Gill Morgan DBE
In 2007 the NHS continues to consolidate on the recent period of reform. All four countries of the UK are well advanced along their respective modernisation agendas, although the speed and nature of the change differs across England, Scotland, Wales and Northern Ireland. A common theme is the future of the acute hospital and the scope of services provided in the community. Realising the benefits of the recent significant investment while improving efficiency and service quality is another shared challenge as negotiations continue for the new spending allocations for 2008–11.
The health reform agenda continues with further national frameworks for system management and regulation and joint commissioning with local government. These documents continue the move to more local determination of key targets for health and care services, with an expectation that local partnerships will deliver improved access to, and quality of, service. Key policy directions include:
- Improved partnership between health and local government, dealing with the wider determinants of health and more effective access to care.
- Use of choice to drive emergence and development of a new market of high-quality healthcare providers.
- Development of a more integrated regulatory system that reduces the existing burden of inspection while maintaining public confidence in the quality and safety of local services.
- Development of interactive systems that support self-care and personal decision-making.
- Greater emphasis on involvement of local people in understanding local needs and the commissioning of services.
The new case payment system (Payment by Results) continues in parallel to these developments, and consultation on the future of the system was undertaken in early 2007.
The financial problems which developed during 2006–07 have, following rigorous turnaround measures in some cases, abated with the NHS in balance for income and expenditure at the end of the financial year. Deficits are heavily concentrated in a minority of organisations. Work continues on historical deficits and restructuring, and some redundancies have occurred in different parts of the country. Some local partnerships between health and local government have also been put under pressure by the withdrawal of joint funding initiatives between health and social care. Redesign of secondary care services continues, but with the emergence of public concerns about the loss of local hospital services (eg, maternity and accident and emergency services) where these are consolidated into larger but fewer specialist units.
The major policy focus for NHS Scotland remains the National Framework for Service Change, heralding a shift in the balance of care from hospitals to communities. Securing support from healthcare professionals, politicians and patients is crucial and time-consuming. Nonetheless, rapid action is expected on the improved management of long-term care, improved access to diagnostics, the
auditing of unscheduled care and the rolling out of various e-health projects.
There is now a minority government with the Scottish Nationalists in power. They have publicly opposed a number of changes in the hospital system, and some reversal of previous policy is likely.
Recent developments in Wales include the introduction of a ban on smoking in public places and free prescriptions for all citizens, both coming into effect in April 2007. Considerable progress has also been made in reducing waiting times for treatment. While Wales is still behind England, the gap is closing. The NHS in Wales is now working towards a maximum total combined wait of 26 weeks by 2009.
Elections in May 2007 resulted in a minority Labour government. As the political landscape changes, the key health issues facing the government and the NHS in Wales are:
- Reconfiguration of acute services across Wales – a programme is underway but at different stages in different parts of the country. It remains controversial in some areas. Design principles for reconfiguration include:
- Taking “hospital” services closer to the patient.
- Different hospitals providing different services to form a network of care.
- One service provided on different sites.
The Welsh Assembly government has been more interested in some of the reforms related to choice than in the past, but policy remains divergent from England. In particular, the abolition of all co-payments for prescriptions represents a very different approach.
Following the Review of Public Administration (RPA) in Northern Ireland, there was to be a new organisational model for health and social care (HSC). By April 2008, HSC organisations would consist of a regional HSC Authority (HCSA), five new integrated HSC trusts, the Northern Ireland Ambulance Service Trust and no more than two small agencies. These would replace the four HSS Boards, 19 trusts and eight agencies. The authority would be responsible for commissioning and performance managing health and social care services, ensuring that services are accessible, responsive, high quality and efficient. Local commissioning groups would act as local offices of the HSCA and work with GPs and other local primary care practitioners to commission services. The five trusts were in place on 1 April 2007, and the draft Order implementing the other changes planned for April 2008 has completed its consultation.
The Northern Ireland Assembly was elected in March 2007, and subsequent discussions between the parties resulted in the setting up of an Executive, beginning on 8 May 2007. The new Health Minister (Michael McGimpsey MLA) is from the Ulster Unionist Party, and the Assembly scrutiny committee is run by the Democratic Unionist Party and Sinn Fein. Indications are that the Assembly and the committee will focus on integrated health and social services with prescription charges, free personal care and legislation to deter attacks on staff already proposed. There is no indication of the approach on issues such as the proposed HSC Authority. It is likely that there will be at least some change to the local commissioning groups – they were to be coterminous with the seven local authorities of the RPA model, but this was rejected by all parties except Sinn Féin. There is potential for delay in implementing further changes by April 2008 if the Minister and/or Assembly have any concerns with the draft Order.