Reform and the NHS

Alan Milburn’s strident article on health reform presents the urgent need for further reform of the NHS in years to come. Unlike another former Health Secretary, Andy Burnham, who seems to have sacrificed his credentials for opposition for opposition’s sake, having once embraced the reforms to GP commissioning and private sector involvement that he now dogmatically opposes, Milburn accepts that reform cannot be an issue simply left to party-politics.

The rise in chronic illnesses, such as diabetes, together with a rapidly ageing population which will see the number of over 85-year olds double by 2030, means that the NHS is facing a perfect storm. As a result, reform is not an option, it is a must: without it, we will not be able to achieve better outcomes at lower costs, or in Milburn’s words, ‘the new holy grail in health policy’.

What is striking about Milburn’s article is its commitment to the understanding that reform is not an event, but must be a continual progress driven by a quest for excellence, productivity and efficiency. This includes a need for integrated budgets for health and social care, advocated by the Health Select Committee last week, increasing payment by results for healthcare providers, ensuring the frontline take ownership of their services, and above all more competition: ‘Monopolies in any walk of life, whether private or public, rarely deliver operational efficiency or respond well to customer demand … competition may not be appropriate for every service, but if the NHS is to meet the challenges of the next decade it will need more of it, not less.’ Andy Burnham would do well to reflect on this.

The most radical of Milburn’s proposals is his insistence that we have to make patients ‘active participants’ in their healthcare. Stating that studies in the US and the UK have demonstrated that giving patients themselves direct personal control over their budgets, as the government has begun to do with personal budgets in social care, ensures that levels of satisfaction rise and public spending fall. He concludes that ‘hundreds of thousands of patients, particularly those with a chronic condition, should have their own personal state-funded healthcare budget.’

These are ideas which Milburn is right to look at- as he suggests, the evidence and experiences in the US demonstrate individual health savings accounts are revolutionising healthcare and delivering better care at better costs. For instance in Indiana, the introduction of Personal Wellness and Responsibility Accounts, which provide the first $500 of preventative care and encourages enrolees to take responsibility for their healthcare, have allowed 40,000 previously uninsured Indiana residents to register with the plan- all of whom are on incomes below 200% of the federally-set poverty level. Health outcomes are up, and costs are coming down.

Obviously the US is a very different case, but if we are to ensure that the NHS remains able to deliver the best possible care to its most vulnerable patients with chronic illnesses, we need to ensure that personal responsibility becomes the watchword within the service. As other evidence from the US shows, by focusing on those with chronic conditions, so-called ‘super users’, often with high rates of obesity, diabetes, or alcohol dependency and addiction, estimated to be around 15-20% of the population who cover 80% of all healthcare costs, healthcare dependency can be reduced and huge savings can be made- to be reinvested in a better service .

With an older population that will be more dependent on care than ever before, tackling the issue of personal responsibility, neglected for too long, is today’s challenge to ensure the NHS’s survival for tomorrow.

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