Chris Ham: A chance to go back to basics on health and social care reform in England?

The government’s decision to consult with stakeholders during this pause in the passage of the Health and Social Care Bill through parliament creates an opportunity to revisit the problems the bill is intended to address.
In our response to the White Paper, published in October, we highlighted the many improvements in NHS performance that have occurred in the past decade. These include much shorter waiting times for treatment, gains in life expectancy, and reductions in infant mortality, and falling rates of premature deaths from heart disease and cancer. We also noted evidence of increasing public satisfaction with the NHS and good performance in the international surveys conducted by the Commonwealth Fund.

At the same time, we drew attention to areas in which performance needs to be improved:  increasing rates of obesity and alcohol-related hospital admissions, persistent inequalities in health, declining productivity, and slow progress in moving care out of hospitals and into the community. Our overall assessment was that while further reform was needed, “the means used need to be proportionate to the problems to be addressed.”

Six months later, we stand by this assessment. While there are no grounds for complacency, and many opportunities for the NHS in England, to emulate levels of performance achieved in other countries, it is not self evident that root-and-branch changes of the kind now being implemented at high speed will deliver the improvements needed. Indeed, there is a major risk that the changes already under way will take time and attention away from the core business of improving patient care and delivering the £20 billion of efficiency savings that David Nicholson has called for.

What then should be done to avoid this risk and to tackle the problems that need to be addressed? As we argued in October, evolution rather than revolution is the best way forward. This includes building on successful examples of practice based commissioning, encouraging partnerships between the NHS and local authorities on public health and other issues, and adopting a nuanced approach to regulation in which choice and competition in elective care goes hand in hand with collaboration among providers of emergency care and care for people with complex needs.

Our thinking on NHS reform has been influenced by the opportunity to work with senior medical leaders from high performing systems across and outside the UK and with NHS colleagues during a programme of work on integrated care. One example is Kaiser Permanente, an organisation widely admired for its work on prevention and chronic disease management. On a recent visit, its leaders were perplexed by the perverse incentives in the NHS, especially the system of payment by results, under which hospitals are rewarded for the number of patients they treat.

Their advice was that the NHS should make serious efforts to develop aligned incentives to facilitate a shift from care in hospitals to care delivered in the community. To borrow a phrase from the health reform debate in the United States, “accountable care systems” – that take responsibility for the care of the populations they serve within a fixed budget – offer a promising way to do this. These systems could evolve from the best of practice based commissioning and the emerging general practice commissioning consortia if the right incentives are put in place to encourage GPs to work with specialists to improve performance.

The point about accountable care systems is that they offer a potential solution to a real problem facing the NHS – an over reliance on hospital care and a failure to make a reality of care closer to home. They will also support greater priority for prevention by rewarding spending now that reduces demand for treatment in the future. Moving in this direction would help to engage a wider range of clinicians and stakeholders and avoid the risks involved in big bang reform, by focusing on progressive improvement of existing arrangements.

David Cameron and Nick Clegg must go back to basics and ask if coalition plans will help the NHS tackle the problems that lie ahead. They should also seek reassurance that the plans are proportionate to the problems to be addressed. Only then should they proceed with legislation that as it stands represents the most fundamental change to the NHS since its inception.

Chris Ham is the chief executive of the King’s Fund.

This blog also appears on the King’s Fund website at