The state of the NHS after ten years of a Labour government is examined by The King's Fund Chief Executive, Niall Dickson, who finds significant progress but warns of major challenges ahead for the Prime Minister's successor.
The Prime Minister chose a debate at The King's Fund to say goodbye to the NHS and to reflect on his health record over the past ten years.
It was a robust defence of his government's achievements – achievements he believes have not been fully recognised by the public, and especially not by the media. He also acknowledged that the service itself felt bruised by the changes to which it had been subjected – for him, this is the inevitable result of introducing far-reaching reform.
Above all though, the Blair years will be remembered as a period of remarkable and unprecedented investment, a time when it became less and less tenable to claim underfunding as the cause of underperformance by the UK health system. Spending on health has more than doubled to the European average spend – increasing by an average of 7.8 per cent in real terms per year since 2001.
Access and quality were identified as the top priorities for this investment; when the Labour government came to power, failures in these areas suggested a second-rate health service that had fallen behind many others in Europe.
And on these priorities there has indeed been progress – the transformation of waiting times in England, the faster access to accident and emergency services, and big strides in improving access to and quality of treatment for cancer and heart disease are all undeniable.
To these achievements must be added the creation of a set of national institutions and initiatives to bring about more uniform and higher standards across the country: the National Service Frameworks, NICE appraisals and guidelines, and the Healthcare Commission – all these are likely to stand the test of time, in one form or another.
But the achievements have not been without cost – within the government there is private acknowledgement that the pay deals have not delivered and dismay that underlying financial weaknesses were not tackled earlier. Public health and productivity remain huge challenges.
There are perhaps two ways of looking at the past 10 years. They can be seen as a series of almost disconnected changes, sometimes pulling in different directions, at other times coming full circle – regions were abolished and have now been reinvented, the internal market and fundholding were scrapped, only for a new market and practice-based commissioning to appear in their place.
But there is another way, which is to see continuity in a set of changes designed to reform a provider-dominated public service – moving from a 'one size fits all', 'take it or leave it' system to something much more differentiated, more responsive to individual needs. This ambition is mirrored in other countries, and whoever is in charge here is unlikely to depart from that ambition.
In that sense the greatest challenge for government today remains what it was in 1997 – how to transform a health service that is still not as efficient or as effective as it could be, that is reactive without being responsive, and that is only now beginning to embrace the information age.
The aim should be to create a service that really does help us all to stay as healthy as possible no matter what our current health status may be. To deliver that, we need to continue to devolve decision-making, empower patients with choice, free up providers, invest in commissioning, re-engage the professions and ensure the incentives are powerful enough and consistent enough to deliver the changes that are needed.
Commissioning in particular needs more thought – it remains ill defined and under resourced and the models for delivering it require further development. In the longer term we should certainly explore whether there are ways of introducing competition between commissioners that do not result in adverse selection.
Three great challenges face a 21st century health care system. First, it needs to find a way to support millions of mostly older people with long-term conditions and to reduce reliance on expensive secondary care. This can be achieved partly by designing better and more aligned financial incentives throughout the system, but there is also a case for considering vertical (or virtual) integration between primary and secondary and community providers so long as it does not undermine choice.
Second, it needs to encourage individuals to look after their own health and support them in managing their long-term conditions, otherwise the system will not only become more expensive than it needs to, it will be less effective.
And third – allied to that – the system needs to foster the incentives that will boost productivity and deliver better value for money by reconfiguring services and tackling large unexplained variations in performance.
In short, what we need from Tony Blair's successors is an intelligent development of current policy that builds on what's gone before, embraces information technology and increasingly relies on clinicians taking responsibility for managing as well as delivering a much more responsive and proactive set of services.