Martin McKee and David Skelton debate the OECD claim that constant 'reforms' are holding our health service back
Martin McKee: 'These changes will be cited as how not to make policy'
As the OECD points out in its report this week, the NHS has been changing, introducing innovative models of care that have been associated with some of the fastest improvements in health in any industrialised country. Our experience, and that of other researchers – such as those who have shown how hospital mergers set the new organisations back several years – confirms the OECD view that what is needed is institutional stability: and that this is what gives rise to effective innovation.
A few weeks ago we launched a major report on what makes some health systems work better than others. We were updating a seminal report undertaken 25 years previously by the Rockefeller Foundation entitled Good Health at Low Cost. The original report had identified China, Costa Rica, Sri Lanka and Kerala, in India, as places that had achieved much better outcomes than might be expected given their level of economic development. In our report we looked at their subsequent experience, which was mixed, but also at five states that had made substantial strides in health outcomes in the years since then. These were Bangladesh, Ethiopia, Kyrgyzstan, Thailand and, again in India, Tamil Nadu.
What did we find? Success was associated with a number of factors. These included: a clear vision of the desired outcome; good communication with those who had to implement it; reforms that were appropriate to the context in which they were taking place; and an ability to take advantage of events. But above all, they had achieved success because they had maintained the stability of institutions. The organisations that were designing and implementing the reforms had, in some countries, survived changes of government and even coups. They provided islands of stability in often rapidly changing circumstances, with institutional memories that minimised the risks of making the same mistakes over and over again, and which provided space to anticipate the future and develop appropriate responses.
The UK's Department of Health argues that the NHS must change because of the rapidly changing environment in which it is operating. But we are being given a disruption so great that, as the NHS chief executive has suggested "it can be seen from space", while the incoming chair of the National Commissioning Board faces the challenge of implementing a bill he describes as "completely unintelligible". In time, the current changes will be cited in textbooks as an example of how not to make policy and the result will be a health system that, as the just-published NHS London risk register confirms, is far less able to adapt to changing circumstances than it is now. Worse, there will be many casualties along the way.
• Martin McKee is professor of European public health at the London School of Hygiene and Tropical Medicine
David Skelton: 'The NHS must be nimble enough to evolve'
A National Health Service, delivering high-quality healthcare free at the point of delivery is, rightly, one of the institutions that British people are most proud of. However, in order to enhance this reputation and maintain quality of service it is vital that the NHS evolves to meet changing health needs, rapidly developing technological innovation and rising patient expectations.
The NHS cannot be preserved in aspic. It needs to be nimble enough to adapt to meet changing circumstances. The health needs that the NHS faces now are so very different to the health needs faced by Nye Bevan in 1948. Since Bevan's masterpiece was created, life expectancy has increased dramatically – male life expectancy has risen from 66 in 1948 to over 78. The challenge facing the NHS is now much more about dealing with long-term conditions, such as diabetes. Far more of the NHS's resources now need to be targeted on prevention – keeping people out of hospital in the first place.
The technology on which the NHS relies is evolving at a rapid rate. Emerging technologies are likely to have a dramatic impact on patient treatment, increasingly enabling patients to be treated at home, rather than spending too much time in impersonal hospital wards. Technology can have a huge impact on dealing with long-term conditions and help provide patients with the information necessary to make their healthcare choices. The number of patients seeking online health information in the UK is also rapidly rising. The NHS will only make the most of emerging technology if it is prepared to change with the technology. A static, reform-resistant NHS would not be able to do this, and so we should not take the conclusions of the OECD report as evidence that the service can simply be left alone.
The NHS also has to meet rising and changing patient expectations. Citizens are now used to using a variety of sources, including the internet, that help them make key decisions in their day-to-day life and raise the bar for NHS performance and responsiveness.
We are justifiably proud of the NHS. The NHS has evolved in the past and it must continue to do so in the future in order to deal with a changing healthcare environment.
• David Skelton is deputy director of Policy Exchange
The Guardian
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