Winter 2004
“A Medical Student’s Review of the British National Health Service” was written with the thoughtful concern of a young man alert to the realities of trying to provide quality health care. It draws the reader to look more closely into the historical, social, and ethical forces that shaped the provision of health care in the United Kingdom, and their expression in that most humane legislation, the National Health Service (NHS) Act of 1948. The Act was the culmination of an ideal present in the program of reforms in health and in general public policy that began 100 years ago, and fully expressed when the 1948 Act enshrined the view that there should be free access to services on the basis of clinical need, and that the service should be funded by the state, from general taxation. The NHS described so ably in Mr. Bricker’s paper has served well at a level commensurate with the resources allocated to it. But for many years its development has not matched the demands made upon it. Among the responses have been restructuring, reorganization, and the introduction of market mechanisms to improve efficiency, effectiveness, and quality. These approaches have not been conspicuously successful, not least because they were not supported by the level of investment now accepted as necessary. The reforms that preoccupy government, the NHS, and the professions today put patients at the center of service thinking and action. They embody national clinical and access standards, accountability, local delivery of services, independent inspection, and a small but growing element of patient choice; and they promote contestability, to drive efficiency and reward innovation. To contain the costs of growing needs and expectations for health and care services, there is an increasing emphasis on the clinical and cost effectiveness of health care, with evaluation of procedures and technologies, targeting of resources to services and interventions of proven effectiveness, and emphasis upon health promotion and the prevention and early detection of disease. To give better access with greater choice there must be increased capacity—more trained staff, more facilities. There must also be changes in the way clinicians work, in which removal of traditional professional boundaries extends the scope of clinical practice. There must be new ways of providing services, with integration of the health and care components and unifying care between community and hospital. There is also another explicit aim—to remove the inequalities in health and in health outcomes, and of access to and uptake of health care, across the nation. There are important implications for the medical profession. The Medical Royal Colleges in the United Kingdom have set and stood by independent standards for postgraduate medical education and practice for many years. But government wishes other stakeholders to have an increasingly influential voice in medical education and training, to bring them into closer alignment with its service priorities. Clinicians regard their service with a sense of ownership. This follows naturally—it is at once a great strength of the service and an impediment to change. Inherent in such ownership is acceptance of accountability for practice, for service improvement, and for the reforms needed to bring about cost effective improvements for patients and for society. It is no surprise that doctors and their clinical colleagues resist change unless they see benefits for their patients, and an improvement in the standard of care. Strategies that appeal to this motivation are more likely to attract commitment than those based on control. Yet the NHS depends on the leadership of clinicians to achieve the desired changes. At the same time, clinicians have a responsibility to ensure the most effective use of limited resources. Authorities in many countries face similar problems, each against the background of its own historical and cultural heritage. We should learn from each other how to do things better, for all our populations. Carol M. Black, C.B.E.
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