Successful public reorganisation and reform is difficult for a number of reasons – I wrote a book about this in relation to healthcare Policy Press published in 2009 (advert over), but a central issue is working out exactly what we want our public services to achieve.
When we think of goals for public services we ask for many things. We want our services to be efficient, but also user-focused (or customer-focused if you prefer, although whether we are customers is a matter for another day), and we get cross when things aren’t fair (in the UK, think of arguments about ‘postcode lotteries’ for example). The problem these things are often pretty contradictory.
For one thing, it’s extremely difficult to define exactly what we mean by ‘efficiency’ – there are tomes out there that go through so many different versions that it can be hard to know what to think. I prefer to keep things simple, as in the old business aphorism that efficiency is doing things well, effectiveness is doing the right things, and economy is dong them at lowest reasonable cost. Lots of definitions of efficiency roll economy in with them, and that seems to me to have some merit. So when we’re talking about doing things efficiency we tend to mean something along the lines of doing things well and not wasting resources. Something about linking inputs and outputs together in cost-effective way, but also delivering a good service at the same time.
One way of solving achieving greater efficiency is to organise production or service delivery according to the scarce resource. In the NHS, this is clinical (especially doctor) time. And that’s kind of what the NHS has always done. At the extreme, it means booking blocks of patients in to see a doctor all at the same time (as in bad practice in outpatient appointments) because the patients can work around the doctor’s limited resource. In some respects, this is really efficient, but it’s not really doing the job ‘well’, at least as far as any sensible independent observer of the service would conclude.
It’s also, of course, not terribly user-focused. If we were organising appointments around users, we’d be allowing them to choose when they saw clinicians. But that isn’t terribly efficient (or very fair, which we’ll come to in a moment). It’s not terribly efficient because it means that patients will want to see doctors at their own convenience rather than the doctor’s. This may result in doctors having periods of activity (probably in the morning, evenings and weekends, when patients would prefer to see them), and other times when few people want to make appointments (typically, at the moment, when the appointments are usually offered to them). It would probably also mean that we need doctors ‘spare’ so that we can see them at short notice. This would mean that user-focused healthcare requires highly-qualified doctors to work unsociable hours (which is going to cost lots, jeopardising efficiency), or to have spare doctor resources available to see us at short notice (which again means slack, jeopardising efficiency again).
Then there is fairness. Many of us think that fairness is very important, but of course, there’s many kinds of fairness as well. We might want to define fairness in terms of equality of access to services, but that is pretty fraught in terms of healthcare – it would mean that we all get to see the doctor we want on a first-come, first-served basis, so it would be independent of clinical need. At present we use GPs as gatekeepers to decide who has access who should access to specialist and community care, and who should not, justified on the grounds that GPs can better understand what is fair – on the basis of clinical need. If you have a significant health need, you should be seen earlier. But one view of widening patient choice would suggest that patients be allowed to decide who they get to see and when – by-passing the gatekeeper function. So it depends what you mean by fair – do you want equality of access, or access on the basis of clinical need?
Then of course there is the idea that the NHS should be fair by providing equality of outcome or equality of service. By equality of outcome I mean fairness on the basis of those with equal needs (as near as possible) having the same result wherever they are treated. That’s a very big ask – doctors’ skills vary, as do preferred treatments. Equality of service would mean that patients with the same needs are treated the same way (including the time they have to wait). That’s not quite the same thing as equally of outcome, as it is possible that different treatments could lead to the same outcomes (and so still achieve equality of outcome), but that would not be equality of service. We often get very cross when some services are available in some parts of the country but not others (‘postcode lotteries’ again), even if representatives of each health area argue they provide appropriate treatments.
Still with me?
Then we get the muddle of putting all this together – trying to simultaneously achieve efficiency, user-focus, and fairness. We want a health service that does all three, but it may well be we have to decide which is the most important, and accept that the others take some kind of a hit. That doesn’t mean we should accept getting the same outpatient appointment time as ten other people (even if we are prioritising efficiency) or that patients should be able to access health services more quickly than others who need them more (even if we prioritise user-focus), or that we we shouldn’t expect care to meet our needs as individuals (even if we prioritise fairness).
But it does mean that we have to be clear that there are no magic answers to health reform – not from top-down reorganisation, or from competition (don’t get me started on that), or from greater local democracy (but we do need more of that). Improving our health services is hard work. We need to stop messing about with costly and ineffective organisations and get on with that work.