory joint disease will still be managed in hospitals, but by a possibly reduced number of fully trained specialists. Further, if independent providers can give the quality of care demanded, then the sky is the limit. Groups of rheumatologists could establish plans for the long-term multi-disciplinary management of RA, for example. Redundancy from traditional employers in NHS-run institutions looms for many colleagues.
The NHS has been a vital tool for clinical research, and access to its patients and their records have provided the backdrop for the strong legacy of academic activity in the United Kingdom. Traditionally, undertaking investigator-initiated clinical trials in the United Kingdom has been much easier than in the United States, where there is a much greater reliance on industry to fund intervention research. The U.K. government, in the strategy document “Best Research for Best Practice,” recognized the synergy between the provision of high-quality research opportunities and excellence in clinical care and is directing NHS funds toward this goal. With increasing amounts of care being undertaken outside the NHS, however, gathering whole population experience may be constrained in the future.
For my generation, a consultant job was a job for life. Today there is no guarantee for the future viability of the hospitals where we work, so we need to justify our continued employment in our specialty. The U.K. rheumatologists, with an eye to mortgage repayments and other family responsibilities, are anxious about the future and wonder why the protection from the harsh external world cannot continue.
In the waiting area of my clinic last week, I saw hordes of patients waiting an hour for their 10-minute follow-up as the agency staff employed to provide para-nursing support worked arduously, stress engraved on the faces. The “utopia” managing our own service, employing our own staff, and setting our own standards for “sale” to the NHS suddenly seemed very attractive. The NHS will continue into the foreseeable future. The question is whether the care will look more like Main Street, U.S.A., than High Street, U.K.
Dr. Silman is director of the Arthritis Research Campaign’s epidemiology unit at University of Manchester in the United Kingdom.