National Research University Higher School of Economics
Masters in Management and Economics of Health Services
Seminar Presentation 21 March 2011
Dr. Christopher Davis
Department of Economics and School of Interdisciplinary Area Studies
University of Oxford

Motivations for Medical System Reform
• Control rising cost of medical care, reflected in increasing health shares of GDP, driven by ageing populations and technological progress
• Improvement in access to medical care and reductions in health inequalities
• Improvement of quality of medical care
• Reductions in inefficiencies , duplication in the medical system
• Improvements in health outcomes (survival rates, raising life expectancy)
• Reducing public dissatisfaction with medical care and increasing patients’ choice of treatment

[Toth (2010) review of reforms in France, Germany, Netherlands,
New Zealand, Sweden and UK]
• Early 1990s: Introduce market-style mechanisms, greater competition, purchaser-provider split, patients’ choice.
• Mid 1990s: Criticism of market mechanisms, unclear impact on efficiency but worse equity and access.
Emphasis on improving integration of components of medical system. UK abolishes fund-holding and adopts
Primary Care Trusts.
• 2000s: Emphasis on quality of care and patients’ rights.
Patients in NHS can choose provider and funds follow.

• Russia 2008 : “Priority Health Project” and
“Conception of Health RF to 2020”
• China 2009 : “Implementation Plan for the
Recent Priorities of the Health Care System
Reform (2009-2011)”.
• USA 2010 : Senate Bill 3590 “Patient
Protection and Affordable Care Act”
• UK 2011 : “Health and Social Care Bill”
4

• What are the main problems in the UK health system?
• Have past health reforms worked?
• What are the features of the announced
2010-11 UK health reforms?
• What are the criticisms of the new health reforms and the prospects for their adoption ?

•
Concepts used in Analysis of Health Reforms
–
Health in Political and Economic Systems
–
Governance in Health Systems
–
Health Production and Health Outcomes
–
Priority of the Health Sector and Health Financing
–
Measurement of Health System Coverage of Population,
Benefits and Cost-Sharing
•
Sources of Data
•
Principles and Development of the UK NHS
•
Health Reforms in UK and Russia 1990-2010
•
2010-11 Proposals for Radical Reform of the UK
NHS and Criticisms of Them

Political System, State Priorities and Health
• Importance of politics in health reform
– Sheiman & Shishkin 2009: “After an unsuccessful start of the programme of monetization of benefits in early 2005 discussion of health reform legislation was minimized
..Transformations in organization, management and financing of the health service were moved to the back burner.”
• Political system
– influences health sector (State bureaucracy, political parties, legislature, interest groups, voters, public opinion and expressions of discontent)
• State priorities
– influence allocations of resources, protection of health sector in a crisis, and degree of inequalities

Political Actors Influencing Health Reform
Defence
Executive Government
Leader
(Prime, Minister,
President
Cabinet, Council of Ministers
Ministries
(including Health)
Health Education
Legislature
Party Leader
Parliament, Duma
Committees,
Commissions
(including Health)
Political Opposition Non-Governmental
(UK Shadow Government)
Media
Opposition Party
Leader
Think Tanks
Cabinet
Professional
Groups
Ministries
(including Health)
NGOs
Public
Regions
Districts
Medical Units
Davis 2011

• Health systems made up of many institutions
(central and regional government, regulators, boards, medical facilities) that need to achieve objectives while maintaining standards and controlling costs.
• To achieve this requires good governance
(Strategy, Leadership, Vision, Assurance, Probity)
[2011 Governing the New NHS]
• Governance different from, but related to, operational management
• Many UK NHS reforms aimed at improving health governance

RUSSIA
USA
CHINA
USA CHINA RUSSIA
10

Health Sector in an Economic System
Economic Policies
Fiscal, Monetary, Industrial, Foreign Trade, Exchange Rate
Economic System
Health Sector
Household
Medical System
Medical Supply
Medical Industry
Biomedical R & D
Medical Foreign Trade
Health Bureaucracy
Performance of Health Institutions
Quantity of Medical Services
Quality of Medical Services
Medical System Efficiency
Sufficiency of Medical Inputs
Effectiveness of Supply System
Production of Medicines and
Medical Equipment
Medical Technology Innovation
Imports of Medicines and
Medical Equipment
Economic Environment
Natural Resources, Population, Integrity of Economic Space,
External Economic Factors,

Consumption
Preventive Services
Health Sector Production Process
Demography
Household Health
Production
Environment
Illness Pattern
Medical
Treatment
Health Output
(Mortality, Invalidity)
Central Health Bureaucracy
Curative Services
Allocation of Resources
1 2 3 4 5 6
Medical System
1
2
Medical Supply System Medical Industry Biomedical R & D
Medical Foreign Trade
12

Impacts of Reforms on Health System Coverage of Population, Benefits and Cost-Sharing
WHO 2008, Fig. 2.2

• Data for Empirical Assessments
– Official Russian sources
– OECD databank and reports
• Data for Diagram of Health Coverage, Benefits and Cost-Sharing
• Information about Current UK Health Reforms
– Official documents (White Paper and Parliament Bill)
– Think Tanks (Kings Fund, Nuffield Foundation)
– Academic Journals
– Newspapers

• X Axis: Coverage of Population (% of population covered by a national health service (NHS) or health insurance (100% public, mixed public-private, or subsidized private)). Government statistics and reports. Reliable estimation of trends.
• Y Axis: Coverage of Benefits (% of potential benefits in a country provided to the population). Measurement more problematic .
Identify maximum standard in a country and evaluate how provision of the average citizen deviated.
• Z Axis: Coverage of Costs (% of health costs covered by public sources). Estimates of this indicator based on government statistics and independent reports. Measurement reliable.
15

• First national health service in democratic system not based on insurance. Established in July 1948 with principles
– Universal coverage
– Free of direct charge
– General taxation source of finance for NHS
– Pooling of financial risk at centre
– Collective provision
– Promotion of advances in medical science
• Political struggle over the reform
– Government and medical professional in favour of reform
– Opposition by Interest groups (hospital doctors, GPs, other medical workers, trade unions, patients, NGOs)
– Local government opposed to centralisation
– Groups fights to maintain “freedom of choice” (patients have right to choose doctors, doctors have right to choose treatments)

Compromises and Actual Arrangements in
Establishing the UK NHS
• More a national hospital service than a national health service
• Compromises
– Teaching hospitals subordinate to centre whereas other hospitals under local government
– Doctors (but not other medical professionals) have key management roles
– Local government keeps control of district nurses, child welfare, public health
– GPs not salaried or employed by government. Sign contracts with Executive Committee run by GPs. Paid on capitation basis (related to patient list)
– Groups of GPs encouraged but not mandatory
– Private practice by hospital doctors allowed

• Substantial growth of NHS and quantities of services provided
• Significant increase in medical technology in NHS and in quality of care
• Continuing increase in the cost of the NHS (HE % GDP rises from 3.5 % to 5.6 %)
• Improvements in almost all measures of health outcomes
(e.g. life expectancy)
• But shortages, queuing, rationing
• Reforms introduced to improve performance
– 1950 – 73 Technocratic change (planning, management)
– 1974 Unification/integration, Regional Health Authorities,
Community Care Councils
– 1982 Introduce general management, outsourcing (contracting out to private sector of non-essential services)

Election
Party in Power
1945, 1950 Labour 1945-1951
Major Health Reforms
1948 Establishment of NHS, technocratic changes to improve planning and management
1951, 1955, 1959 Conservative 1951-1964
1964, 1966
1970
1974
1979, 1983
Labour 1964-1970
Conservative 1970-1974
Labour 1974-1979
Conservative 1979-1987
More technocratic reforms, greater attempts to reduce regional inequalities through planning and re-distribution
More technocratic reforms, greater attempts to reduce regional inequalities through planning and re-distribution
More technocratic reforms, greater attempts to reduce regional inequalities through planning and re-distribution
1974 focus on unification and integration. Establishment of
Regional Health Authorities (15), Area HA (90), and 200 District
Mangement Teams and Community Health Councils (voice of consumers). 1976 Resource Allocation Working Party (RAWP) to re-distribute funds across regions.
1979 Royal Commission on NHS criticises 1974 reforms for increasing bureaucracy. 1982 reform promotes simplification and decentralisation. Elimination of Area Health Authorities.
Family Practitioner Councils become independent. Encourages local fund-raising and private sector involvement.
C. Davis 2011

Political system
UK
Emphasis on individual rights
Multiple political parties
Contested elections
Free press
Firm party discipline
Strong popular support for the NHS
Popular dissatisfaction with performance of NHS an important political issue
USSR
Emphasis on the collective and the state
Single Communist Party
Uncontested elections
Censored press
Rigid party discipline
Strong popular support for the NHS
Popular dissatisfaction with performance of NHS an insignificant political issue
Economic system
UK
Most property in private sector
USSR
Most property in state sector
Market regulation of the economy Central plan regulation of the economy
Consumers have strong market power relative to suppliers Consumers have weak market power relative to suppliers
(buyers' market) (sellers' market)
Weak government control of income and consumption Strong government control of income and consumption
Economy open to world competition (private control of foreign trade)
High consumption share of national income
Economy closed to world competition (state monopoly of foreign trade)
Low consumption share of national income
Chronic excess supply in consumption markets
Unequal distribution of income and wealth
State-owned NHS an anomaly in market economy
Chronic excess demand in consumption markets
Unequal distribution of income and privileges
State-owned NHS typical component of centrally planned economy
Davis 1990

[Davis 1990 chapter in Social Policy Review]
• Rising demand for medical care
• Successful cost containment in both countries
[1984 The Painful Prescription]
• Shortages in both health services, but more acute in USSR
• Pervasive rationing of medical care in both health services
• UK lags behind most EC countries in availability of medical technology (71 % average MRI), but is substantially more advanced than USSR
• Almost all health outcome indicators better in UK than in USSR

Russia Health System Coverage of Population,
Benefits and Costs in 1990
Total Health Expenditure
100
80.0 %
100
Russia Health 1990
Universal Coverage in 1990
Width: % of Population Covered
State
Guarantee
Height:
% of Costs
Covered by
Public
100
80.0 %
Depth:
% of Benefits
Covered by
Public
0
Davis 2010 (Concept from WHO 2008, Fig. 2.2)

80.0
75.0
70.0
65.0
60.0
55.0
50.0
USA
China
Russia
UK

• Control cost of medical care
• Improve efficiency so that health spending has greater impact
• Reduce bureaucracy, strengthen purchaserprovider split, increase competition
• Devolve decision making and resource allocation to consortia of GPs
• Give patients greater choice of treatment paths

• 1990 NHS and Community Care Act of Conservative government
• 1991 Introduction of the “internal market”. Purchaserprovider split. Two models of purchasing: health authorities and GP fundholders (non-urgent elective and community care for patients).
• 1994 Total Purchasing Pilot Scheme allows GPs to commission all services
• 1997 GP fundholders abolished in favour of Primary
Care Groups and Trusts (PCG, PCT) that maintain
Purchaser-Provider split

Election
1987, 1992
Party in Power Major Health Reforms
Conservative 1987-1997
1990 NHS and Community Care Act introduces "internal market" and general management, creates Hospital Trusts
("sellers"), health authorities become "commissioners"
(buyers). 1992 Private Finance Initiative for mixed funding of
NHS facilities. 1997 White Paper The New NHS. Modern,
Dependable establishes Primary Care Trusts (PCTs).
1997, 2001, 2005 Labour 1997-2010
1997 Devolution of UK NHS to England, Scotland, Wales,
Northern Ireland. 2000 The NHS Plan creates Care Trusts.
2001 Creat National Patient Safety Agency. 2002 Create
Strategic Health Authorities. 2004 Create Create Commission for Healthcare Audit and Inspection (CHAI). 2005 Create
National Institute for Health and Clinical Excellence (NICE) from old NICE. 2006 Commissioning a Patient-Led NHS establishes GP Practice-Based Commissioning.
Source: C. Davis 2011

Evolution of Purchaser-Provider
Relationships in UK NHS

Health Reforms in Russia 1990-2008
•
1991-1993 Introduction of CMI and other health reforms
•
Deterioration of economic performance, weak state, overambition means most health reforms fail in 1990s
•
In 2000s more emphasis on health education, prevention
•
Intensified reforms related to management and incentives in the medical system
•
Improvements of CMI system
•
Adoption of Federal Goal Programs in health for 2002-06 to supplement normal activities
•
Priority National Project in Health 2006-10
•
Adoption in December 2008 of Conception of Health RF to 2020
•
Real health expenditures from state budget, CMI and private sector increase substantially

Medical Systems in China, USA, Russia, UK
Indicators 2007
Doctors
Hospital Beds
Middle Medical per doctor
Doctors
Hospital Beds
Middle Medical per doctor
Doctors
Hospital Beds
Middle Medical per doctor
Doctors
Hospital Beds
Middle Medical per doctor
Units 2000
China
Per 1,000 population 1.7
Per 1,000 population 2.4
Number 2.8
USA
Per 1,000 population 2.3
Per 1,000 population 3.5
Number 4.6
Russia
Per 1,000 population 4.7
Per 1,000 population 11.6
Number 2.3
UK
Per 1,000 population 2.0
Per 1,000 population 4.1
Number 4.4
1.5
2.7
3.1
2.4
3.1
4.6
5.0
10.7
2.2
2.5
3.4
3.8

Russia Health System Coverage of Population,
Benefits and Costs in 1990, 2007
Total Health Expenditure
100
Russia Health 1990
80.0 %
65.0 %
Height:
% of Costs
Covered by
Public
State
Guarantee
Russia Health 2007
100
80.0 %
60.0 %
100
Universal Coverage in 1990, 2007
0
Depth:
% of Benefits
Covered by
Public
Width: % of Population Covered
Davis 2010 (Concept from WHO 2008, Fig. 2.2)

80.0
75.0
70.0
65.0
60.0
55.0
50.0
USA
China
Russia
UK

ДЕМОГРАФИЧЕСКАЯ ПОЛИТИКА В
РОССИЙСКОЙ ФЕДЕРАЦИИ
ИЗМЕНЕНИЕ ЧИСЛЕННОСТИ НАСЕЛЕНИЯ
МЛН. ЧЕЛОВЕК
Population: 142 million
Area: 17 million км 2
Birth Rate: 11.3 per 1,000
Crude Death Rate: 14.6 per 1,000
150
146 Россия
142
142 млн
Цель
145 млн
17
15
СМЕРТНОСТЬ НАСЕЛЕНИЯ РФ
Россия
13
11
«Новые» страны ЕС
«Старые» страны ЕС
10
9
1980 1985 1990 1995 2000 2005 2010 2015 2020
138
1990 1995 2000 2005 2010 2015 2020
ДИНАМИКА ОЖИДАЕМОЙ ПРОДОЛЖИТЕЛЬНОСТИ ЖИЗНИ В
РОССИИ И В СТРАНАХ ЕВРОСОЮЗА
ВОЗРАСТ
«Старые» страны ЕС
80
76
Цель
75 лет
«Новые» страны ЕС
72
68
Россия
67,5 лет
64
1980 1985 1990 1995 2000 2005 2010 2015 2020
1

Russia Health System Coverage of Population,
Benefits and Costs in 2007, 2020
Total Health Expenditure
100
Russia Health 2007
100
Russia Health 2020
Universal Coverage in 2007, 2020
Width: % of Population Covered
65.0 %
60.0 %
Height:
% of Costs
Covered by
Public
0
State
Guarantee
Depth:
% of Benefits
Covered by
Public
100
70.0 %
60.0 %
Davis 2010 (Concept from WHO 2008, Fig. 2.2)

• In 2002 Phasing out of Health Authorities, move to 152 PCTs with ave pop of 300,000 and responsibility for £ 80 b (80% NHS)
• 2004 new form of commissioning Practice-
Based Commissioning (PBC): GP practices given indicative budget by PCT and encouraged to make savings while achieving quality targets
• 2007 World Class Commissioning. Set standards for PCTs and PBCs

•
300 (reduced to 150) Primary Care Trusts are subordinate to the Strategic Health Authority and represent the local
Primary Care community (GPs, dentists, public health).
•
Objectives are to improve the health of the community, engage in partnership work and community-based health and care initiatives, implement population screening programmes, develop and integrate family health services, medical (primary care), dental and optical
•
Have assumed responsibility from district health authorities of commissioning (purchasing) of community, secondary care and tertiary/specialised services
•
Also responsible for mental health, emergency ambulance and patient transport services, NHS Direct and walk-in centres

• NHS Hospital Trusts
– Hospital trusts subordinate to Strategic Health Authorities and need to satisfy annual accountability agreements
– More freedom of activities than previously
– Provide services to PCTs
– Must satisfy standards set by Care Quality Commission
• Foundation Trusts
– NHS Trusts that are promoted by Monitor because they satisfy stringent criteria concerning financial viability
– Greater autonomy in medical and financial activities
– Provide medical services to PCTs in accordance with contracts
– Must satisfy Monitor and Care Quality Commission

• Monitory established in 2004. Executive nondepartmental public body
• Oversees performance of NHS Trusts (primarily on financial grounds) and grants selected ones licences to operate as Foundation Trusts.
• Has sole responsibility for overseeing Foundation
Trusts to ensure their financial viability while maintaining agreed safety and medical quality standards
• Assigns each FT risk ratings on an annual basis, which influences detail of supervision
• Can intervene to direct activities of failing FTs

•
In 1999 National Institute for Clinical Excellence established to provide information to patients, the public and medical professionals on evidence-based practice in the prevention and treatment of illness. Carried out costeffectiveness studies of diagnostics, medicines, medical devices, clinical management of illnesses, and public health interventions.
•
In 2005 old NICE merged with Health Development
Agency to form the National Institute for Health and
Clinical Excellence, but has kept the acronym NICE.
•
Produces clinical guidelines concerning treatment, appraisal guidance on drugs and techniques, and guidance on safety and efficacy of curative and preventive interventions.
•
Developing 150 new standards of treatment for specific diseases that will be used in National Service Frameworks

• In 2009 CQC established as new “superregulator” to supervise and inspect the quality of all providers of secondary/tertiary medical care and social care
• Ensures that all organisations adhere to detailed Essential Standards.
• Promotes achievement of outcome measures.
• Rates the performance of NHS Hospital Trusts

8
7
6
5
4
10
9
3
2
1
0

Russia
UK

Economic Significance of Health
Sectors in UK and Russia
USA
China
UK
Russia
Health and GDP 2008
% Global
GDP in PPP HE % GDP
HE % Global
GDP
20.6
16.5
3.4
US HE %
Country GDP
16.5
11.4
5.5
0.6
29.8
3.2
3.3
8.4
6.0
0.3
0.2
106.3
103.0
50

Mortality and Life Expectancy:
China, USA, Russia, UK
Indicators (2009)
Infant Mortality Rate
Units
Deaths per 1,000 live births
Deaths/1,000 General Mortality Rate
Life Expectancy at
Years
Birth, Total Population
Sources: CIA World Factbook 2010
China USA Russia UK
20.3
7.1
73.5
6.2
8.4
78.1
10.6
16.1
66.0
4.6
9.3
80.1

UK Health System Coverage of Population,
Benefits and Costs in 1990, 2007
Total Health Expenditure
100
90.0 %
85.0 %
UK Health 2007
UK Health 1990
Height:
% of Costs
Covered by
Public
100
85.0 %
80.0 %
100
Universal Coverage in 1990, 2007
Width: % of Population Covered
Depth:
% of Benefits
Covered by
Public
0
Davis 2011 (Concept from WHO 2008, Fig. 2.2)

Parliamentary Report on Commissioning
(Purchasing) in the UK NHS in March 2010

Conclusions from House of Commons
March 2010 Report on Commissioning
• Expensive: rise in share of NHS administration from 5 % pre-reform to 14 % (lack of transparency)
• PCTs lack necessary skills (analysis, clinical knowledge, management), do ineffective job in commissioning
• Weaknesses of PCTs force them to make extensive use of expensive outside consultants
• PCTs remain weak relative to providers and do not insist on hospitals using evidence-based procedures
• Adversarial system without benefits. “After 20 years of costly failure, the purchaser/provider split may need to be abolished.”

Parliamentary Election, July 2010 White
Paper, December 2010 Health Reform Bill
• May 2010 parliamentary elections in UK. A government formed from a coalition of
Conservative and Liberal Democrat parties.
• Neither party had radical reform of the NHS in its election manifesto
• July 2010 government published White Paper on
Equity and Excellence: Liberating the NHS
• Proposes radical reforms to organisation and functioning of the NHS

Health and Social Care Bill: January 2011
• Abolish all 150 Primary Care Trusts and 10
Strategic Health Authorities
• Establish GP Commissioning Consortia
– GP practices to continue to offer community based services as independent contractors
– But groups of GPs to form Commissioning Consortia that will be NHS organisations and to be given £ 70-80 billion to purchase services
• Create new NHS Commissioning Board
• All NHS Hospital Trusts will become Foundation
Trusts and be regulated by Monitor according to financial criteria

Political Actors Influencing 2011 Health Reform
Coalition government proposes radical reforms
Prime Minister
Cameron, Deputy
Clegg
Defence
Legislature
Party Leader
Political Opposition Non-Governmental
(UK Shadow Government)
Media
Opposition Party
Leader
Think Tanks
Cabinet
Cabinet
Parliament Professional
Groups
Ministry of Health
(Minister Lansley)
Health
Regions
Districts
Medical Units
Ministries
(including Health)
Committees,
Commissions
(including Health)
NGOs
Education
Shadow government
Public strongly opposed to
Conservative party in favour, labour opposed, reforms and Liberal Democrats
Almost all comments divided over reforms from non-governmental groups hostile to reforms
Many professionals within
HS critical of reforms
Davis 2011

• Labour Party official position is strong opposition to the radical health reforms. All relevant members of the shadow government have publicly criticised the proposals and members of the parliamentary party will vote against it.
• Liberal Democrat party is divided. 12 March 2011
LD party conference supported resolution condemning the reforms and putting forward alternative proposals (restrict power of GP consortia, limit private sector involvement, reduce use of market mechanisms)

• Most recent television reports and articles in printed media have been critical of the health reforms
• 7 March “The non-national health service”
• 10 March “Lib-Dems from top to bottom are in revolt over NHS reforms”
• 15 March “Doctors gunning for Lansley over reforms”
• 20 March “David Cameron's health reforms risk destroying the NHS, says Tory doctor”

• 15 March Special Conference of British Medical
Association to discuss reforms. Almost all motions before conference are negative.
• Most doctors opposed to reform and believe it will result in a worsening of the quality of patient care and increased inequality
• 7 March Chairman of BMA Consultants’ Committee argues that reforms will damage management of the NHS, waste resources, and give the private sector the most lucrative components of treatment, with the NHS responsible for the unprofitable residual care

“David Cameron's health reforms risk destroying the NHS”: GP in Conservative Party
• "It is one thing to rapidly dismantle the entire middle layer of NHS management but it is completely unrealistic to assume that this vast organisation can be managed by a Commissioning Board in
London with nothing in between it and several hundred inexperienced commissioning consortia.
• New commissioning consortia are "doomed to fail and will have to hand over their commissioning to the private sector".
• “An organisation responsible for £100 billion needs people who seriously understand accountancy and, trust me, GPs do not.“
• "It is no use 'liberating' the NHS from top down political control only to shackle it to an unelected economic regulator. If Monitor, the new regulator, is filled with competition economists with a zeal for imposing competition at every opportunity, then the NHS could be changed beyond recognition.“

Critical Analyses of Health Reform Proposals by Think Tanks (Nuffield, Kings Fund)
•
Financial environment of reforms
– Tight constraints on real health spending in NHS. PCTs facing 2% cuts in real health spending. Need efficiency savings of £ 20 billion 2011-14.
–
UK health spending (8.7 % GDP) low by OECD standards.
–
Difficult to keep financial control during time of reorganisation
–
Reforms require better management, but overall NHS target of 45% cut in management costs over next several years.
•
GP Consortia
–
Past experience with GP fund-holding reveals many deficiencies. Years needed to develop necessary expertise. GP Consortia won’t have necessary competence in commissioning and planning.
– GP Consortia should be subjected to same critical evaluation as NHS
Trusts currently receive. Should have to prove themselves.
– Need safeguards to prevent conflicts of interests of GP Consortia

• NHS Commissioning Board
– New Board will play important role. Will be able to intervene in work of GP Consortia.
– But lack of clarity of functions and accountability of Board.
Experience from New Zealand reforms not positive.
– Unclear if Board can ensure high standards in both GP commissioning and provision of medical care.
• Abolition of Strategic Health Authority
– Huge reorganisation will distract management and entail substantial additional costs
– Will result in loss of experience leadership with long-term vision because not many managers will transfer to GP Consortia
• NICE
– New freedoms to GP Consortia raise possibility that they will not adhere to standards developed by NICE
– Conservative government not supportive of quasi-governmental organisations

• UK NHS has been performing well over past several decades given tight financial constraints
• NHS has been subjected to many reforms, not all of which have been successful
• New radical health reforms promise to reduce bureaucracy, improving efficiency and quality of care, providing more choice for patients
• But most independent analysts highly critical or reforms and most political forces against it
• Modified version of bill is likely to be adopted, but the reforms will not deliver promised results