By the time the two new doctors arrived, the patient looked in a bad way. Mrs NHS was hyperventilating, dehydrated, had an irregular heartbeat, chronic fatigue and was displaying signs of mania.
Dr Tony Blair, an electoral psychologist, and Dr Gordon Brown, an expert in cash transplants, conferred in a corner of the room. “She won’t last long,” declared Blair the day before the 1997 election. “We’ve got only 24 hours to save her.”
As so often in medicine, however, the diagnosis was far from clear. Neither doctor knew exactly what ailed poor Mrs NHS or, indeed, how to cure the malaise. But what they could do, they decided, was to alleviate the symptoms of her distress.
Their medicine? An injection of billions of pounds. The patient grew calmer. The pain eased. Blair and Brown looked pleased with themselves — and still do. But should they?
Blair promised that his treatment would produce a “more efficient NHS”, one in which money was spent on “patients, not bureaucracy”. He linked huge new funding to a “step change” in reform. The party manifesto boasted that under Labour the measure of success in the NHS would be “quality of outcome”. In other words, the generous investment ought to mean healthier people.
Those claims have left troubling questions. Has the treatment actually made the NHS any better or merely masked its sickness? And is it now addicted to massive doses of cash?
It is high time for a second opinion. In 1997-8 the NHS in England cost taxpayers £34 billion; in 2004-5 it cost £69 billion. By 2007-8 it will be costing £90 billion — more than £1,500 for every man, woman and child in the country. To maintain such a level of spending, say independent economists, will require higher taxes or stronger economic growth.
This massive injection of cash equates to a real increase in funding — after taking account of inflation — of about 70% so far. So it is reasonable to ask whether the service has improved by a similar amount and whether the “quality of outcomes” has risen commensurately.
To find out, The Sunday Times commissioned the King’s Fund, an independent research body specialising in health issues, to conduct an audit of the NHS’s performance since Labour took power in 1997. The conclusions, drawn after two months of analysis, are striking.
“The ambition for the NHS has been appropriately high,” write the report’s authors. “There has been unprecedented investment. There has been significant improvement in most areas the government has focused policies on.
“However, the NHS as a whole has not been transformed.
“There are still important problems to be solved and there is as yet no firm evidence to show that Labour’s reforms have produced a marked difference in health outcomes.”
The government can rightly claim to have reduced waiting lists and improved resources, says the report. But after all this taxpayers’ money has been put in, is there any sign that it is creating a healthier nation? The authors say it is too early to tell — so far, they conclude, there is little sign of health outcomes improving.
IN 1997 the NHS was widely held to be in crisis. Government spending on the service was 6.8% of gross domestic product, well below the level of countries such as France and Germany.
The number of hospital beds had been falling for years and 1.2m people were waiting for operations. Doctors and nurses complained of being overworked and underpaid. What happened when Labour took power? Having pledged not to raise income tax, Blair and Brown were at first rigidly prudent, resisting any splurge on NHS funding. Waiting lists continued their rise in spite of Labour’s pledge to bring them down by 100,000.
But as Labour was establishing its credentials for prudence, it was also planning huge investment. In January 2000 Blair promised to match European levels of health spending and the Treasury began to turn the money taps full on.
Targets were set in key areas, in particular to reduce waiting times for treatment for cancer and heart disease, two of the biggest killers. A third area of emphasis was mental health. To achieve these gains, the government also set targets for increasing the number of doctors and nurses, and certain types of hospital beds.
The good news, according to the audit, is that most of these objectives are being met or on the way to being met. In England — though not in Scotland and Wales where reform has been less marked — Mrs NHS’s most obvious ailments are responding to treatment.
“Very long waits (more than 12 months) have been eliminated,” says the report. “The government has tackled other difficult areas . . . patients should wait no more than 18 weeks from GP referral to treatment by 2008.”
Key attainments already achieved include:
The report also says the government has “broadly met” targets to increase general and acute beds by 2,100, intermediate beds by 5,000 and critical care beds by 300. The report also concludes that, on the surface at least, government promises to provide 10,000 more doctors and 20,000 more nurses have been fulfilled. In addition numerous new facilities are being provided under the private finance initiative, which means that the average age of NHS buildings is tumbling.
“In 1997, the average age of NHS buildings was older than the NHS itself (it was founded in 1948),” says the report. “In 2005, less than a quarter of its buildings predate it. By 2010, 40% of NHS buildings will be less than 15 years old.”
From this welter of targetry and statistics a rosy paint-by-numbers picture emerges of a shiny new NHS. There is, the report makes clear, much to commend.
The bad news, however, is that on closer inspection many serious problems remain. And in spite of the report’s cautious optimism about what has been achieved so far, there is as yet no sign of an overarching solution to the problems, which still leave the NHS lagging behind its European counterparts.
AS Brown delivered his budget last week, patting himself on the back for investing in public services, voters were horrified by reports of a cannibal in that day’s newspapers. Peter Bryan, a man with a history of psychopathic violence, had been released from care after being deemed safe. Within hours he had killed a friend and cooked part of his body. “I ate his brain with butter. It was really nice,” he told detectives.
One ghastly incident does not condemn an entire system. But the Bryan case was not an isolated failure. Last week Margaret Dixon, a pensioner from Cheshire, finally had her shoulder repaired after the operation had been cancelled seven times. It had been done only after Michael Howard, the Tory leader, had confronted Blair with her case in the House of Commons.
Last week, too, a pensioner in Staffordshire suffering from back pain said she was told she would have to wait two years for a diagnostic test.
Evidence of wider disarray emerged in a parliamentary answer that revealed that almost one-third of NHS trusts are running significant debts. To balance budgets they might have to cut beds, operations or staff.
How can this be after all the billions poured into the service by Blair and Brown? Some of the answers are identified in the King’s Fund audit.
This year hospitals are getting an additional £5 billion but most of it will go on existing staff and services rather than adding new capacity.
“Most of the money has been earmarked for ‘cost pressures’ such as increased pay and new terms and conditions for GPs, consultants and other NHS staff,” says the report.
Doctors and nurses have negotiated substantial pay rises; a settlement agreed last week on backdated equal pay for women staff at one NHS trust could lead to further bills for hundreds of millions, possibly billions of pounds.
So while the government boasts of a 7% increase in spending, the report concludes that the “extra money available for additional services is only 2.4%”.
Nor do doctors and nurses appear to be doing significantly more for the additional money. The “efficiency index” of the NHS, a crude measure of productivity, has been falling since 1998.
The government claims this is a statistical quirk. “Everything we do to keep people out of hospital appears as a reduction in efficiency,” said Richard Douglas, finance director at the Department of Health. “Every time you train a new doctor it looks like a fall (in efficiency). If we invest in buildings, food or cleaner hospitals, that shows as a fall in efficiency.”
Up to a point this is fair comment. But Nigel Edwards, policy director of the NHS Confederation, which represents NHS trusts, suggests another reason for falling efficiency: when doctors get more resources they “tend to do more with the people they see, not see more people”.
More importantly the King’s Fund highlights a statistical dodge that belies Blair’s claims on increasing the number of doctors and nurses. The government figures are merely a headcount of staff — but an increasing number of doctors and nurses now work part-time.
The net result, says the report, is that “headcounts must increase simply to keep the real supply of staff constant”.
One full-timer replaced by two part-timers is no increase at all. Overall staff numbers have jumped up but not by as much as the government claims.
“We are barely keeping pace, let alone increasing numbers,” said Dr Tony Matthie, chairman of the Royal College of General Practitioners’ workforce committee. “There certainly hasn’t been a transformation in the number of GPs.”
What has increased markedly is the number of senior managers and managers in the NHS, albeit from a low level. Between 1997 and 2003 they shot up by 58%, according to the King’s Fund report. Often working in better premises than doctors who once ruled the roost in terms of status, they are seen by critics as an expensive bureaucratic waste.
“There are too many primary care trusts,” said Nick Bosanquet, professor of health policy at Imperial College, London. “Surrey and Sussex have 15. They all have boards of five, plus executive directors and supporting staff of deputy directors.
“They represent a tier of advisers without any clear executive responsibility which has been set above people actually doing the job.”
Large investment requires sound control and few would object to more managers if they proved their worth. But the evidence for that is mixed at best. A report last month by the pressure group Reform was scathing about how £2 billion has been invested in cancer care.
“Several hundred new, highly paid administrative staff have been appointed to re-engineer the journey of patients (through the cancer service),” it said. “But this has not resulted in an increase in clinical capacity.” In other words, a lot more expense for no more treatment.
Amid the swamp of statistics, political claim and counter claim, one simple comparison stands out. Despite the vast new investment, which brings the NHS close to continental levels of health spending, England still has fewer practising doctors per 1,000 people than all other comparable countries.
Despite all these discrepancies and weaknesses, the overall results remain “very positive”, says the King’s Fund. Starting from a low base, the NHS is making strides forward and delivering more resources and more care.
The report’s authors give the government an informal “7 out of 10” for its performance to date, even though many actual health benefits are yet to be seen.
BLAIR was right: what ultimately matters is quality of outcome, more than quantity of treatment. Targets can help stimulate change, but they can also be highly misleading.
As John Seddon, an expert in public service management reform, pointed out: “Ambulance services have to reach a patient within eight minutes. We’ve designed a system where if you get there in 7½ minutes, but the patient dies, you’ve met the target.”
It begs the question: is all the new investment producing better health as well as hitting statistical targets? By 2010 the government aims to reduce the number of people dying from cancer before the age of 75 by 20% and from heart disease by 40%. It also aims to increase average life expectancy at birth to 78.6 years for males and 82.5 years for females.
It is on course to achieve all these targets — but the King’s Fund audit concludes that these results are simply in line with trends taking place before all the investment poured in.
The government recognises that smoking and diet may have a greater influence on mortality than doctors and scalpels, and that prevention is better than cure. Yet amid the £34 billion extra for the NHS, efforts to improve prevention have been feeble.
The report reveals that the government’s programme to reduce smoking counts people as “quitters” when they have not smoked for four weeks. But studies show that a year later only 15% of such people remain non-smokers. It also finds that “no targets have been set for improving eating habits even though ‘increasing fruit and vegetable consumption is the second most effective strategy for reducing the risk of cancer’, according to the most recent departmental report”.
In the longer run prevention could prove vital because the government’s spending has not addressed the fundamental problem of the NHS: how to reconcile limited resources with apparently insatiable demand.
The dilemma is that as services improve, expectations rise and people demand more. The government is introducing some measures to link performance and pay, and some regulation to restrict demand. But it has yet to have much effect.
It means, as the King’s Fund audit concludes, that after billions of pounds a year of extra investment and a real increase of 70%, the NHS has yet to be “transformed”.
The bills are landing on taxpayers now. But many of the benefits are still around the corner.
“While much of the improvement in the NHS has been achieved through central fiat and targets,” concludes the report, “it is too early to predict whether the more recently introduced tools to lever up performance — greater use of market incentives and regulation — will achieve the desired transformation”.
The fund, though, is optimistic. Mrs NHS may not yet be cured, it believes, but she is on the mend.
To read the complete King’s Fund independent audit of the NHS under Labour go to www.kingsfund.org.uk
Party policies
Labour
If re-elected, Tony Blair has promised more of the same treatment for the NHS. He would:
Increase NHS spending by 7% a year in real terms Guarantee that no patient will wait more than 18 weeks from GP to operating theatre by 2008 Increase private sector involvement in the NHS Conservatives
Michael Howard wants to cut red tape. He would:
Introduce a health “passport” entitling people who go private to have 50% of the cost met by the NHS Replace targets with less rigid “standards” Set up special teams to “search and destroy” the MRSA bug Liberal Democrats
Charles Kennedy wants to see more emphasis on preventative medicine in the NHS. He would:
Give the elderly free care in their homes Provide free eye and dental checks for all Tackle hidden waits Taking the voters' pulse
If Tony Blair could arrange for every voter to have hospital treatment, his NHS problems would virtually be over, writes David Smith. A Sunday Times-YouGov poll shows that among the population as a whole, 39% believe the NHS has got better since 1997, while 31% say it has got worse.
But among those who have had hospital treatment as inpatients, the NHS fares much better: 48% say it has improved, against 27% who believe it has got worse. Not overwhelming, but getting there.
Some people — nearly a quarter of the sample — would like the government’s record injection of money into the NHS to be accelerated, in spite of a doubling of spending since 1997, and would be prepared to pay higher taxes for this purpose. But most, 51%, are happy with the planned rate of increase and only 15% would like to see the growth in the health budget pared back to fund tax cuts.
Despite a successful Tory attack in the war over Margaret Dixon’s shoulder operation, Labour remains in a strong position on the NHS.
By nearly two to one, 40% to 22%, people think the NHS will improve if Labour is re-elected. In contrast they think, by 38% to 26%, that the price of a Tory victory would be a deteriorating NHS.
Voters believe that the private sector is heading for a bigger role in the NHS whoever is elected: 58% say this will happen under Labour, 65% under the Conservatives.
