|Home | About | Journals | Submit | Contact Us | Français|
The government has willed the ends, but will it provide the means and mechanisms for effective prevention and improved outcomes?
Gordon Brown’s first major speech on the National Health Service was spun to the media as a populist plea for health checks and screening programmes to be made widely available. In reality, it offered a reflective and wide ranging assessment of the state of the NHS in England in its 60th year and a broad indication of the future direction of reform.1 2In the process, the speech gave the clearest indication yet of the prime minister’s agenda for health policy.
At the heart of this agenda is the need for the benefits of medical advances to be made available in the NHS. In words that echoed Harold Wilson’s advocacy of the white heat of technology in the 1960s, Brown praised the progress already made through developments in clinical research, and welcomed the establishment of Europe’s largest medical science centre in London. He also indicated his willingness to accept increased concentration of services and hospital closures where there was evidence that this would deliver improved outcomes, even if this risked unpopularity with the public.
The speech emphasised the importance of the prevention of illness as well as the treatment of sickness. Prevention will be promoted by offering easier access to health checks and the provision of screening services recommended by the UK National Screening Committee. Primary care will be expected to play its part, with patients accessing routine tests such as blood tests, electrocardiography, and ultrasound in general practitioners’ surgeries. Alongside these NHS measures, Brown called for promotion of exercise in schools, a single labelling system to describe clearly the nutritional value of food products, and a more active role by employers in improving health in the workplace.
The prime minister signalled a renewed commitment to improve the care of people with chronic diseases. Specifically, the NHS will be expected to do more to support people to manage their own conditions through a major expansion of the lay led Expert Patient Programme3 and, more radically, by extending to health care the use of the direct payments—personal health budgets—announced last month for older and disabled people to buy personal (mainly social) care.4
The speech also underlined the need to match increased rights for patients with clearer responsibilities. In an adaptation of John F Kennedy’s aphorism, the prime minister argued that patients should ask of the NHS “not just . . . what it can do for you but what, empowered with new advice, support and information, you can do for yourself and your family.” More detail will be available later in the year when the much trailed NHS constitution is published, which will set out the “NHS offer” to the public and clarify how the government expects people to take responsibility for managing their own health.
Another key theme was the government’s commitment to improve access to primary care services. As well as the familiar refrain that practices should extend opening hours in the evenings and weekends, the prime minister indicated that NHS foundation trusts would be allowed to provide primary care in future. This opened up the prospect of increased competition in primary care, both from the independent sector and from other parts of the NHS—Brown’s speech indicated that there would be no “no go” areas of reform as further progress is made in extending patient choice.
Lastly, the prime minister asserted his view that “the NHS is the best insurance system for the long term,” with the founding principle that health care should be available on the basis of need and not ability to pay. The importance of public funding is underlined by the need to pool risks as medical advances offer increased potential to diagnose illnesses, the increasing costs of some treatments, and the value of these costs being shared to promote equity.
In setting out the direction of travel for the NHS, the speech was much stronger on the government’s priorities rather than how these will be achieved. The emphasis on prevention is welcome, but will more resources be shifted to make these aspirations a reality? Prevention has had numerous false dawns, extending back at least as far as 1976, and it is not clear how the health reform programme in England will be more successful than previous efforts in making prevention “everybody’s business.”5
More detail is also needed on the plans to improve care for people with chronic diseases. Personal health budgets may empower some people, but they may not be appropriate for people with complex comorbidity—the heaviest users of NHS services with the greatest need for higher standards of care. Equally challenging will be changing the culture of provision of health care to ensure that patients really are seen as partners and are genuinely empowered to be active participants in care.
These arguments indicate that there is a lacuna in the prime minister’s announcements, namely the lack of an explicit theory on how to change public services like the NHS. Gordon Brown clearly does not share Tony Blair’s enthusiasm for the use of markets (a word notable by its absence from this speech), but he is yet to reveal his alternative. This week’s statement is best seen as the beginning of the process of identifying a distinctively Brownite agenda for the NHS rather than the final word.
Competing interests: CH was director of the strategy unit in the Department of Health between 2000 and 2004.
Provenance and peer review: Commissioned; not externally peer reviewed.