Clinical Effectiveness in the National Health Service in Scotland
Keaney, Michael, Lorimer, A. R., Journal of Economic Issues
In the industrialized West, the welfare state has undergone reforms of varying significance during the past two decades. At the root of these transformations has been the ascendancy of neo-liberal thought, grasped by an eager political class desperate to find ways out of the apparent mire of postwar Keynesianism. This was especially the case in the United Kingdom, where Margaret Thatcher, aided and abetted by Milton Friedman and Friedrich von Hayek, among others, set about dismantling much of the fabric of what she regarded as the monolithic state. One consequence of this is that the National Health Service (NHS) has undergone various organizational upheavals since 1979, which have attracted both praise and criticism. In line with the elevation of the "straightforward, uncomplicated, free-enterprise mind"(1) thought to be typical of the successful businessperson, NHS reforms were geared to the promotion of greater managerial efficiency through the institution of quasi markets. As a result, it has been said that a greater market sensibility has, for the first time, made clinicians more aware of the actual costs of treatment and has therefore focused thinking on optimizing outcomes with the level of resources. The downside of these developments has been the effects on staff morale, the public's perceptions of general malaise caused by underfunding, and an emergent managerialism.
Despite the election of a new government on May 1, 1997, the policy emphasis upon value for money remains, and recent developments have been designed and implemented with that aim in mind. The foremost of these is the clinical effectiveness initiative, launched in 1996. While its explicit commitment to the promotion and delivery of clinically effective care is, on the face of it, laudable, it is not clear how exactly it will be implemented, although policymakers are now attempting to address this issue. More fundamentally, however, there are differing views as to what constitutes the conceptual basis underlying the initiative. For it is this that will guide the design and implementation of clinical effectiveness policy, both nationally and locally.
This paper is divided into three main sections. The first of these describes the concept of clinical effectiveness, breaking it down into its six component parts and detailing how these connect. The second section examines the strengths and weaknesses of the clinical effectiveness agenda as it has been conceived to date. Finally, there is a critique of the latent consumerism underlying much health care policymaking, which is itself increasingly informed via the questionable means of health economics. Proposed is an alternative model of health care that emphasizes the partnership between patient and clinician.
Throughout the paper is the underlying view that a democratically accountable and responsive health care system is both desirable and feasible. Its desirability and feasibility depend upon our conceptions of democracy, health care, and the patient-clinician relationship. In line with William Hildred and Fred Beauvais [1995, 1083], it is argued that John Dewey's philosophy provides the best set of criteria with which to ascertain the likely benefits to patients and clinicians of any health care policy developments.
Clinical Effectiveness and Its Components
Changing the way that people are treated by the NHS to improve the health of individuals and the population as a whole, in the most cost effective way, is a complex process. It involves clinicians, managers and patients themselves. Everyone has a part to play in bringing clinical evidence, judgement and experience together to make rational decisions about changing health service practices [NHS Executive 1996a, 1].
So begins the document that launched the clinical effectiveness initiative in 1996. The idea of clinical effectiveness itself is the culmination of a number of separate developments that have been combined to form this policy agenda. …