UK NHS Reforms: The Role of Engagement

By Marie-claire Wilson

Whilst change within the UK’s NHS has perhaps one of its most constant features since its inception in 1948, the latest reforms (detailed in The White Paper Equity and Excellence: Liberating the NHS) have attracted much attention. These represent a destruction of the old model of a centrally-managed, hierarchical organisation and the birth of a market-based system with competing providers.

Those working with the NHS must develop an understanding of the nature of the planned changes and the inherent issues and opportunities, if their products and services are to remain relevant. This article summarises the key aspects of the NHS reforms, and why engagement is key to their success and to that of other healthcare stakeholders.

Value for money

A prominent attribute of the new NHS is a growing emphasis on accountability, quality and value for money. Holding providers to account for their quality of care is central to patient safety and improving outcomes, and will be of increasing importance as new provider organisations begin to operate.

Theoretically, this situation will improve clinical outcomes and efficiency, and is to be welcomed – organisations that cannot prove that their services benefit patients will be unable to operate; those that demonstrate excellent outcomes, whilst remaining within budget, will flourish. However, we must be concerned about how quality and performance are measured – healthcare may become a box-ticking exercise, with services offered because of their tariff or their amenability to measurement. Corners may be cut with essential parts of the service that are not directly reflected in targets, resulting in healthcare that performs well on paper, but which does not meet patients’ needs.

The role of GPs

Another important feature of the reforms is the role of GPs (General Practitioners – Family Physicians) in making decisions about healthcare spending.

The old model from which the NHS is now transitioning in terms of primary care is based on the following hierarchy:

  • Health policy determined at the level of the Department of Health/government
  • Decisions for sub-sections of the country being taken by Strategic Health Authorities (SHAs – 10 of these in England)
  • Commissioning and providing of local services being the responsibility of Primary Care Trusts (PCTs – around 150 of these in England)
  • Groups of GP practices having some control over commissioning services (Practice-Based Commissioning)

There are interactions between these bodies and secondary care organisations, such as foundation or hospital trusts, as well as with Mental Health Trusts and local authorities.

The current move involves the abolition of SHAs and PCTs, with more responsibility for commissioning services and managing the associated budget lying with groups of GPs. The first GP consortia – the Pathfinders – have now been approved; all GPs must be part of a consortium by April 2013, by which point they will effectively be in control of a budget of £70bn-£80bn.

At first glance, this seems like a simplification to the current system, but a new NHS Commissioning Board, which allocates funds to consortia and holds them to account, will be introduced, as well as a new regulatory body.  The National Clinical Commissioning Network, the National Leadership Council and the Royal College of General Practitioners will also all have a role to play, and so it will remain a complex system, with many points at which misunderstandings can be introduced.

A proposed advantage of the new NHS is that efficiencies will be created by reducing the number of layers between the government and the patient – the ultimate goal is to give patients more control over their own health, through the introduction of personal budgets. This would involve patients being allocated a sum of money to “spend” on their healthcare, after agreement of a care plan with a doctor or nurse. Such care would be truly patient-centred (see below for definition), and research suggests that this type of care can help improve health outcomes – for example see the work by Stewart et al. However, it remains to be seen how such a scheme could be implemented nationally, how the creation of a two-tier system could be avoided (where some patients top up their allocations with their own savings), and how it will be ensured that care is planned in a consistent manner.

Furthermore, it is proposed that GPs have a better understanding of the needs of their patients than healthcare managers within PCTs, and allowing them to commission services will result in emphasis on the areas most relevant for their particular populations, with scarce resources diverted away from services that are likely to be less important. The size of the task and the potential pitfalls must not be underestimated though – as a body, GPs are now asked to run a business worth £80bn, and most GPs have little, if any, training or experience in business and finance.

Why engagement is key to the success of the reforms – for all stakeholders

Engagement with patients

One definition of patient-centred care is that provided by the Institute of Medicine – “care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions”. It can therefore be assumed that engagement with the patient is a key part of care design. If patient preferences, needs and values are not known, or not communicated, it is not possible to take them into account.

Digital strategies can be helpful here – the internet can be employed to capture data on illnesses, aid communication between the public, healthcare professionals and policy makers and to sample patients’ perception of services. The latter already takes place to an extent – it is possible to make comments about experiences at local UK hospitals online (see example below from The Royal Free Hospital, London).

Example of online UK hospital ratings/comments, where patients can share their views on their experiences

YouTube could be leveraged to explain to the public the impact of the changes on how care is organised, and a patient portal could help inform and support patients as they plan their care. Care planning itself could be greatly supported by digital tools.

As local healthcare economies undergo transition, there may be gaps to be filled from the perspective of patients and carers – existing structures and resources will disappear, and may not be replaced in a timely manner. There could be an opportunity for commercial healthcare stakeholders to help meet patient and carer needs, perhaps in a similar manner to how popular websites such as Qype work for entertainment and personal services.

On Qype, users can find information about local entertainment and personal services, provide ratings and connect with other members. A similar concept for healthcare could be supported by commercial healthcare stakeholders, and could be invaluable to patients and carers as local services and points of contact change or disappear.

Engagement with GPs

Pharmaceutical companies, patient groups, local authorities and private healthcare providers are some of the groups that must maintain effective interaction with GPs – now increasingly so, as GPs begin to wield increased power over the healthcare budget. In many cases, little will change in terms of day to day work, and those individuals and organisations who have engaged effectively with GP colleagues in the past may now reap the benefits, as their colleagues exert greater control over the local healthcare economy.

However, decisions around investments may become more complex as these could need to be approved by other members of the consortium (see below). Additionally, there is likely to be a growing emphasis on the cost effectiveness of interventions, and understanding these points is key  if pharmaceutical companies are to engage in a relevant way with doctors. One way in which pharmaceutical companies could add value for healthcare professionals is to support the development of digital decision making tools that would simplify any new procurement and planning processes for staff on the front line. Additionally, through drawing on digital tools to facilitate communication within and across consortia, pharmaceutical companies could help provide a much-needed service to doctors, thus maintaining and furthering relationships.

Consortium level

Engagement at this level should focus on providing or supporting the development of cost-effective healthcare solutions, and on understanding the difficulties inherent in having a diverse group of professionals make joint financial decisions. There may thus be potential for a mediator  or business/finance skills training role for commercial partners here. An online support facility for Pathfinder consortia is already live, and this includes case studies, education material and guidelines, an interactive map of consortia and a calendar of events. Online interaction may be key for consortia, particularly where members are geographically separated.

At this level, the independent (private) provider organisations, who will be providing aspects of healthcare, instead of NHS departments, must also be considered. As “outsiders” to the traditional NHS model, they may require a specific approach, with a view to ensuring alignment between their individual objectives, and those of the wider healthcare economy.

National level

In the previous NHS model, “change fatigue” amongst PCT employees was common. It is imperative that policy makers engage effectively with commissioners, providers and front line staff, and as mentioned before, with patients. The areas of health quality assurance and value based payments should be transparent, and would merit specific engagement strategies. Healthcare professionals should be able to quickly and easily understand how the interventions they select (or choose not to select) for their patients fit into their budgets and the wider policy, and how any new initiatives fit into the wider common goal of improving the population’s health.


The latest round of NHS reforms will result in a radically different healthcare system – the ways in which care is commissioned and provided will be transformed. We must all be prepared for the relative inexperience of many of the new healthcare decision makers – GPs with no formal training in finance – and for a growing emphasis on cost savings. However, there are also many opportunities – for patients to improve their health and their experience of healthcare, and for organisations to enjoy greater efficiency, profit and scope, if they are ready to adapt. For example, if patient power does become a true driving force in healthcare, pharmaceutical companies and other stakeholders must be ready to respond.

Effective engagement on the local, consortium and national level will be crucial for all individuals and organisations involved in healthcare. Understanding the needs of patients, the concerns of healthcare professionals and the objectives of policy makers, and ensuring these are all linked, could result in a health service that is efficient and relevant. If this work is not prioritised, there is a risk of patients losing out as a result of latest reforms.

Creation Healthcare is trusted by healthcare companies and organizations as a partner in developing strategies for effective stakeholder engagement in the UK and worldwide. To discuss your needs and find out how we can help, contact us.

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Meet the Author

Marie-claire Wilson