The national health service plan: further reform of British health care?

Voice or choice? Patient and public involvement in the National Health Service in England under New Labour

Involving patients, caregivers, and citizens in health care and health policy has been recommended by international organizations for over a decade. This article focuses on developments in England under New Labour, places them in the context of broader health policy, and assesses them in the light of the limited empirical evidence. The authors consider a range of possible explanations for these developments. They suggest that we need to distinguish between individual and collective forms of patient involvement, and they chart patient and public involvement in England before New Labour and in three distinct phases under New Labour. There has been a significant extension of opportunities for individual patients and the public to communicate their views, albeit with twists and turns in the policy over time. The authors explain these developments in terms of New Labour's ideological attachment to pragmatism and the Third Way, political calculations about the need to reinvigorate political culture, and attempts to enhance cost-effectiveness. Patient and public involvement seems to be here to stay, but whether this will result in greater equity and a real shift in power away from professionals to citizens and patients is another matter.

Breaking down barriers: integrating health and care services for older people in England

Like many other post-industrial societies, England is facing demographic and political pressures to reduce the fragmentation of services for older people. Moreover, current government policies emphasise collaboration and 'partnership', particularly between health and social care services. Recently, two new policy initiatives have enabled the full integration of services to take place, involving formerly separate health and social care organisations-between family doctors (general practitioners) and community health services, and between health and social services organisations. Both initiatives also allow the pooling of previously separate funding streams. This paper presents findings from evaluations of these two initiatives. Drawing on this evidence, the paper concludes that structural integration can transform preoccupations over narrow sectoral responsibilities and boundaries to a 'whole systems' paradigm of service planning and delivery. However, major internal barriers to integration may remain: these include professional domains and identities, and differential power relationships between newly integrated services and professionals. Moreover, the success of these new horizontal, inter-organisational arrangements is profoundly influenced by the wider policy environment and by vertical relationships with national government. Together, these pressures exclude the voices of older people, and therefore call into question whether the considerable organisational upheaval of service integration will be able to deliver the changes valued by older people themselves.

Back to the market: yet more reform of the National Health Service

Yet more reform of the National Health Service in England has been announced by the Department of Health. In opposition, the Labour Party criticized the creation of an "internal market" for health care by the Conservative government, but five years into the Blair administration, market incentives are to be reinvigorated and the private sector is to be embraced in ways not seen hitherto. New guidance signals the introduction of competitive contracting using cost-per-case currencies, more choice for patients in where they will receive hospital treatment, and the freeing of NHS care providers from the direct political control of ministers. It is intended that the monopolistic features of the NHS in England should give way to greater pluralism, in particular through contracts with privately owned health care organizations. However, there is little evidence to suggest that these policies will be effective, and a number of practical problems may obstruct implementation.

Widening the debate? Consultation and participation in local health care planning in the English and Swedish health services

In both English and Swedish health care, there is currently much interest in encouraging public consultation and participation in public service planning in order to improve quality, enhance local accountability, and help to inform and legitimize difficult decisions about health care priorities. This article explores the progress of local budget holders for health services in the two countries--primary care groups/trusts in England and county councils and municipalities in Sweden--in developing consultative and participative processes. Using secondary and primary research methods, the study identified much activity among English primary care groups/trusts, although with less certainty of outcome. In Sweden, initiatives were limited to a few county councils, were more distinctive, and in the case of one county council, resulted in the sustained channeling of citizens' views. In comparing and contrasting the approaches in the two countries, the authors note the importance of political cultures and institutional arrangements as well as, more generally, the complexities and challenges of consultation and participation in health care planning.