This chapter describes and analyses the three phases, and contrasting models, of reform of the UK NHS that have occupied governments, principally key ministers and their advisers, from 1997 up to 2015. They have been articulated by one of the last Labour government’s most influential health policy advisers, Simon Stevens, who labelled the phases as follows:
command and control
Stevens left his position as adviser to former prime minister, Tony Blair, to take up a new post as president of United Health in Europe, a major US health care provider, which over the years has competed for work in the UK, including providing general practitioner services in parts of the country. In April 2014, Stevens returned to the UK to take over as NHS chief executive. Although his phases of reform were developed during the Labour government’s term of office, they remain relevant to the more recent changes introduced by the coalition government in 2013.
Britain is something of a market leader in health care reform, having been at it longer than most countries and with a determination and persistence not evident to quite such an extent anywhere else. One eminent commentator, Rudolf Klein, argued that although health care reform ‘has been one of the worldwide epidemics of the 1990s … Britain stands out from the rest’ (Klein 1995: 299). Moreover, since 1999, and as is described later, post-devolution Britain has created growing interest as a laboratory for the study of differences emerging in the health systems taking shape in England, Wales, Scotland and Northern Ireland (Connolly et al 2010; Timmins 2013; Bevan et al 2014).
A recurring policy dilemma for health systems concerns the rationing of health care, or, as some prefer to call it, priority setting. The discourse here is about the extent to which rationing health care should (or can) be explicit or whether the implications of this are too painful to contemplate, which makes implicit rationing a more attractive option. This chapter reviews the arguments on both sides. These continue to preoccupy commentators. Taking issue with Mechanic’s (1995) argument that explicit approaches to rationing are ‘too damaging to public and patient trust in services’, and one with which this author has much sympathy (Hunter 1997), Williams and colleagues are convinced that implicit rationing is both ‘ethically and politically unacceptable.’ They proceed from the assumption that ‘explicit priority setting is a legitimate and necessary feature of contemporary policy and practice in health care’ (Williams et al 2012: 125). For their part, Light and Hughes consider that critics of explicit rationing make important points about the limitations of formal attempts at rationing but that implicit rationing can cover up poor professional practice and quality of care. They favour a solution that ‘lies in re-conceptualising professionalism around accountability rather than autonomy’, thereby ensuring that ‘the use of power in both explicit and implicit rationing are subject to transparent review’ (Light and Hughes 2002: 12). They also make a plea for a sociological perspective to counter-balance and challenge the dominant economic view with its tendency to frame the issues ‘in a narrow and misleading way’ (Light and Hughes 2002: 17) and ‘set up an over-blunt dichotomy between treatment and denial, when what is at issue is more nuanced and uncertain’ (Light and Hughes 2002: 15).
Health system reform is likely to remain an international preoccupation as countries of different political persuasions and at different stages of development seek to balance rising demand and limited resources. In balancing these, policy makers have to wrestle with a variety of interlocking political cleavages that constitute an ongoing health debate. The spread of universal health coverage, actively encouraged by the World Health Organisation (WHO) and others, is an example of this global phenomenon.
The purpose of this book has been to describe and analyse several of the principal policy cleavages that have exercised, and continue to preoccupy, policy makers in their never-ending pursuit of the perfect health system. On the evidence reviewed here, such a laudable goal is probably unattainable – less imperfection is the best that can be hoped for – although this truism will not prevent policy makers and their advisers from making the attempt, especially in a context where there is a loss of institutional memory and a seeming reluctance to learn from history. As Judt perceptively cautions: ‘there is something worse than idealising the past … forgetting it’ (Judt 2010: 41-2).
Running through each of the policy cleavages considered here – the funding and organisation of health systems, the attempt to shift the emphasis from health care to health to combat dramatically rising lifestyle problems like obesity, alcohol misuse and mental ill-health, priority setting and rationing health care, and the appeal of markets and choice and competition as drivers for reform – is a tension between the bureaucratic reformers and market reformers that Alford (1975) described over 30 years ago.
This chapter presents qualitative research findings of the views of frontline practitioners and service users of public health partnerships in four selected tracer issues. The topics examined include: the benefits and barriers to partnership working, the effectiveness of partnerships in providing a more seamless service for users, and what is needed to improve services for users through the aegis of partnership working.
The chapter reports on the findings of a systematic review of the impact of partnership working on public health, and considers whether these partnerships have delivered better health outcomes for local/target populations. It finds that there is little evidence that partnerships have produced better health outcomes for local/target populations or reduced health inequalities.
Partnership working is central to British public policy. Few challenges facing government can be tackled successfully without working across boundaries and in partnership. Public health issues are particularly complex in this respect and yet little is known about public health partnerships. The research reported in this book seeks to go some way to closing the knowledge gap employing the notion of a public health system to explore the issues raised. The book brings the discussion up-to-date by examining the evolving public health system in England and the major changes introduced in April 2013. These have introduced new partnership forms that remain to be tested. Our research offers useful insights and learning points.
This chapter discusses the various theories and concepts of partnership working and explores what partnership working is, the opportunities and barriers to working in partnership, and the various modes of governance underpinning partnerships. It argues that a networked approach to the governance of partnerships is needed based upon systems thinking to tackle the complex ‘wicked issues’ found in public health.
In the light of the research presented and the public health changes underway in England, assesses the future prospects for public health partnerships which will become more complex and challenging. This chapter argues for a different approach which emphasizes the importance of relationships and suggests the need for less attention being given to structures and order. Partnerships in future need to be much more flexible and task oriented, engaging with those who can effect change on the frontline. The public health challenges facing society have few obvious or clear-cut solutions. Partnerships need to experiment and take risks to find out what works and why. If this requires being a little messy in how the work gets done then that may be desirable. The chapter offers some learning points for effective partnership working.
This chapter presents the research findings, through qualitative research, derived from the views of senior practitioners and their perceptions of the effectiveness and efficacy of public health partnerships. Interviewees include: Directors of Public Health, Directors of Commissioning, Councillors, and other senior public health practitioners.
Chapter 6 describes the changing context for partnership working in public health following the UK coalition government’s plans for returning lead responsibility for public health in England to local government while also creating a new agency, Public Health England, to provide support and national system leadership. The changes, contained in the Health and Social Care Act 2012 and introduced in April 2013, reinforce the importance of partnership working while introducing new partnership forms that are yet to be tested and evaluated. The new health policy landscape is described and an interim assessment of progress provided.