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TheNEW ENGLAND JOURNAL ofMEDICINE

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a crisis that can be resolved onlyby altering the fundamentalprinciple on which it was found-ed provision of funding fromgeneral taxation, with care be-ing free at the point of use. Al-though the criticism was sparkedby a February report on an in-quiry into shortcomings at one

hospital,1

the problems originat-ed in 2010, when two profoundforces were unleashed on the NHS:public-sector financial austerityand administrative reorganization.Together, these three factors havecreated the current turmoil.

Never before has the NHS hadto cope with no increase in fund-ing for a sustained period. With

rising demand, the NHS is re-quired to improve its productiv-ity at an unprecedented rate of4% per year.2 The government isconvinced that to achieve thisimprovement, two fundamentalchanges are needed.

The first concerns the localcommissioning organizations that

are responsible for purchasinghospital and community servicesfor their geographically definedpopulations of 200,000 to 1 mil-lion people. The 151 existing ad-ministrative bodies called PrimaryCare Trusts, which were led bynonclinical managers, have beenreplaced by 212 Clinical Commis-sioning Groups that are led by

primary care doctors (generalpractitioners [GPs]) who, thegovernment believes, will bemore effective in controlling theuse of the 60 billion (approxi-mately $90 billion) spent on sec-ondary and community care ser-vices. (Spending on tertiar y care 20 billion [$30 billion] will be managed at a nationallevel by a new entity called NHSEngland.) The second means ofachieving better productivity isby increasing the competitionamong providers of hospital and

community services through thegreater use of non-NHS provid-ers (including private for-profit,not-for-profit, and charity orvolunteer organizations).

Prolonged financial stringencyand a reorganization were chal-lenging enough without a high-profile report suggesting that NHShospitals may not be safe.1 The

Can Englands NHS Survive?Nicholas Black, M.D.

The past few months have witnessed the mostintense and prolonged criticism of EnglandsNational Health Service (NHS) in its 65-year histo-ry. Some critics have suggested that the NHS faces

The New England Journal of Medicine

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Francis Report on the inquiry intothe Mid Staffordshire NHS Foun-dation Trust told a sad and trou-bling story of a hospital in whichthe humanity of care in somewards was appalling and in whichthe proportion of deaths deemed

avoidable may have been higherthan the 5% observed elsewhere inEngland and in other high-incomecountries. Despite uncertaintyabout the appropriateness of al-lowing public inquiries to influ-ence policy,3 the government hasresponded by announcing sever-al initiatives: commitment to asimple single rating of the qual-ity of a hospital (despite the factthat an independent expert review

panel established by the govern-ment offered no encouragementfor taking this approach4); a re-view of 14 other hospitals con-sidered suspect on the basis oftheir standardized mortality ra-tios (despite the lack of validityof this measure5); a review of pa-tient safety in the NHS, chairedby Donald Berwick; and the cre-ation of a position for a chiefinspector of hospitals to strength-en the existing quality regulator,the Care Quality Commission(despite a lack of evidence thatregulation and inspection areeffective mechanisms for im-provement).

For the NHS to survive in itspresent form, it will need toovercome four formidable chal-lenges. The first is financial con-straint. Although the government

claims to be maintaining fundingin real terms, high rates of infla-tion in health care plus some fi-nancial maneuvers, such as with-holding from the NHS any fundsin its budget that it hasnt spent,mean there has been an actualfunding reduction of almost 1%per year since 2011. Of greaterconcern is that social services

have undergone a substantial cutof about 7% per year since 2011,which is resulting in more emer-gency admissions to hospitalsand delays in discharges. Theseproblems will be exacerbated ifthe new GP-led commissioners

succeed in shifting some carefrom hospitals to more appropri-ate settings, since such a shift willfurther reduce the funds thathospitals receive. And overshad-owing all these funding issues,the governments policy of pro-tecting the level of health carespending is increasingly beingquestioned in Parliament by back-bench members of the rulingparty (i.e., those who do not oc-

cupy positions in government)who are unhappy about the re-percussions that this protectionhas for other spending areas,such as defense and law enforce-ment. The final note of gloom isthe growing realization that fi-nancial austerity seems to be setto continue beyond 2015.

The second challenge is thatthe NHS may face opposition to itsattempts to improve productivity.During the first 2 years of aus-terity, improvement was achievedmostly by freezing (or even reduc-ing) staff pay, a policy that willnot be sustainable. Similarly, driv-ing down prices paid to suppliersfor consumables cannot be extend-ed indefinitely. In addition, pro-fessionals may oppose changesin working arrangements, such asrequirements that hospital doc-

tors work in the evenings and onweekends to boost the intensityof use of hospital facilities. Butits the more major initiatives toimprove productivity, such asmerging, downgrading, or clos-ing hospitals, that will meet withthe greatest opposition notonly from staff and the public,but also from politicians con-

cerned about being reelected. Andin the brave new world of markets,opposition to structural changeswill even come from the economicregulator seeking to ensure thatcompetition is maintained, re-gardless of its effect on the

quality of care.The third challenge is a lack

of managerial capacity, stemminglargely from the governmentsimposition of a reorganizationthat had little support from keystaff members.This problem hasbeen exacerbated by widespreadcriticism of managers, in thewake of the Francis Report, bymembers of the public, the me-dia, and politicians. Although

criticisms of some clinical andmanagerial staff were justified,wholesale condemnation was in-appropriate and has contributedto the departure of some excel-lent managers (particularly whengenerous retirement options wereavailable). The loss of managersis particularly apparent in thecommissioning arena, where theeffects will be intensified by theshifting of responsibility to GPs,most of whom will initially lackappropriate experience and train-ing. Although they will receivetechnical help, it is unclear wheth-er the initial enthusiasm of thoseGPs who have opted to take onthis role will last. The honeymoonmight end when GPs realize howuncomfortable it can be to rationcare to patients and reduce fundsfor their local hospital.

Finally, there is concern thatthe way the NHS has been reor-ganized will impede attempts toachieve greater integration of ser-vices across health care and withsocial services integration thatis essential to achieving eff icient,high-quality care.

So, will the NHS survive thesechallenges? There are three rea-

Can Englands NHS Survive?




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sons for optimism. First, thereare already examples of enterpris-ing clinicians, managers, andpoliticians working together toreengineer their local services inimaginative ways. Second, despitelegitimate concerns about the

quality of some services, publicsupport for the NHS is undimin-ished, as witnessed by the inclu-sion of a celebration of the NHSin the Olympics opening ceremo-ny last July and as reflected innational surveys. Public enthusi-asm is mirrored not only by thatof most clinicians and managersbut also by the majority of poli-ticians (including the current gov-ernment, even if not by all its

backbenchers). Though partly ide-ological, such support reflects thesteady annual improvements inthe NHSs effectiveness and safetyseen in recent years. And third,

turmoil provides an opportunityfor innovation. It can producecollective efforts in which fac-tional interests are set aside andlong-standing controversial issues,such as bringing health care andsocial services closer together

(even by combining their budgetsinto one), are finally addressed.

Although some of the chal-lenges in England are unique,the underlying problem of meet-ing rising demand for care withsteady or diminishing resourcesis faced by many countries. Justas we can learn from other healthcare systems, our experiences overthe next few years in redesigningthe organization and delivery of

services will undoubtedly providelessons for others.

Disclosure forms provided by the authorare available with the full text of this arti-cle at NEJM.org.

From the Department of Health ServicesResearch and Policy, London School of Hy-giene and Tropical Medicine, London.

This article was published on June 19, 2013,at NEJM.org.

1. Report of the Mid Staffordshire NHSFoundation Trust public inquiry (RobertFrancis, chair). Staffordshire, United King-dom: Mid Staffordshire NHS FoundationTrust, February 2013.2. Roberts A, Marshall L, Charlesworth A. Adecade of austerity? The funding pressuresfacing the NHS from 2010/11 to 2021/22.London: Nuffield Trust, December 2012.3. Black N, Mays N. Public inquiries intohealth care in the UK: a sound basis for policy-making? J Health Serv Res Policy 2013;18:129-30.4. Rating providers for quality: a policyworth pursuing? London: Nuffield Trust,March 2013.5. Shahian DM, Wolf RE, Iezzoni LI, Kirle L ,

Normand S-LT. Variability in the measure-ment of hospital-wide mortality rates. N EnglJ Med 2010;363:2530-9. [Erratum, N Engl JMed 2011;364:1382.]

DOI: 10.1056/NEJMp1305771

Copyright 2013 Massachusetts Medical Society.

Can Englands NHS Survive?




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