The National Health Service (NHS) is still, some 60 years after its founding, considered one of my country’s greatest strengths. It promises healthcare “free at the point of delivery,” funded from general taxation and providing access to necessary services for everyone, independent of income and means. There is a continuing attachment to this notion across the political spectrum and the relative credence given to promises to maintain this concept has been similar among political parties at every general election.
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Explore This IssueApril 2007
Reading the tabloid press, one would be forgiven for believing that the basic tenets underlying the NHS are under severe threat. In truth, they are not—but there are seismic changes in the way healthcare will be delivered in the future. History will judge whether reforms will deliver the quality and efficiency politicians desire. What is certain is that these changes will affect U.K. rheumatologists; their concerns and anxiety are palpable at every level. Some see nothing but doom and gloom (and early retirement as leading to some form of salvation), while there are the entrepreneurs who see the opportunities to deliver a level of service to which they have always aspired.
What is the nature of this revolution? Since its inception, the NHS has been both purchaser and provider of both primary and secondary healthcare. Whereas hospital doctors were salaried full-time employees, primary care physicians (or general practitioners—GPs) secured themselves “independent contractor” status. The GPs provided primary care within the NHS, but as a delivery and business model they had some freedom to develop. Access to hospitals was channeled via GP gatekeepers. A geographically devolved system decided what secondary care was needed and aimed to ensure that there were services to meet these demands. In comparison with their GP colleagues, hospital consultants had nationally fixed salaries that were (apart from various extra merit award schemes) independent of performance. In this model, the salaries of hospital consultants mirrored the situation of U.K. hospitals as institutions because their funding was determined from a historical baseline and incentives to improve were limited.
During the 1980s and 1990s the conservative governments of Margaret Thatcher and subsequent prime ministers attempted to stimulate improvement by marking the difference between purchasers and providers of secondary care. They achieved this goal by putting GPs in a pivotal position to purchase healthcare for their patients from the available secondary care providers. As a result, patients found themselves having their hip replacements performed at the other end of the country as hospitals began to compete on price and waiting time.