Reforming the NHS

From Floreat Domus Issue: 
Issue year: 
[Tony Blair]

With Britain’s National Health Service (NHS) reaching its 60th anniversary in 2008, Matthew Pennycook (2005) interviews Simon Stevens (1984), architect of NHS reform.

In the late 1990s the NHS was an institution faltering after decades of chronic under-investment. The results of this shortfall were evident in key measures such as falling life expectancy, rising infant mortality, and decreasing survival rates from cancer and heart disease relative to other European countries.

[Simon Stevens quote]

New Labour’s 1997 manifesto promised to remedy this situation by rebuilding the NHS. The resulting adoption of the NHS Plan in 2000 signalled the beginning of a decade of reform in the UK’s healthcare system. Substantial investment would be used to cut waiting times for treatments, to rectify underperforming clinical priorities such as cancer, and to improve public health more generally in a move towards preventative care.

More importantly, the NHS Plan also initiated a rapid, and controversial, transition away from a system of publicly owned and provided healthcare towards the introduction of a quasi-market, in which public providers of services compete with private ones for NHS funds, and legal contracts and external regulation replace direct political accountability.

An influential voice

As the British government’s Health Policy Advisor from 1997 to 2004, Simon Stevens was a central architect of these reforms. The Guardian described him as the person “who has probably had more influence on NHS policy over the past seven years than anyone else in Britain.” Key policy-makers echo this judgment. Surgeon turned Health Minister, Lord Darzi, has recently lauded Stevens’s influence in “developing an acceptable face for commercial medicine and privatized care.”

Lord Darzi’s praise is not shared by all, and the reforms begun in 2000 have initiated a controversial – and often acrimonious – debate about the future of the NHS itself. Supporters see the introduction of increased marketization, the breaking of local provider cartels through increased competition, and an emphasis on patient ‘choice’ as the means to drive up quality of patient care and reduce waiting lists. Opponents of the reforms see them as the thin edge of the private wedge; prising open what would be an especially lucrative healthcare market. They argue that ‘choice’ is an illusion and will widen health inequalities.

[Protesting about the cuts]
Midwives march past the Houses of Parliament in protest over proposed NHS cuts to maternity services and the closure of small maternity units throughout the country, 1998.

As Allyson Pollock, Director of the Centre for International Public Health Policy at Edinburgh University, argues, “One thing we know is that markets create winners and losers. In health this is done by squeezing services to people on the margins: the poor, the sick, and the non-productive.”

After some initial signs that a Gordon Brown-led government might decelerate the pace of reform, the Prime Minister stated in January 2008 that “we will reject the views of those who say the NHS must put a moratorium on change and reject those who oppose further reform.”

It therefore appears that the reforms which Simon Stevens helped set in motion will continue unabated. Stevens himself – now a senior figure at America’s largest public sector-facing healthcare company, UnitedHealth – remains passionately committed to them and to the view that only through successful reform on the lines of the NHS Plan will the demand for private practice outside of the NHS be curbed and poorer patient care be guaranteed in a public healthcare service.

Interview with Simon Stevens

What are your most enduring memories of Balliol?

[Healthcare spending quote]

Coming from a comprehensive school, Balliol was very welcoming. Studying PPE, I learnt a lot from two very different characters – Steven Lukes and Jonathan Barnes. More generally, student politics in the mid-80s were fairly intense: Mrs Thatcher was going head-to-head with the NUM [National Union of Mineworkers] and the JCR was funding striking miners from Mardy Colliery. As President of the Union I got stuck in to various controversies but, more bizarrely, became (probably the heaviest ever) cox of the Balliol Women’s 1st VIII!

Can you give us some idea of the path you took after university that led to your appointment as the government’s Health Policy Advisor in 1997?

After Balliol, I moved to South America to work on agro-industrial development in Guyana. When I came back to Britain I then joined the NHS, and, after training in the old steel town of Consett, was assigned my first job running a large psychiatric hospital outside Newcastle. I then moved through a variety of jobs: health work on the Mozambique/Malawi border; time managing London teaching hospitals; and a move to New York City Health Department. In 1997, I was appointed the UK government’s Health Policy Advisor at the Department of Health and 10 Downing Street, where I spent the next seven years.

[Chlamydia Screening]
A free NHS Chlamydia screening service provided by Boots, the high street chemist, in its Oxford Street store, 2005

Looking back on your time at No 10 in this role, what do you feel were your main achievements?

Well, first this was a government willing to be incredibly honest about NHS under-funding (between 1972 and 1998 we spent £220 billion less on healthcare than the EU average) – and willing explicitly to put taxes up to pay for a decent health service. The corollary was an equally important appreciation that, in a democracy, the NHS has to be about more than equity and efficiency; it has to be responsive to the needs and preferences of patients, citizens, voters. So there was a willingness to confront some quite powerful defenders of the status quo by unleashing high-octane reforms to try and modernize a system that was creaking at the seams.

In doing this maybe we’ve been able to change the political weather, at least for now. All three main parties now say they support this level of tax-funded NHS care. And most of the health reforms of the past ten years have now entered the political mainstream – no party is proposing overturning the key building blocks.

Do you have any regrets about your time in Downing Street? Is there anything you would have done differently in retrospect?

[NHS Walk-In Centre]
An NHS Walk-In Centre in Soho, central London, part of the Westminster NHS Primary Care Trust

Sure, lots could have been done better. For example, the government was too timid in starting its smoking ban, getting junk food out of schools, and harmful advertising aimed at children. We were arguably too slow to move from targets to incentives as a way of raising NHS standards and productivity. Clearly, the Department of Health should have been much tougher in negotiating the new NHS pay reforms. And only now are new models of primary care being developed for deprived communities. However, the biggest gap is probably on the demand side not the supply side of the NHS: the bodies that plan and fund NHS care, the ‘primary care trusts’, need to become much stronger.

What is your response to critics of the reforms who argue that ‘choice’ as a defining principle of the NHS will inevitably result in a two-tiered system – the slow decline of those hospitals which cannot perform and over-demand for those that can?

Patient choice obviously has more salience for some conditions (childbirth, routine surgery, terminal illness) than for others (emergency care). Also, it isn’t a magic bullet that guarantees high quality services. But in trying to create a high performing healthcare system it clearly has a role, alongside proper funding, well motivated professionalism, and appropriate regulation. There’s very little doubt – either from actual practice in the NHS, the international experience in countries such as Sweden or the Netherlands, or from the research literature – that allowing patients to choose their hospital helps cut long waiting times.

[No Smoking]
A no-smoking policy was introduced in public spaces throughout the UK by 2007

The interesting question is whether patient choice can also improve equity. Despite the relative absence of financial barriers, NHS care is still skewed by class, ethnicity, gender and geography. And better-off patients often buy care privately. So we don’t start from a position of high equity and low choice; we start from a position of partial equity and class-based choice.

Public services have to be sufficiently good that people want to use them, not just are forced to use them. So by putting pressure on providers to raise their game, choice can in principle help ensure that services are better both for poorer people and the middle classes, which in turn should sustain political support for decent levels of equitable tax funding.

Is the current phase of the reform process – the intended move towards a culture of prevention – bearing fruit?

There are contradictory trends in play. Life expectancy is steadily increasing, and death rates from the main killers of cardiovascular disease and cancer are falling sharply. But despite rising incomes, lower long-term unemployment, targeted anti-poverty measures and so on, health inequalities are still rising. That’s partly because as much as half of the class difference in life expectancy is now caused by differential smoking rates. And for the population as a whole, obesity and lifestyle-related chronic disease is the ‘new smoking’, and the really large health threat to our future wellbeing.