GreatExpectations

Achievingasustainablehealthsystem
JenniferRankinandJessicaAllenwithRichardBrooks

Executivesummary
©ippr2007
2 GreatExpectations|Aboutippr

Aboutippr

TheInstituteforPublicPolicyResearchistheUK’sleadingprogressivethinktank,producingcutting-
edgeresearchandinnovativepolicyideasforajust,democraticandsustainableworld.

Since1988,wehavebeenattheforefrontofprogressivedebateandpolicymakingintheUK.Through
ourindependentresearchandanalysiswedefinenewagendasforchangeandprovidepracticalsolutions
tochallengesacrossthefullrangeofpublicpolicyissues.

WithofficesinbothLondonandNewcastle,weensureouroutlookisasbroad-basedaspossible,while
ourinternationalandmigrationteamsandclimatechangeprogrammeextendourpartnershipsand
influencebeyondtheUK,givingusatrulyworld-classreputationforhighqualityresearch.

Trustees
MrChrisPowellChairman
MrJeremyHardieTreasurer
DameJaneRobertsSecretary

ProfessortheLordKumarBhattacharyya
LordBrookeofAlverthorpe
LordEatwellofStrattonStMargaret
LordGavronofHighgate
LordHollickofNottingHill
ProfessorJaneHumphries
ProfessorRogerJowell
LordKinnockofBedwellty
MsFrancesO’Grady
MsKateParminter
DrChaiPatel
SirMichaelPerry
MrDavidPitt-Watson
MrDavePrentis
LordPuttnamofQueensgate
LordReesofLudlow
BaronessWilliamsofCrosby
BaronessYoungofOldScone
 3

Abouttheauthors

JenniferRankin wasaResearchFellowatippr,whereshewroteseveralreportsfortheHealthandSocial
Careteam,includingMeetingComplexNeeds:theFutureofSocialCare(2004)andMentalHealthinthe
Mainstream(2005).Sheiscurrentlyafreelancejournalist.

JessicaAllenisheadofHealthandSocialCareatippr.Sheisco-authorofEquitableChoices forHealth
(2005).PriortothissheworkedattheKingsFundwheresheco-authoredHealthintheNews (2003)
andFindingoutWhatWorks (2004).ShehasalsoworkedattheLondonSchoolofEconomicsandat
Unicef,NewYork.

RichardBrooks iscurrentlyaSeniorPolicyAdviserattheDepartmentforChildren,SchoolsandFamilies.
UntilAugust2007hewasanAssociateDirectoratipprandledtheinstitute’spublicserviceswork.Prior
tothathewasResearchDirectorattheFabianSociety,andhehasalsoworkedinthePrimeMinister’s
StrategyUnit,theLabourPartyPolicyUnitandtheinvestmentbankWarburgDillonRead.Between2002
and2006hewasaTowerHamletsCouncillor,andheiscurrentlyagovernorofBethnalGreenTechnology
College.
4 GreatExpectations|Ackowledgements

Acknowledgements

ipprisextremelygratefultoitsfundersfortheirgeneroussupportofthisproject.Withoutthemitwould
nothavebeenpossibletodothiswork.TheyareGlaxoSmithKline,Merck,Sharpe&Dohme,the
PharmaceuticalAssociationofGreatBritain,andWyeth.WeareparticularlygratefultoLouisCoiffait,
CatherineMcGovern,GillMarkham,RosMeek,KatyMunns,GopaMitraandStephenRea.

Wewouldalsoliketothanktheotherpeoplewhocontributedtothiswork,atpolicyseminarsandto
otheraspectsoftheresearch.Inparticular,thankstoeveryonewhospokeatourseminars.Weare
gratefultoJohnAppleby,WillCavendish,AnnaCoote,andCliveSmeefortheircommentsonearlier
draftsofthisreport.

Wewouldliketothankallofouripprcolleagues,inparticularJohnCannings,MattJackson,IanKearns,
MirandaLewis,HowardReed,PeterRobinson,KateStanleyandGeorginaKyriacou.

Whilethisprojecthasbenefitedfromtheinputofmanypeople,theviews,interpretationandany
mistakesaretheauthors’responsibilityalone.

Anyomissionsanderrorsremainourown.
 5

Executivesummary

Ithaslongbeenunderstoodthatrisingpublicexpectationsareoneofthemaincostpressuresonthe
healthservice.Thisstudysetouttoassesshowpolicymakerscanreconcilehighandrisingpublic
expectationswiththeneedforahealthsystemthatisfinanciallyandpoliticallysustainable.

Publicexpectations
AneurinBevan,architectoftheNHS,statedin1948,that:‘Weshallneverhaveallwe
need…expectationswillalwaysexceedcapacity.’Sincethen,people’sexpectationshaverisen
dramaticallyandthepressureshaveintensifiedoverthelasttwodecadesaspeoplehavebecomemore
sophisticatedconsumersandricher,bettereducatedandlessdeferentialtoexpertopinion.

Highexpectationsarenotabadthing.Bothastaxpayersandserviceusers,itisrightandnecessarythat
thepublichashighexpectationsaboutwhatpublicservicescandeliver.Thepublic’sexpectationsplaya
vitalroleinholdingpoliticiansandproviderstoaccountandmaintainingmomentumforprogressand
improvement.

However,whenexpectationsbecomeunrealistic,thiscreatesproblemsfortheservice.Thisisbecause
expectations,oftenrefractedthoughthemedia,candrivethehealthsystemininappropriateways.For
example,peopleareoftenattachedtotheirlocalhospitalevenwhenthatdoesnotrepresentthebest,or
eventhesafest,useofresources.Onlyoneinfourpeopleseesvalueformoneyasanimportantfactorto
takeintoaccountwhendecidingwhatdrugsandtreatmentsshouldbeprovided.Withoutpublic
awarenessofthechoicesthatmustbemadeinanyresource-constrainedhealthsystem,unreasonable
expectationscancreatepressuresongovernmenttointerveneindecisionsthatarenotnecessarilyinthe
bestinterestsofthesysteminthelongrun:forinstance,indecisionsaboutlocalhospitalconfigurations
orpromisinguniversalandfreelyavailabledrugsdespitecostconstraints.Thefocusofpeople’s
expectationsalsoreinforcesanunhealthyemphasisontheacutehealthsectorattheexpenseof
improvinghealthmorebroadly,whichunderminesthefinancialsustainabilityoftheNHSinthemedium
tolongterm.

InthisreportweassessexpectationsasoneofanumberofcostpressuresontheNHS.Wedescribethe
interrelationshipsbetweenexpectationsandhealthpolicysince1948.Particularly,weassesshow,since
1997,theLabourGovernmenthasattemptedtomeetexpectationsthroughreformandincreased
fundingbuthassimultaneouslyraisedpeople’sexpectations.Weassesswhatinfluencespeople’s
expectationsaboutthehealthsystemandpresentoriginalresearchshowinghowexpectationsofaccess
tohealthcareandtreatmentsarerunningaheadofgovernmenttargets.Weexaminehowexpectations
varyacrossgroupsofthepopulation,particularlybetweenpatientsandthewiderpublic,andweassess
whethergovernmentscanevermeetexpectationswithinthecurrentstructureofthehealthsystem.

Highexpectationsandthepoliticalvalueattachedtosatisfyingthemcanbeparticularlydamaging
becauseofthewaytheEnglishNHSisorganised.Strongcentralcontrolandaccountabilityhaveledto
politicalinterferenceindecisionsthatshouldbemadebylocalbodiesorindependentorganisations.We
proposedistancingnationalpoliticiansfromday-to-daydecision-making,withoutlosingcrucialnational
politicalaccountability.Weargueformorelocallegitimacyforhealthsystemdecisionsthroughstronger
6 GreatExpectations|Executivesummary

localaccountabilityandpublicengagementandthroughtheintroductionofPrimaryCareTrust(PCT)
foundations.AlloftheseideasshouldbeexploredfurtheraspartoftheNHSNextStageReview,being
conductedbyProfessorAraDarzi,andbereflectedinanewNHSconstitution.

Thepressuresonspending
SincethebeginningoftheNHS,professionalsandpunditshaveclaimeditisunaffordable.Wehavejust
seenthefastesteverincreasesintherateofgrowthinhealthspending.IntheUKthepercentageof
GDPspentonhealthhasrisenmarkedlyfrom6percentin1990to9.2percentin2007-08.Thishas
beenfundedthroughincreasedNationalInsurancecontributionssince2001,somethingthatprevious
administrationsprobablywouldhaveregardedasbothunaffordableandunacceptable.Butthe
appropriatelevelofspendingchangesovertime.Ultimately,affordabilityissomethingwechoose.

Thecombinationofageingpopulations,risingconcernsaboutpublichealth,theincreasingcostsof
drugs,technology,andworkforce,heighteneddemandforhealthcareandrisingpublicexpectationsall
putpressureonhealthspendingtogrow.Politiciansareacutelyawarethatsupportforpublicservices
alsodependsontheeffectivenessandefficiencyofspending.In2000,theGovernmentwasconcerned
thatdecliningpublicconfidenceinthehealthsystemmightthreatentheviabilityoftheNHS.
PolicymakersrealisedthatiftheNHSwasgoingtosurviveasauniversalservice,ratherthanasa
residualistserviceforthepoor,thereneededtobeawaytopreventthemiddleclassesfrombuyingtheir
wayout.Thismeantthatthegapbetweenpublicexpectationandperformancehadtonarrow.The
Governmenthadtomeetexpectationstoguaranteethesustainabilityofauniversalhealthsystem.

Whatshapesexpectations?
Governmentandpolicymakersplayasignificantroleinshapingpublicexpectations.Clinicianshave
accusedministersofatendencytopromisemorethancanbedeliveredandraisepublicexpectationsto
levelsthatcannotbemet(HamandAlberti2002).Politiciansshapeexpectationsnotonlythroughwhat
theysay,butalsothroughwhattheydonotsay.Politicianshavenotstartedapublicdebateonthelimits
ofhealthcare.Bothgovernmentandoppositionpoliticianshavecontributedtotheimpressionthatthe
NHScandoeverything.Thisisnotapartypoliticalissue.Politiciansofallpartiescolludeintheideathat
everythingispossibleandthatthelimitstoimprovementonlyexistintheplansoftheiropponents.

Mediareportsalsoinfluencepublicexpectationsaboutthehealthsystem.Themediasometimes
encouragespeopletobelievethestateofpublicservicestobeworsethantheyare.Thereisevidence
thatNHSstaffinfluencepatientdissatisfactionandnegativeopinionsfromsomestaffareakeydriverof
overallsatisfaction.Itissometimesclaimedbygovernmentpolicymakersthatchangesintheprivate
sectorareshapingpeople’sexpectationsofpublicservices.Justaspeoplehavegreaterchoiceand
flexibilityoverwhereandwhentheyshopandwhattheybuy,theyexpectsimilarflexibilityinthedelivery
ofpublicservices.Theyalsoexpecttheexperienceofcare,notjusttheoutcomes,tobeofhighquality.

Risingexpectations
SincetheNHSwasfounded,therehavebeenchangesinhowpoliticianshavemanagedpublic
expectations.DuringtheearlyphaseoftheNHSpublicexpectationsweredampenedbycostconstraints.
Bythe1980sthisapproachdisintegrated,amidincreasinganxietyaboutunderfundingandagrowing
sensethattheNHSwasfailingtomeetpublicexpectations.Since2000,theGovernmenthasactively
soughttoraiseexpectations,firstaboutthequalityandresponsivenessoftheNHS,andsecondabout
howtheNHScanimproveservicesforthosegroupsithasservedtheleastwell.

Since1997theGovernmenthastriedtomeetrisingexpectationsthroughincreasedfundingandsystem
reformandthroughensuringminimumqualityservices,throughregulation,nationalframeworksand
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improvedaccess.However,despiteimprovementsinmanyareasthereisstillastrongpublicperception
thatthehealthsystemisinadequateandfailingtomeetexpectations.

Thereisalsoaperceptionthatthepublicismoredemandingthaneverbefore.Oneofthedominant
themesofthepublicservicereformdebatehasbecometheneedtoensurethatpublicservicesmeetthe
attitudesandexpectationsofthepublic.ThisisreflectedinthenewPrimeMinister’sassertionin2007
thatthehealthserviceishistoppriority,andthatitneedsto‘respondto…citizens’needsand
expectations’.

In2006ipprcommissionedasurveyofthepublicabouttheirexpectationsofaccesstoNHSservicesand
availabilityofdrugsandtreatments.Overall,people’sexpectationsaboutspeedofaccesstoservicesare
runningaheadofthecurrentaveragewaitingtimes.Highexpectationsarenotconfinedtoanyparticular
groupinsociety,butaresharedbymenandwomen,peopleofdifferentagesandsocialbackgrounds.
However,olderpeoplethinkthattheeffectivenessofdrugsandtreatmentsandtheirvalueformoney
shouldbeimportantfactorsindeterminingwhethertheyshouldbeprovided,whileyoungeragegroups
arelesslikelytoperceivelimitsonNHSresources.

Otherstudieshaveshownthatthereissignificantvariationinattitudesbetweenthepublicandpatients.
ThepublichastworelationshipswiththeNHS.Theyarepatientswhoareconcernedwithwhathappens
tothemwhentheyusehealthservices.Buttheyarealsocitizenswhohaveabroaderinterestinthe
healthofthewidercommunityandachievingacost-effectivehealthservice.Thesetwoaspectsoften
conflict,especiallywhendecisionshavetobemadeaboutallocatingscarceresources.

Inthefuturetherewillbenoslackeninginexpectations,buttherewillbeafallintherateofgrowthof
spendingafter2008.Thissuggeststhatthegapbetweenpublicexpectationsandhealthsystemcapacity
willwiden.Itispossibletopredictthatdebatesaboutrationingwillbecomeprominentagain.Withouta
clearerframeworkforrationing,therewillbeincreasingpressureforconflictstoberesolvedbythecourts,
ratherthanNICE(theNationalInstituteforHealthandClinicalExcellence).Dissatisfactionwithhealth
serviceperformancemaywellincreaseandcallswillbemadefornewfundingsystems,forachangeof
governmentpolicy,fornewministersandmoreresources,andcentralgovernmentwillagainfeelthe
intensepressureofdisappointedexpectations.

Conclusionsandrecommendations
Ourargumentisthattheappropriatewaytorespondtohighexpectationsincludesimprovingthe
legitimacyofhealthservicedecisions,alongsideimprovinghealthserviceperformance.Theseissues
shouldbecentraltoProfessorAraDarzi’sNextStageReviewofthehealthservice,whichpresentsa
significantopportunityforimprovingpublicunderstandingofthelimitstothehealthsystemaswellas
addressingtheseissuesoflegitimacy.

Publicexpectationsarenotaone-offproblemtobe‘solved’.Thegoalofourrecommendationsisto
understandhowtodevelopahealthsysteminwhichthepublicisinformedandengagedinthedifficult
decisionsthathavetobemade,wherelocalorganisationshavepowertomakeappropriateand
accountabledecisionsandwherethepublic,theworkforceandnationalpoliticiansunderstandboththe
limitsoftheNHSandwhereitshouldbeperformingbetter.

NosuddenNHSindependence
Thereisnoreasontobelievethatmoreindependencepersewouldsolvethefundamentallypolitical
problemofreconcilingpeople’sunlimitedaspirationswithlimitedcapacity.Itisimportanttoretainand
clarifyministerialaccountabilityforhealthservicesandhealthmorebroadly.Ministersshouldbe
8 GreatExpectations|Executivesummary

responsiblefortheoveralldirectionofhealthpolicy,forimprovinghealthandfortheoutcomesofthe
healthservice.AnindependentboardfortheNHSwouldnotclarifyaccountability;infact,itmayworsen
it.TheboardofanindependentNHSwouldstillhavetomakewhatarefundamentallypoliticaldecisions
aboutallocationofresources,performanceandaccessibility,butwithouteffectivepublicaccountability.

Membershipoftheboardwouldbehighlycontentiousandmayriskspecialinteresttake-over.We
thereforeproposethatmoreindependenceisintroducedthroughoutthecurrentsystem–distancing
ministersfromspecifictypesofresponsibility,suchasdecisionsaboutreconfigurationsofhospitalsand
aboutwhichtreatmentsanddrugsshouldbeavailableontheNHS.Wealsosuggestthatclarifying
centralministerialaccountabilityisaccompaniedbymuchstrongerlocalaccountabilityandlegitimacy.

Availabilityoftreatmentsanddrugs
BasedonevidencefromothercountrieswerejecttheideaofdevelopingalistofcoreNHStreatmentsas
partofanewNHSconstitution.Suchlistsarerelativelybluntinstrumentsandhavenotprovedsuccessful
inothercountries.However,wearguethatrationingoccurseverydayineverysettingintheNHS.Until
thebasicfactofresourcescarcityismorewidelyunderstoodoutsideofthesystem,itwillbeimpossible
todetermineanyprioritiesfortheNHSinawaythatsecuresadecentlevelofpubliclegitimacy.To
ensurethesustainabilityofthehealthsystem,thereneedstobeatransparentandrobustprocessthat
informsresourcedecisions,andthenafairanddemocraticmeansoftakingdecisionsaboutpriorities.We
recommendthatapriorityforfuturespendingplansshouldbetoexpandtheremitofNICEsothatitis
abletoreviewallnewNHSdrugsandtreatmentsbyefficacyvaluewithinareasonabletimeframe.

Publicdebateanddeliberation
Atthemomentpublicdebateaboutthehealthserviceischaracterisedbythedamagingmyththat
certainhealthtreatmentsshouldbeavailablewhateverthecost.Politiciansofallpartieshavefailedto
dispelthismyth.

Weneedtoincreasepublicunderstandingthatthereisrationingortargetedresourceallocation(or
anothertermdeemedmoreacceptable)ateveryleveloftheNHS.TheNextStageReviewisagood
opportunitytobeginthisprocess.Amongitsobjectivesshouldbe:

• Toraisepublicawarenessabouttheneedforresourcedecisions

• Tounderstandbetterwhatitisthatthepublicvaluesinthehealthservice

• Tounderstandwhatdecision-makingprocesseswillgainpublictrustandthereforefurtherthe
legitimacyofthosedecisions.

TheNHSNextStageReviewistherightopportunityforUKcitizenstodeliberateonhealthcarepriorities.
Thisshouldentailavarietyofwaysofconsultingthepublic,includingaseriesofdeliberativeworkshops.
Theendresultshouldbetoproduceadraftstatementofvalues,objectivesandprioritiesforthemedium
tothelongtermtoinformanewNHSConstitution.

Improvedlocalaccountabilityandlegitimacy
LocalmattersaboutservicedeliveryhavetoooftenbecomenationalmattersfortheSecretaryofState.
WeproposetheNextStepsReviewshouldproposetheestablishmentofaFoundationPCT,inwhichlocal
peoplebecomemembersoftheirPCT,andvoteforandsitontheBoard.Directgovernmentinvolvement
inthemanagementofthePCTwouldbereducedandtherewouldbestrongerlocalaccountabilityand
legitimacyandownershipofthedecisionsmadebythePCT.
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In2008theNHSwillbesixtyandnearingtheendoftheten-yearNHSPlanandhighratesofgrowthin
spendingwillfallsignificantly.Thisisatimelymomenttorevisittheaimsandobjectivesofthehealth
systemandhowbesttoachievethem.TheNHSReviewoffersanopportunitytoaddresstheissuesof
howtoinformthepublicdebateaboutourhealthsystem;howtorespondtopublicexpectationsofthe
healthserviceinawaythathaseludedgovernmentforthepastdecade;andhowtocapturethisinboth
institutionalchangeandanewNHSconstitution.Onlybymakingthehealthsystemmoretransparent,
democraticandaccountablecanpoliticianscomeclosertomeetingpeople’shighexpectationsand
supportingthehealthofthenationeffectively.