The impact of the NHS reforms on social welfare: the case of coronary revascularisation services

This thesis assesses the impact of the 1991 health care reforms on the British National Health Service with respect to one specialist service, coronary revascularisation, and examines the ways in which greater improvements in social welfare could be achieved. It is divided into three broad sections. The first section outlines the background to the reforms, the assessment criteria against which the reforms are to be measured and the service to be evaluated. The second section measures the impact of the reforms on efficiency and equity, the chosen assessment criteria, by means both of quantitative and qualitative analyses. The analyses describes the changes which had occurred since the introduction of market mechanisms into the NHS in 1991. Variations in the availability and use of coronary revascularisation services decreased and the contracting process became more sophisticated which suggested the reforms had been instrumental in increasing efficiency and equity. However, large variations remained and market mechanisms continued to cause a series of problems which signified that the reforms were still a long way off achieving an efficient allocation of resources. The third section considers how greater social welfare could be achieved. A strategy for improving social welfare involved managing the market for coronary revascularisations more effectively. An audit of waiting list management in three hospitals demonstrated that patients were often not treated within an appropriate time. The potential to improve efficiency and equity by more effective management of demand for coronary revascularisations therefore existed and the development of guidelines was recommended. Such guidelines were developed with the aim of prioritising patients according to their urgency of need. Finally, the thesis discusses the implications both for health care policy and future research.