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Social Science & Medicine 72 (2011) 815e820

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Liberating the NHS? A commentary on the Lansley White Paper, “Equity andExcellence”

Sheena Asthana*

Faculty of Health, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, United Kingdom

a r t i c l e i n f o

Article history:Available online 6 November 2010

Keywords:NHSWhite paperUKPolicy

* Tel.: þ44 1752 585753.E-mail address: sasthana@plymouth.ac.uk.

0277-9536/$ e see front matter � 2010 Published bydoi:10.1016/j.socscimed.2010.10.020

a b s t r a c t

In July 2010, the new Coalition Government unveiled its plans to make major changes to the EnglishNational Health Service (NHS). This paper, which provides a commentary on the NHSWhite Paper, Equityand Excellence: Liberating the NHS, casts doubt upon the extent to which the proposals will bring aboutthe fundamental reform that the Government intends, not least because both the British public and GPcommissioners (who are expected to play a central role in transforming the NHS) appear to havea limited appetite for radical market reform. The paper also identifies a number of unintended risks,including the large transitional costs and organisational turbulence resulting from further NHS reor-ganisation; and the fact that key aspects of the White Paper proposals could result in significant financialinstability. Given the real world limitations to translating a rhetoric of localism and democratic legiti-macy into reality and a lack of hard evidence about the benefits of market reform, the Government wouldbe well advised to take a more cautious approach to health policy formulation and implementation andto ensure that any further changes to the NHS are based on evidence, piloting and evaluation.

� 2010 Published by Elsevier Ltd.

Introduction

Although the National Health Service (NHS) in England is stillthe largest publicly financed health system in the world, it has beenincreasingly exposed to market principles over the last twenty tothirty years. Against this background, the Coalition Government’splans to reform the NHS, described in the White Paper itself as ‘far-reaching’, perhaps represent more continuity than change. Thus,while commentators to the right of the political spectrum havewelcomed the White Paper as a bold step towards finally realisingthe benefits of a competitive market (Stevens, 2010) and those tothe left believe that it opens the door to the comprehensive pri-vatisation of healthcare and the end of the NHS as a national service(Milne, 2010; Pollock & Price, 2010), others have cast doubt uponthe extent to which the proposals will bring about fundamentalreform (Ham, 2010; The Nuffield Trust, 2010).

This is not to say that the Coalition Government’s plans will bewithout impact, albeit of an unintended kind. As outlined in thispaper, key risks include the large transitional costs and organisa-tional turbulence resulting from further NHS reorganisation; theassumption that GP commissioners are willing and able to driveforward improvements in service quality and efficiency; and the

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fact that the creation of an NHS that is totally ‘locally driven’wouldresult in significant financial instability. Against indifferentevidence that these reforms can deliver financial savings andimprovements in quality, one is tempted to argue that the real‘change’ that is needed is an end to permanent NHS revolution!

The reforms in a nutshell

The White Paper, Equity and Excellence: Liberating the NHS(Department of Health, 2010a,b) reflects a belief that, in order toincrease service quality and efficiency, the NHS must be freed fromtop-down management. To this end, financial control over thepurchasing of services will be devolved to general practice (GP)commissioners, based in commissioning ‘consortia’. This, it isargued, will shift decision-making as close as possible to individualpatients. At the same time, the professionals who are best placed tocoordinate the commissioning of care will be empowered toredesign patient pathways and local services in a way that is locallyresponsive, extends patient choice and results in the more efficientuse of resources.

On the provider side, it is expected that all NHS providers willbecome ‘Foundation Trusts’, some of which may transform them-selves into employee-led social enterprises. Foundation Trusts willbe expected to compete with other providers, whether from theprivate or voluntary sector. To help open up the NHS market tocompetition, the foundation trust regulator Monitor will be

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developed into an economic regulator, the role of which will be toregulate the prices paid to providers, ensure continuity of serviceprovision and, importantly, apply competition law to prevent anti-competitive behaviour. The Care Quality Commission will workalongside the regulator to license providers and inspect services.The direction of travel is thus to move to “a system of control basedon quality and economic regulation, commissioning and paymentsby results, rather than national and regional management”(Department of Health, 2010a, p. 44).

Supporting this vision of an NHS driven by choice and compe-tition (as opposed to command and control) is a raft of proposals.These include the promotion of greater patient involvement (e.g.through better access to information - including patient recordsand the establishment of local ‘HealthWatch’ organisations) andgreater patient choice (of any provider, GP practice, consultant-ledteam or treatment). Centrally managed performance targets are tobe scrapped on the assumption that improvements in performancewill be driven by patient choice and commissioning. Instead,outcome measures which capture both clinical effectiveness andpatient experience will be used to monitor progress and set stan-dards that can inform effective commissioning.

In order to reduce the scope for top-down political interference,a new NHS Commissioning Board is to be established, the role ofwhich is to provide leadership on commissioning for quality,promote patient and public involvement and choice, support thedevelopment of GP commissioning consortia, commission specificservices (including national and regional specialised services) andto allocate and account for NHS resources. Finally, as it will now bedown to front-line professionals to structure services around whatworks best for patients, the Government proposes that the layers ofexcessive bureaucracy that have accumulated over the past decadeshould be slashed. To this end, Strategic Health Authorities (SHAs)and Primary Care Trusts (PCTs) are to be abolished, together witha number of arms-length bodies (popularly known as quangos).This, it is proposed, will reduce the NHSs management costs bymore than 45% (Department of Health, 2010a,b, p. 43).

Revolution, evolution or plus ça change?

Unsurprisingly, the Coalition Government’s proposals have beenwarmly welcomed by advocates of market-based reform such asSimon Stevens, president of global health at United Health Group,and a trustee of the King’s Fund:

“More patient power; a greater role for GPs in planning andfunding decisions; a stronger focus on clinical outcomes; NHShospitals with operating freedoms similar to universities; anend to day to day politicisation thanks to arms’ length regulationand an expert national commissioning boarddwhat’s not to likeabout the new NHS White Paper?” (BMJ, 2010).

However, others question whether, in the absence of key shiftsin culture, values and norms in the NHS, yet more organisationalrestructuring represents a triumph of hope over experience(Edwards, 2010). Even the new Commissioning Board has a prece-dent in the NHS Management Board that was established followingthe publication of 1983 Griffiths report. The aim of this was tooversee the running of the NHS e without political interference. Inpractice, it proved impossible to keepMinisters and their officials atarm’s length. Indeed, following the resignation of its first inde-pendent Chair, the Management Board was soon led by.theMinister for Health (Klein, 1990).

The organisational turbulence that is likely to result from theWhite Paper proposals will be even more familiar territory forthose working in the health service. Over the past two decades,commissioning structures have been subject to regular change. In

the 1990s, approximately 100 English Health Authorities, someworking alongside GP fund-holders and Total Purchasing Pilots,acted as purchasers of health services. These bodies, which servedpopulations of around 500,000 were replaced by 302 PCTs(average population 170,000), the number of which was reducedin 2006 to 152 (average population 350,000). The decision toabolish PCTs and to instead give commissioning powers to GPconsortia (the number of which is unknown but, due to risk offinancial instability, is likely to be fewer than the widely toutedfigure of 500 and 600) thus continues a well-known theme of theNHS over the past 30 years: that it is in a state of perpetualreorganisation.

As with previous NHS reorganisations (including the intro-duction of the internal market), the new system of GP consortiahas not been piloted. The limited involvement to date of GPs inPractice-Based Commissioning (PBC) does not provide a sufficientevidence base upon which to introduce such fundamentalreform, not least because there is little evidence that PBC hasbrought about the anticipated shift in GP culture nor had much ofan impact with respect to better services for patients or a moreefficient use of resources (Audit Commission, 2007; Curry,Goodwin, Naylor, & Robertson, 2008; Wood & Curry, 2009). Atthe same time, the assumption that abolishing PCTs and SHAswill reduce the NHSs management costs by more than 45% is an“astounding claim” (Walshe, 2010). GP consortia will have tofulfill the same commissioning functions (from needs assess-ment, priority setting and risk management to provider devel-opment and the implementation and monitoring of contracts) asPCTs. It is a leap of faith to assume that replicating these func-tions across as many as 500e600 organisations will notsubstantially increase transaction costs. Add to this the transi-tional costs of reorganisation, and the White Paper proposalscould prove to be very costly indeed:

“Closing down or merging organisations produces a round ofexpensive redundancies, early retirements, and redeployment,while new organisations find new premises and appoint lots ofnew staff.. . I estimate that the proposed NHS reorganisationwillcost between £2bn and £3bn to implement, at a time ofunprecedented financial austerity.” (Walshe, 2010).

Of course, the Coalition Government may hope that transactioncosts will be reduced by outsourcing the management and admin-istration of commissioning to the private sector. PCT commissionershave increasingly turned to the independent sector for support withcommissioning e both within and outside the Framework forprocuring External Support for Commissioning (FESC) (Naylor &Goodwin, 2010), a policy designed to allow PCTs to purchase addi-tional skills in services such as data analysis and contract manage-ment. However, this does not appear to have addressed concernsabout the commissioning skills deficit nor produced value formoney (House of Commons Health Committee, 2010). Care shouldalso be taken in assuming that the private sector will want to takeover the commissioning roles of GP consortia. As discussed below,unless consortia merge to the size of, say, previous PCTs, they arelikely to face significant levels of budgetary risk. Thus, while mediareports suggest that private sector companies are chomping at thebit to expand their role in commissioning (Campbell, 2010;Timmins, 2010), a cautious foothold (in the form of FESC-styleconsultancy) is likely to present less of a business risk thana wholesale takeover (including the assumption of budgetary risk).Finally, there is no guarantee that GP commissioners will be morelikely to seek management support from the private sector thanfrom known ex-managers of PCTs. As much is acknowledged ina letter written by the BMA Council Chairman to doctors andmedical students, following publication of the White Paper:

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“.We fully expect that consortia will wish to engage withexperienced NHS managers to work with them, both in devel-oping their plans but also in the longer term” (BMA, 2010).

The White Paper proposals thus herald further reorganisation,with the strong possibility that NHS managers will be doing thesame job in yet another new structure, while the private sectorcherry-picks non-risky but lucrative business from commissioningagencies that are struggling with an impossible remit. Plus çachange, plus c’est la même chose.

The role of choice and competition in the NHS: questioningthe assumption base of the proposed reforms

A clear assumption underpinning the NHS White Paper is thebelief that a more decisive market orientation of the NHS will bringabout greater patient choice, improved quality and increased effi-ciency. The Coalition Government is not alone in making thisassumption. Health care reform in both the NHS and internationallyhas been driven by market principles for over two decades. Despitethis, evidence that markets are the key to driving up quality anddriving down costs remains remarkably thin. Indeed, healthsystems in which both the financing and provision of healthservices are administered by government are likely to have theedge with respect to cost containment because they result insignificantly lower transaction costs (Moreno-Serra & Wagstaff,2010; Webster, 2002). Greater choice with respect to providerscan mean greater complexity with respect to contractual arrange-ments. In England, for example, the shift from locally negotiatedblock contracting arrangements to activity-based payments led toadditional data collection, contract monitoring and contractenforcement needs - and significantly higher transaction costs(Marini & Street, 2007).

Empirical evidence that competition is the key to improving thequality of care is also lacking. Due to differences in institutionalcontext, much of the evidence e which comes from the UnitedStates - may not be generalisable to the UK. There are also incon-sistencies in findings which in part reflect the use of differentmethodologies, competition measures, quality measures and so on.One key issue is the extent to which studies control for the con-founding effects of factors that might otherwise influence qualityoutcomes.

Against this background, the conclusion of a recent Englishstudy (Gaynor, Moreno-Serra, & Propper, 2010) should be treatedwith caution. The observation that higher competition betweenhospitals is positively correlated with higher quality (as reflected inlower death rates and shorter lengths of stay) does not necessarilymean that improved outcomes should be attributed to marketreform. As the study itself points out, a significant proportion of thehospitals that were subject to increased competition serveddensely populated, deprived urban catchments. During the periodin question, there was a significant shift in NHS resources towardsthese very areas. This not only resulted in large differences in percapita funding. The results of a government-funded review of theallocation formula (Morris et al., 2007) suggest that urban deprivedareas have received significantly higher allocations relative tounderlying health care need than demographically older, moreaffluent areas (Asthana & Gibson, 2010). Thus, it is as plausible toattribute improved hospital outcomes in these health communitiesto generous funding as to market reform.

Regardless of whether pro-market reform is a ‘good thing’, theextent to which the radical intentions behind the White Paperreforms can be practically translated is open to question. Since theintroduction of the purchaser-provider split, a series of policymeasures have aimed to stimulate the use of market mechanisms in

the health service. In practice, however, marketisation has provedelusive. Independent sector care accounts for less than 5% of acuteexpenditure. This may be as much a reflection of the British publics’limited appetite for market reform (Wallace & Taylor-Gooby, 2010)as a failure on the part of NHS managers to stimulate the market.While NHS patients have a right to choice with respect to hospitaltreatment, those who are offered choice tend to choose their localNHS provider (Dixon et al., 2010).

As the public is unlikely to take kindly to attempts to proactivelystimulate competition if this is seen to threaten local NHS services,tensions exist between the Government’s desire to create a levelplaying field for all providers (public, private and voluntary) whileat the same time strengthening local democratic legitimacy. Thereis also professional opposition to market reform. The BritishMedical Association (BMA) has reaffirmed its belief in the princi-ples of its ‘Look After Our NHS’ campaign, which include caring forpatients through cooperation not competition and reducing com-mercialisation. Thus, Monitor’s duty to promote competition mustalso be reconciled with GP commissioners’ interests in supportingcollaboration and service integration.

The White Paper places great emphasis on the role of GPcommissioners in transforming the NHS. Thus, the fact that there islikely to be significant variation in thewillingness and ability of GPsto take on this role should be taken seriously. Considerable faithappears to have been placed in the example of early wave fund-holding and total purchasing pilots, the relative ‘success’ of whichmay have been due to the skills and enthusiasm of a particular (andnot necessarily representative) cohort of GPs or, indeed, to biasedfunding (Jones, 2009). Consequently, the extent to which a suffi-cient number of GPs will engage meaningfully in the process(rather than calling upon ex-managers from PCTs or from theprivate sector to drive commissioning) is open to question. Even ifa critical mass of GPs can be effectively engaged, there are likely tobe differences in competencies with respect to commissioningacross different clinical areas and different levels of servicedelivery. According to a survey commissioned by Rethink, themental health charity, GPs feel more equipped to commissiondiabetes and asthma than mental health services. They may also bebetter placed to redesign primary and community services than tocommission care from secondary and other providers (Smith,Wood, & Elias, 2009).

The point is that the belief that a greater market orientationwilldeliver the quality and efficiency improvements envisaged by theCoalition Government and that GPs are best placed to drive thisprocess is based on ideological assertion rather than hard empiricalevidence. This is not to say that the White Paper proposals cannotwork, but it is as well to acknowledge that they are based on an actof faith and, as such, should be properly piloted.

Safe in their hands? implications of the White Paperproposals for financial stability

Good housekeeping (doing more with less) is a key theme inCoalition Government rhetoric. The need to cut waste and improveproductivity has been highlighted as a top priority across allGovernment departments, including health. Blaming the previousLabour administration for increasing public sector expenditure toa level that was neither justifiable nor sustainable, the newGovernment has been at pains to stress that it is possible to makeswingeing cuts without compromising service quality or equity.The sub-text is that the Coalition parties can be trusted to act fairlyand responsibly: public services are safe in their hands.

Although the NHS has been relatively protected from cuts, theWhite Paper proposals introduce the potential for considerablefinancial instability with important implications for service

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delivery and equity. Two developments are of particular signifi-cance. The first is the creation of GP consortia that may be too smallto manage financial risk. The second is the proposal to shiftresponsibility for public health to Local Authorities.

GP consortia: why size matters

The key to reducing financial risk is to ensure that allocatedbudgets (which reflect ‘expected’ costs) are closely in line withactual costs. This is determined by a number of factors, includingthe range of health care events (with respect to cost and frequency)that are to be purchased from allocated budgets; the predictiveaccuracy of the allocation formula; and the size of the population towhich resources are allocated.

While risk adjustment models are available that can predictaround 30% of individual level prospective use (Winkelman &Mehmud, 2007), such results tend to be yielded for specific pop-ulations (e.g. the chronically ill, patients at risk of re-hospital-isation). For obvious reasons, it is more difficult to predictindividual level use in general populations, models tending toexplain around 10% of variation in prospective expenditure. This iswhy giving a fixed NHS ‘budget’ to every citizen would make nosense (Martin, Rice, & Smith, 1997). The vast proportion of healthcare spending at an individual level is unpredictable, so somepeople would not need to use their budgets while others wouldrequire significant additional funds.

For this reason, risks are ‘pooled’ or aggregated into largerpopulations in which the unexpected expenditure incurred byhigh-cost individuals can be offset by lower demand from others(Smith & Witter, 2004). In insurance-based health systems, riskpools are not always geographically contiguous, either because ofcompetition or because funds cater for specific population groupssuch as employees and older people. As noted above, such targetingcan improve accuracy with respect to measuring actuarial risk. Inthe NHS, by contrast, risk pools have been geographically based,PCTs purchasing services for general populations.

There are also differences in the mechanisms available to offsetthe risks of unpredictable costs. In insurance-based systems,insurers or ‘sickness funds’ may provide policies that meeta minimum standard level of care (i.e. pay for a fixed number ofservices and/or a percentage of costs), requiring additionalpremiums or co-payments for more comprehensive coverage. Atthe other extreme, they may resort to adverse selection (i.e. theexclusion of high risk patients). In the NHS, purchasers commissiona comprehensive range of services for their patients and it isdifficult (nigh impossible) for them to select individual citizens.

Due to these key differences, size matters. At present, NHSrevenue resources are allocated to 152 PCTs averaging a populationrisk pool of 350,000. While this is not sufficiently large to offset theimpact of particularly rare and high-cost events (which arecurrently commissioned by NHS specialised services), it exceedsthe 100e150,000 threshold that several studies suggest is theminimum risk pool required to bring the level of financial riskdown to an acceptable level (Jones, 2009; Martin et al., 1997). Withthe introduction of GP consortia, the average size of the populationrisk pool served by commissioning groups could decline signifi-cantly. If, for example, 600 consortia were to be established, thesewould serve, on average, 87,000 patients.

Quantifying the budgetary risk associated with allocatingbudgets formental health services to consortia of this size, the teamresponsible for setting national Practice-Based CommissioningMental Health allocations estimate that around 26 consortia wouldoverspend by at least 5% each year in order to meet the legitimatemental health needs of their patients. Two or three consortia eachyear would overspend by at least 10% (Asthana et al, 2010). Thus,

the establishment of as many as 600 consortia would expose thehealth system to undue budgetary risk.

In order to reduce the potential for financial risk, consortia willeither have to merge to the size of previous PCTs (an outcomewhich would raise legitimate questions about the purpose of thisreorganisation) or enter into complex and potentially costly risksharing agreements with other consortia. Another alternative isthat the NHS Commissioning Board assumes responsibility fora more comprehensive range of national and regional specialisedservices than is currently envisaged (which might also providea mechanism through which to push forward the privatisationagenda). As, according to the Government’s consultation documenton commissioning, the approach to managing financial risk isexpected to “evolve over time” (Department of Health, 2010b,p. 25), it is difficult to predict what will unfold. In all likelihood,however, the outcome will be difficult to reconcile with the visionof an NHS that is totally ‘locally driven’.

Implications of proposals for public health

At the time of writing, the Coalition Government has yet topublish its detailed programme for public health. However, theWhite Paper signals a number of significant changes, includingproposals to ring-fence the public health budget and transferresponsibility for local health improvement from PCTs to LocalAuthorities.

These proposals should be broadly welcomed. A significantproportion of NHS funding (around 13% or £10bn of PCT revenue) iscurrently allocated to health inequalities. While part of this isdesigned to address unmet need, it is generally accepted that themain focus of a health inequalities strategy should be to preventinequalities from arising in the first place. However, the extent towhich the funding has been used to drive forward a truly preven-tive agenda is open to question. Due to the failure to ring-fencepublic health monies, health inequalities budgets are all too oftenspent on other priorities (House of Commons Health Committee,2009). As most of the determinants of health inequalities lieoutside the remit of the NHS (Asthana & Halliday, 2006; Marmot,Allen, Goldblatt, & Boyce, 2010), it is also legitimate to proposethat this element of NHS funding would be better spent on services(e.g. early years, education, youth, employment, housing, financialand social services) that might address the causal pathways thatgive rise to health inequalities.

Yet, it will be difficult to separate public health from the NHSwithout causing significant financial turbulence. At present,revenue allocations to PCTs are informed by research conducted bya team from BrunelUniversity (Morris et al., 2007). Their report,Combining Age Related and Additional Needs (CARAN) responded toa number of concerns about the Allocation of Resources to EnglishAreas (AREA) formula (which distributed NHS funding to PCTs from2003/2004 to 2008/2009). Resulting allocations based on CARANconfirmed suspicions that the AREA formula had overestimated thehealth care needs of younger deprived and urban areas andunderestimated the needs of demographically older areas (Asthana& Gibson, 2008; Stone, 2007). Despite this, overall allocations didnot fundamentally change. Due to an explicit ministerial decision tokeep the distribution of funding between the most and leastdeprived areas in line with the previous formula, the gap betweenCARAN and AREA allocations for deprived populations was filledwith anew ‘Health Inequalities’ adjustment.

Whilst the overall Health Inequalities element amounts to 13%of the total allocation, the proportion of PCT-level allocations thatderive from the Heath Inequalities element varies enormously. Inseveral urban PCTs, the figure exceeds 20% of total funding (Asthana& Gibson, 2010). It is extremely unlikely that PCTs are spending

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anything approaching this amount on interventions that addresshealth inequalities. In 2008/2009, total expenditure on ‘HealthyIndividuals’ (i.e. people who have ‘no current problems but who areinvolved in programs for prevention of illness and promotion ofgood health’) amounted to £1.83 billion, considerably less than the£9.85 billion allocated to health inequalities in 2009/2010. Thus, inall likelihood, a significant proportion of the health inequalitiesbudget is being spent on other activities such as maintaining acuteservices or strengthening World Class Commissioning competen-cies (an area in which several urban deprived PCTs have madesizeable investments and performed well).

It is currently uncertainwhether future allocations will be basedon the CARAN formula or the capitation models that have beendeveloped for practice-based commissioning (Asthana, Gibson,Bailey, Hewson, & Dibben, 2009; PBRA Team, 2010). Whichevermodel is used and whichever approach is taken to adjust for unmetneed and additional needs for NHS preventive, screening andtherapeutic activities, it is likely that core health care budgets willfall considerably short of current overall allocations in the mostdeprived, urban areas. This means that, should the CoalitionGovernment succeed in both reducing the health inequalitiesadjustment (the figure of 4% is currently being bandied around) andtransferring responsibility for public health funding to LocalAuthorities, urban deprived communities stand to lose a significantamount of NHS funding.

In the past, damping mechanisms (minimum funding increaseguarantees) have been used to reduce the effects of such shifts inrevenue support. Given the financial climate, however, theGovernment may be less disposed to protect health communitiesthat appear to have been very generously funded with respect tounderlying health care needs. To do so would arguably weakenpolicy drivers to improve efficiency. Thus, there is a real risk thatthese proposals will result in financial volatility and significantdisruption to services and that the poorest communities will sufferthe brunt.

Conclusion

The White Paper proposals are undoubtedly bold and, havingbeen released within two months of the new Government’s office,have prompted the observation that Andrew Langsley, the newSecretary of State for Health, is a ‘man in a hurry’ (Hawkes, 2010).Only time will tell whether this will earn him a reputation forcourageous leadership or reckless tyranny. However, as theproposals suggest a disregard for the lessons of the history of NHSreorganisation, for hard evidence about the benefits of marketreform, and for the real world limitations to translating a rhetoric oflocalism and democratic legitimacy into reality, one is reminded ofthe adage that “fools rush in where angels fear to tread”.

Much, of course, will depend on how the Coalition Governmentresponds to the various consultations on the White Paper. Bydemonstrating a willingness to listen to its detractors, many ofwhom are not driven by ideological objections to market-basedreform but by concerns to ensure that any further changes to theNational Health Service are based on evidence, piloting and eval-uation, the Government could go a long way towards assuringcritics that the NHS really is safe in its hands.

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