An independent NHS: what’s in it for patients and citizens? DAVID A.L. LEVY Picker Institute Europe The Picker Institute works with patients, professionals and policy makers to promote understanding of the patient’s perspective at all levels of healthcare policy and practice. We undertake a unique combination of research, development and policy activities which together work to make patients’ views count. There are three key strands to our work: • Measurement – researching and evaluating patients’ experience • Improvement – leading initiatives that make improvements happen • Policy – building evidence to inform health policy. ISBN 1 905945 18 3 and 978 1 905945 18 4 © Picker Institute Europe 2008 Items may be reproduced free of charge in any format or medium provided that they are not for commercial resale. This consent is subject to the material being reproduced accurately and provided it is not used in a derogatory manner or misleading context. 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Contents Acknowledgements 2 About the author 2 Foreword 3 Angela Coulter, Chief Executive, the Picker Institute Overview 5 Introduction 7 1 Public service reform agendas, Public Value and valuing the public 9 2 The BBC, Public Value and its relevance to the NHS 13 3 The theoretical case for increased NHS independence 20 4 The BBC and the NHS – similarities and differences 29 5 What do citizens and patients want from the NHS? 32 6 Organising principles for a more independent NHS 36 7 An outline structure to deliver patient and citizen interests within a more independent NHS 45 8 Commentary by the Picker Institute 48 9 Conclusion 54 References 56 Appendix: models for NHS independence 61 Copyright Picker Institute Europe. All rights reserved 2 An independent NHS: what’s in it for patients and citizens? Acknowledgements I would like to thank Angela Coulter and Don Redding of the Picker Institute and Jo Garcia for their help, contributions and comments; and Patrick Diamond, Harry Cayton and Professor Brian Edwards for some very helpful conversations early on in my research. The approach adopted here is my own viewpoint. About the author Dr David A L Levy is an Associate Fellow at the Said Business School at Oxford University, and a consultant in the areas of media policy and strategy and public service reform. He worked as Controller, Public Policy at the BBC from 2000 until September 2007 where he led the policy dimensions of the BBC’s Charter review and was in charge of the BBC’s public policy and regulatory strategy in the UK and EU. He previously worked as a journalist; as a radio producer and reporter on File on 4; as a TV reporter on Newsnight, and as Editor of Analysis on Radio 4. He is the author of Europe’s Digital Revolution: Broadcasting regulation, the EU and the Nation State, Routledge, 2001 and of The European Information Society, in Rhodes M (Ed), Developments in West European Politics, Macmillan, 2003. Copyright Picker Institute Europe. All rights reserved 3 An independent NHS: what’s in it for patients and citizens? Foreword Angela Coulter, Chief Executive, the Picker Institute Whenever the Picker Institute, which researches patients’ experience of healthcare and how to improve it, is confronted with new initiatives and reforms in the health service, it asks some simple questions: • who benefits? • specifically, do patients really benefit? • has this clearly been done to focus on patient needs? • does it accord with what patients tell us that they value and want? • will it work, for patients? In 2007 a debate over whether the NHS should be independent from government, and/or have a formal constitution, reawakened with a vengeance. So we began asking our questions again. Did patients – as opposed to politicians, or clinicians, or managers – really stand to gain anything from the various constitutional proposals? In what ways, if indeed any, did such proposals really focus on benefits to patients? Were they paying attention to what patients value and want? And if we did want to design a new constitutional arrangement, how could we be sure that improved outcomes for patients would be an integral part of its aims? What would be the essential elements that would take us further towards that elusive ‘patient-centred NHS’ to which everyone subscribes, but which patients experience too infrequently? To help it with this interrogation, the Picker Institute decided to commission an independent policy analysis which could draw on another recent experience of constitutional review and the redrawing of objectives in a public service – the case of the BBC and its new Charter from 2007 to 2016. Why? Not because we necessarily want a ‘Charter model’ for the health service, but because in this particular review we felt there may be lessons and approaches relevant to today’s NHS. Copyright Picker Institute Europe. All rights reserved 4 An independent NHS: what’s in it for patients and citizens? The BBC, a longstanding, traditional, paternalistic national broadcaster, was confronted with some challenges that would sound familiar to any analyst of the future of the health service: • new technological advances and the challenge of getting the best use from them • changing expectations and behaviour among large sections of its users • the increasing potential – and user demand – for a decisive shift away from top-down paternalism towards engagement and interaction with users, and responsiveness to their values and preferences • pressure to redefine the service’s purposes, moving away from process (broadcasting) towards outcome measures (impact on the service users and wider society). Who better, we thought, to ask for help than David Levy, who had recently left the BBC after seven years leading its policy function, helping to steer it successfully through the Charter review. When, in 2003, a small team was convened within the BBC to map out the legitimising arguments for its future, David was part of that developing, radical conversation about using the approach of ‘Public Value’ to inform the BBC’s mission. ‘Building Public Value’ became the Corporation’s future manifesto, determining both the purposes driving all the activities of the BBC, and the means by which its success or failure would be measured. David is modest about stepping into health sector territory. But we believe he has produced both a highly stimulating analysis and an exciting first description of the essential elements that should be included if we want a true patient focus when redrawing the settlement between government, the health service, health professionals and, most importantly, patients and the public. The Picker Institute agrees with his analysis and takes ownership of its recommendations. I am delighted to present his analysis here, and believe it deserves very serious consideration by all those who may now or in the near future be called upon to work to establish a new constitution, and/or greater independence, for the NHS. We stand by to welcome all expressions of interest in debating these ideas further, and all constructive criticism. Copyright Picker Institute Europe. All rights reserved 5 An independent NHS: what’s in it for patients and citizens? Overview Greater NHS independence is on the political agenda. But how can we be sure that if it occurs it will actively promote patient and citizen interests? Past reorganisations have been strong on proxies for these interests – measures which are supposed to result in responsiveness but are only indirectly related to patients’ values, whether through focusing on internal markets, top down targets, or greater patient choice. These have fallen short of ensuring that the NHS delivers a completely patient- and citizen- focused service. Indeed, at times the proxies have distorted incentives and produced perverse outcomes. So while NHS spending has increased and there have been notable improvements in some key areas, we also know that the NHS is insufficiently responsive to the needs of patients and citizens, whether that is judged by access to healthcare, for example through out of hours GP services, or by the nature of patients’ engagement with health professionals, or by other indicators. This paper argues that the theoretical case for greater NHS independence is strong. However, a further wave of reorganisation should only be considered if the reformed and more independent NHS can be designed in a way that puts the interests of patients and citizens at its core. The paper examines recent trends in public service management and the move to a Public Value approach elsewhere, to assess possible lessons for the NHS. It asks whether the BBC of the 2007 Charter might offer a model for the NHS, as an organisation where there are: strong imperatives for arms length relations with government; inbuilt incentives to engage its users; a long term framework agreement and funding settlement; and where we all have interests both as consumers and as citizens. The paper finally builds on the BBC Public Value model to develop some key criteria for a reformed NHS that could combine much higher levels of independence with clear patient- and citizen-focused objectives, and a new approach to ensuring accountability to patients, citizens and other stakeholders. Copyright Picker Institute Europe. All rights reserved 6 An independent NHS: what’s in it for patients and citizens? Structure of this report Section 1 describes how the concept of ‘Public Value’ may act as a corrective to some of the dangers now apparent in the public service reform agenda of the last decade.