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Introduction

2.1 Britain is committed to the National Health Service. Everyone - no matter how much they earn, who they are, how old they are, where they come from or where they live - should have the health care they need from themselves and for their families. Four-fifths of people today say the NHS is critical to British society and the country must do everything it can to maintain it.

NHS achievements

2.2 The NHS has delivered major improvements in the health of our nation. Free at the point of use, the NHS has freed millions of individuals from worry about the costs of falling ill. In the five decades since the NHS was formed quality of life has improved, with people living healthier as well as longer lives. A baby girl born in 1948 could expect to live for 71 years, a boy for 66 years. Today it is 80 years and 75 years. In the years since 1948, the death rates for babies under a year old have fallen from 34 out of every 1,000 births to six per 1,000 today.

2.3 The NHS has been at the centre of a range of pioneering medical and technological breakthroughs. NHS doctors developed the technique on which the modern approach to hip replacement was based. Cataract surgery is an NHS innovation. Hospitals like Papworth, Great Ormond Street, the Freeman Hospital in Newcastle, Addenbrooke's, St James', Leeds and the Royal Marsden are internationally renowned and respected. Today the NHS is still home to international pioneers in the fields of vaccine development, imaging and gene therapy and many other fields of endeavour. The British system of primary care is envied and copied throughout the world.

2.4 The NHS continues to work at the cutting edge of new forms of health services, inventing new ways of meeting patients' needs, with pioneering developments such as NHS Direct, the Commission for Health Improvement and the National Institute for Clinical Excellence.

2.5 The NHS remains one of the fairest health care systems by international standards. The World Health Organisation recently reported that the NHS was performing better than Germany, the United States and Australia. In surveys, Americans, Canadians and Australians are 50% more worried than British people about affording medical care if they became seriously ill. The NHS is effective and efficient at meeting its goals. The NHS gets more and fairer health care for every pound invested than most other health care systems.

Public views

2.6 Yet for all the support the NHS enjoys there are widespread public concerns about it. Most people in Britain support the NHS and are broadly satisfied with its overall performance. But many people have real and significant concerns. Young people are the most dissatisfied. About a quarter of the public feel dissatisfied overall with the NHS.

2.7 As part of preparing this Plan a major consultation with members of the public and NHS staff was conducted to gauge their views on the NHS. 152,000 members of the public and 58,000 staff wrote in with their views and their ideas for improving the service. Opinion research asked people about their experience of the NHS. The Office for Public Management (OPM) sat down with groups of people who had used the NHS recently and talked through with them in detail their impressions of the NHS and their hopes for its future. OPM also spoke to the many organisations which represent patients to find out what they thought needed to change. A summary of public views from the consultation can be found in Annex 1.

Staff views

2.8 Most of the public's concerns are shared by NHS staff. Staff views on the NHS were vital to the formation of this NHS Plan. Frontline staff were members of the Modernisation Action Teams which helped in the preparation of the Plan. Hundreds of thousands of staff took time to give their views on how to improve the NHS.

The underlying problems

2.9 In essence the problem is that despite the best efforts of doctors, nurses and other staff the NHS is not sufficiently centred around the needs of individual patients. There are two major reasons why this is the case. First, decades of under-investment and second, because the NHS is a 1940s system operating in a 21st century world.

An under-invested system

An under-invested system

2.10 The NHS is too much the product of the era in which it was born. In its buildings, its ways of working, its very culture, the NHS bears too many of the hallmarks of the 1940s. The rest of society has moved on.

2.11 On July 5th 1948, the day the NHS was founded, the high street banks were open between 10am and 3pm. Today, the public has 24 hour access to banking services. In 1948, women formed a third of the workforce. Today, they make up nearly half. We now live in a diverse, multi-cultural society. Family lives, social structures and public expectations have moved on too. In 1948, deference and hierarchy defined the relationships between citizens and services. In an era of mass production needs were regarded as identical and preferences were ignored.

2.12 Today, successful services thrive on their ability to respond to the individual needs of their customers. We live in a consumer age. Services have to be tailormade not mass-produced, geared to the needs of users not the convenience of producers. The NHS has been too slow to change its ways of working to meet modern patient expectations for fast, convenient, 24 hour, personalised care.

2.13 Staff in the health service have tried to lead change. In many places they are doing just that. Their efforts to modernise services all too often founder on the fault lines in the NHS which are a hangover from the world of 1948.

A lack of national standards

A lack of national standards

2.14 From its creation in 1948 there were no national NHS standards. The assumption was that standards would rise automatically in all parts of the country. This is changing now with National Service Frameworks (NSFs) and the National Institute for Clinical Excellence (NICE). But for fifty years it was left to individual health authorities (and during the internal market of the 1990s, to individual GP practices) to decide levels and types of treatment. Professional groups in each area conducted their own evaluation about new treatments. The result was a postcode lottery of prescribing and care.

2.15 An absence of clear national standards made planning and deploying resources including staff numbers and training more difficult. Health inequalities were compounded by a failure to match provision of services with health needs.

2.16 There is a huge gap between the best and the rest within the NHS. Rates of hip replacement for those aged over 65 vary from 1.5 per 1,000 population in Doncaster to over 4 per 1,000 in Devon. Some hospitals carry out almost 100% of cataract removal operations as day cases, others less than 10%. For many surgical specialties the top 25% of hospitals get nearly double the output from their consultants as the bottom 25%. In the worst hospitals cancelled operations are running at 5%. The best ones have cancellation rates close to zero. Often the poorest services are in the poorest areas with the poorest results. The NHS has been unable to tackle these unacceptable variations because the 1948 settlement left it with inadequate means to drive up performance.

Demarcations between staff

Demarcations between staff

2.17 Old-fashioned demarcations between staff mean some patients see a procession of health professionals often recounting the same details to the GP, practice nurse, hospital booking clerk, hospital nurse, care assistant, therapist, junior doctor and consultant. Information is not shared and investigations are often repeated. Delay seems designed into the system.

2.18 Unnecessary boundaries exist between the professions which hold back staff from fulfilling their true potential. Three quarters of house officers do two or more basic tasks not specifically requiring medical training. Up to 40% of patients seeing an orthopaedic consultant in outpatients would be better off being treated by a trained physiotherapist in the first instance. These practices frustrate staff and cause longer waits for patients.

A lack of clear incentives

A lack of clear incentives

2.19 The NHS currently lacks the incentives many private sector organisations have to improve performance. Until recently there have been precious few incentives in the system to encourage better performance. Worse still there have been perverse incentives which have inhibited improvements.

2.20 The consultant contract provided incentives for hospital doctors as a combination of a flat salary structure plus rewards for those who build up strong academic reputations and a large private practice. There have been few comparable rewards for the hospital doctors who work hardest to improve services and the quality of care for NHS patients. The way family doctors are rewarded today remains largely unchanged from 1948. GP fees and allowances are related to the number of patients registered with them and insufficiently to the services provided and the quality. The GP remuneration system has failed to reward those who take on additional work to make services more responsive and accessible to patients and to relieve pressures on hospitals. The system has not succeeded in getting the right level of primary care services into the poorest areas which need them most.

2.21 The existing incentives for improved performance by NHS organisations are too narrowly focused on efficiency and squeezing more treatment from the same resources. The incentives have not supported quality, patient responsiveness and partnership with local authorities.

2.22 The current system penalises success and rewards failure. A hospital which manages to treat all its patients within 9 or 12 months rather than 18 may be told that over performance means it has been getting too much money and can manage with less next year. By contrast, hospitals with long waiting lists and times may be rewarded with extra money to bail them out even though the root of the problem may be poor ways of working rather than lack of funding. The NHS has to move from a culture where it bails out failure to one where it rewards success.

Barriers between services

Barriers between services

2.23 Rigid institutional boundaries can mean the needs of individual patients come a poor second to the needs of the individual service. On one day in September last year, 5,500 patients aged 75 and over were ready to be discharged but were still in an acute hospital bed: 23% awaiting assessment; 17% waiting for social services funding to go to a care home; 25% trying to find the right care home; and 6% waiting for the right home care package to be organised. Almost three quarters were not getting the care they needed because of poor co-ordination between the NHS and other agencies. This experience is repeated daily throughout the NHS. Partnerships with local authorities have not been as close or effective as they could be. The 1948 fault line between health and social care has inhibited the development of services shaped around the needs of patients.

2.24 The 1948 settlement more or less separated the provision of NHS healthcare from provision by the private sector. There has been an uneasy truce ever since. Patients who wish to pay for their own care are free to do so but that should not prevent the NHS from using spare private health sector capacity to enhance services for NHS patients.

2.25 The wider inability to forge effective partnerships with local government, business and community organisations has inhibited the NHS ability to preventill health and tackle health inequalities. The NHS has done too little to prevent ill health in the first place. The health gap between the better off and the worst off in society has widened in the last 50 years. The gap between health need and health services remains stubbornly wide. The opportunity of good health and good health services has not been as widely available as it should. This fault line too has to be addressed.

A lack of support and intervention

A lack of support and intervention

2.26 For too long NHS organisations have been left to sink or swim. There is a tremendous appetite for change in the NHS. What holds back improvement everywhere is lack of time and support to learn from others about what works. The isolation of individual hospitals and primary care services from one another slows the spread of good practice. Good and bad practice are stuck in their own ghettos because there has been no means of meeting the challenge Aneurin Bevan set out in 1948: how to universalise the best.

2.27 Performance has been inhibited by lack of reliable information for clinicians, managers and patients. Data on clinical, primary care and hospital performance is only now being published annually. The NHS is poor at linking related pieces of information, such as prescription to diagnosis, so results can be collated and used nationally to inform practice, monitor and learn from errors. Most GPs are only just now compiling registers of their patients at risk from heart disease.

2.28 Managers cannot compare costs of services or establish how different staff and organisations are delivering different results for patients. Too often they have to rely on outdated or generalised data when commissioning services and allocating resources to frontline staff.

2.29 For 50 years there has been no systematic way of independently assessing NHS performance. Independent inspection was, until the creation of the Commission for Health Improvement, completely lacking.

2.30 A small minority of organisations and individuals within the NHS persistently fail to deliver high standards of care. The instruments for dealing with persistent failure are old-fashioned and inadequate. The NHS needs a system which spots problems early, takes action swiftly and can act decisively. Persistent failure should be met with an escalating scale of sanctions.

Over centralisation

Over centralisation

2.31 The relationship between central government and the NHS has veered between command-and-control and market fragmentation. Neither model works. The NHS cannot be run from Whitehall. Standards cannot simply be set locally either. Until the 1990s the NHS was run hierachically with little room for local innovation or independence. In the 1990s the internal market introduced competition but failed to bring improvements. A new model is needed where intervention is in inverse proportion to success.

2.32 Clinicians and managers want the freedom to run local services. They want to be able to shape services around patients needs. Inspection, incentives, information and intervention, operating under the umbrella of clear national standards, will help reshape services around the patient.

Disempowered patients

Disempowered patients

2.33 The relationship between service and patient is too hierarchical and paternalistic. It reflects the values of 1940s public services. Patients do not have their own health records or see correspondence about their own healthcare. The complaints system in the NHS is discredited. Patients have few rights of redress when things go wrong.

2.34 The patients voice does not sufficiently influence the provision of services. Local communities are poorly represented within NHS decision-making structures. Despite many local and national initiatives to alter the relationship between the NHS and the patient, the whole culture is more of the last century than of this. Giving patients new powers in the NHS is one of the keys to unlocking patientcentred services.

The challenge for the NHS

2.35 When the NHS was created it gave Britain a healthcare system in tune with the times. Today its values and principles hold good but NHS practices have become outdated. Too much of what the NHS does and how it does it belongs to a different era. The challenge for the NHS is to prove it can reform its practices to match the high ideals of its principles; to remove the fault lines it inherited from 1948.

2.36 Some say the alternative is to accept the NHS has had its day. To seek a new method of funding healthcare in England. This alternative proposition is examined in the next chapter.