Mohammed T. Abou-Saleh

UK HEALTH AND SOCIAL SERVICES 659A NEW NHS?In fact, perhaps partly because of public disatisfaction with whatwas happening to the NHS, the government was not re-electedand a radical reforming Labour government came to power. Theengines of privatization and the internal market were reversed andnew reforms were produced. In December 1997 a White Paper,The new NHS: Modern, Dependable 18 , outlined a comprehensivenew vision for the NHS. Two of the main planks of the new policywere the setting up of primary care groups (PCGs) to replace thefundholding/non-fundholding split and the introduction ofcomprehensive quality controls to ensure high standards andequity in access across the country. PCGs are local groupings ofgeneral practices that are involved in the commissioning of localcommunity and secondary services and may eventually becomePrimary Care NHS Trusts, providing community services andcommissioning secondary services. More recently still, the concepthas been developed of ‘‘Care Trusts which could provide primarycare and some secondary services, such as mental health services’’.The quality framework involves a three-layer approach 19 . Clearstandards of service will be set by National Service Frameworksand a National Institute for Clinical Excellence (NICE), whichwill evaluate new treatments. An SF for Older People waspublished in 2001 20 . The first of eight standards was ‘‘rooting outage discrimination’’. The seventh concerned mental health andincluded NICE guidelines for anti-dementia drugs. The new NSFmade it clear that standards in the Mental Health NSF alreadypublished applied to older people. Local delivery of services willbe made dependable by a combination of lifelong learning 21 linkedto professional self-regulation and clinical governance. Clinicalgovernance 22 places obligations on Chief Executives of NHSTrusts to make arrangements to monitor and continuouslyimprove the quality of health care they provide. Finally, all thiswill be underpinned by the national monitoring of standardsinvolving a National Performance Framework, an inspectorate(the Commission for Health Improvement) and a NationalPatient and User Survey. This ambitious vision sets a massiveagenda for change and demands radical shifts in the managementand clinical cultures of the NHS of a magnitude that will noteasily be achieved 23 . Without adequate resources, these wellintentionedreforms may well overload the capacity for change ofboth managers and clinicians working in the NHS.Primary care groups (in England) result in a much greaterinfluence for general practitioners and other primary care workersin the commissioning of secondary services. Their boards aredominated by primary care workers. When they become PrimaryCare Trusts, good corporate governance demands a boardstructure with executive and non-executive directors, moreanalagous to the boards of existing Hospital and CommunityTrusts. This will result in general practitioners effectively losingtheir quasi-independent status. The Trusts are likely to be directproviders of many community services currently provided byCommunity or Community and Mental Health Trusts. InScotland, where different arrangements pertain, mental health ispart of primary care groups, but they do not control the budgetsof secondary care Trusts in the same way as in England. In Walesthe arrangements are closer to those in England. In England andWales it seems likely that, in the larger cities at least, ‘‘standalone’’Mental Health Trusts will be the order of the day. For oldage psychiatry, this probably means that the managerial separationbetween old age psychiatry and geriatric medicine will beperpetuated. Unless imaginative and pragmatic solutions arefound, this could result in many demarcation problems. However,a new culture of collaboration rather than competition and agovernment apparently committed to encouraging ‘‘joined-up’’thinking and working means that these difficulties may beovercome.The funding of the NHS is probably even more important thanits organization in determining the future of health care in theUK. It was the squeeze on NHS development in the 1980s thatprovoked the medical profession to campaign for more developmentmoney. In the light of international comparisons, both ofspending on health care and the age structure of the population,this campaign seemed fully justified. The previous reorganizationincreased management costs and reduced the morale of many inthe NHS. So far, although the new government has promisedmore capital investment in the NHS, it has continued to supportthe controversial Private Finance Initiative (PFI) as a main strandof funding, which reduces the Public Sector Borrowing Requirement.There is concern that PFI will result in a reduction in bednumbers and diversion of money away from services to supportrepayments to private providers in respect of capital developments.If more money for services comes with the newreorganization, then the potential for positive change exists. Ifit does not, then the new reforms, like the Internal Market beforethem, are doomed to failure. Another problem with introducingimprovements is the shortage of trained staff. The governmenthas recognized the need to train more doctors and nurses, but itwill take time to turn this recognition into staff-deliveringservices.OTHER INNOVATIONSThe direct reforms of the NHS have been accompanied by aRoyal Commission to review long-term care. The report of thisCommission 24 controversially suggested that the personal careand residential elements of continuing care should be separatelyfunded. Personal care should be paid for from general taxation,whilst living and housing expenses should continue to bemeans-tested and subject to co-payment. The government hasyet to make an unequivocal positive response to this. Standardsin psychiatric services for old people continue to improvegenerally but it remains to be seen whether the latest reformswill ensure that quality is universally high and that funding isadequate.REFERENCES1. Brocklehurst JC. Textbook of Geriatric Medicine and Gerontology.Edinburgh: Churchill Livingstone, 1978: 747.2. Pater JE. The Making of the National Health Service. London: KingEdward’s Hospital Fund for London, 1981: 2–4, 7.3. Ham C. Health Policy in Britain. London: Macmillan, 1985: 11–12,24–5, 180–3.4. Warren MW. A case for treating chronic sick in blocks in a generalhospital. Br Med J 1943; i: 822–3.5. Warren MW. Care of the chronic aged sick. Lancet 1946; i: 841–3.6. Post F. Some problems arising from a study of mental patients overthe age of 60 years. J Ment Sci 1944; 90: 554–65.7. Lewis A. Ageing and senility: a major problem of psychiatry. J MentSci 1946; 92: 150–70.8. Affleck J. Psychiatric disorders among the chronic sick in hospital.J Ment Sci 1948; 94: 33–5.9. Means R, Smith R. The Development of Welfare Services for ElderlyPeople. London: Croom Helm, 1985: 25.10. Tinker A. The Elderly in Modern Society. London: Longman, 1984:37–8.11. Martin DV. Adventure in Psychiatry. London: Cassirer, 1974.12. DHSS. Better Services for the Mentally Ill. London: HMSO, 1975.13. DHSS. A Happier Old Age. London: HMSO, 1978.14. DHSS. NHS Management Inquiry (‘‘The Griffiths Report’’). London:HMSO, 1983.