Pharmafocus: The NHS in Review

pharmafile | January 24, 2008 | Feature | |  2007, NHS, healthcare, year in review 

First, the good news. So easy to overlook when the headlines are filled with tales of threats to close A&E departments, job cuts and killer superbugs, but there was much progress to report for the NHS in 2007.

Waiting lists continued to be cut down, treatment for cancer and cardiovascular disease improved (albeit too slowly for some) and at least one survey found most patients satisfied with services.

Add to that, fewer individual trusts are in debt and some areas are going beyond simply staying within budget, with frontline clinicians engaged in transforming services with real benefits for patients.

And yet 2007 was a rollercoaster year for the NHS, with clinicians and managers once again being asked to deliver far-reaching systematic reform and achieve financial balance in a destablised system.

At the beginning of the NHS 2006/7 financial year in April 2006, Patricia Hewitt had made enemies by declaring it was enjoying its 'best year ever' and subsequently pledged to resign if the NHS failed to break even in April 2007.

The Department of Health and Strategic Health Authorities guaranteed a break-even position by creating a reserve fund by 'top slicing' PCT budgets and dipping into training fund. This enraged doctors already upset by the shambolic reform of junior doctor training, but did produce a £500 million surplus in April this year.

While much maligned, Hewitt had been the first health secretary to enforce some simple accounting disciplines on the NHS, abolishing mechanisms which allowed debts and poor financial management to be concealed within the system.

But Hewitt was too closely associated with NHS job losses and threats of A&E closures to stay in the post when Gordon Brown moved into Number 10, and Alan Johnson subsequently took on the job in June.

Brown unveiled a well-rehearsed series of initiatives to win back public trust in Labour's stewardship of the health service, including co-opting renowned surgeon Ara Darzi to be a roving minister and NHS reformer, a move intended to reassure clinicians and voters that reform was based on improving patient care.

In public terms, this reassurance was greatly needed, as plans to re-configure services saw the threat of closure hang over A&E departments and other services held dear by local people across the country.

Some of the most unpopular decisions on reconfiguring have been put off until 2008, and the decision on whether or not to close much-loved local hospital units will be a test of Gordon Brown's political will first, and secondly a challenge to local NHS managers who will have to make it work.

And while the NHS is expected to end this financial year with a surplus of £1.8 billion, 2008 will be a decisive year as the budget increases which the health service has enjoyed come to an end, with spending rises falling back into line with inflation.

A report published by the Audit Commission in December warned that frontline clinicians needed to be more engaged with the cost and financial implications of the services they are providing.

This seems like a mammoth task for many local health economies and PCTs, some of which are not engaging with GPs on practice-based commissioning, to name just one reform, but one they will increasingly turn to as budgets come under new pressure – and expectations of patient services continue to rise.

Ministerial massage helps NHS hit waiting targets

By 2008, the government has pledged that all patients who need an operation will be treated within 18 weeks of their first visit to their GP – an ambitious target for a health service which has traditionally not focused on cutting waiting times.

While the target is for December 2008, local health economies needed to make significant progress in 2007 in order to stand any chance of meeting it.

But the health service as a whole looks unlikely to meet the target, prompting the government to massage the figures and lower expectations in November this year.

The government had some good news to report – for patients who don't need to be treated in hospitals, more than three quarters (76%) of non-admission patients are now treated within 18 weeks of their first visit to the GP.

But cutting hospital admission waiting times is proving much more difficult, with just 56% currently seen within the timeframe. The figure represents an 8% increase since March – a substantial improvement, but too slow to help the NHS reach 100% in just over 12 months time.

If this rate of improvement were to continue in 2008, the figure would reach less than 90% for hospital admissions, significantly short of the total.

To help massage the figures, health minister Ben Bradshaw announced that the target may be lowered to 90%, allowing for 10% of patients to wait longer where it is 'clinically justified'.

Examples of this would be where a patient needs to lose weight before having an operation, or where it is convenient to have the procedure later.

The proposed lowering of targets has already proved popular with surgeons' representatives, who say the 90% target would help shift the focus towards quality and ease the pressure on the service.

Orthopaedics struggling

Not surprisingly, some regions are nearer to hitting the target than others, and some specialists are cutting their waiting list faster than others.

Gastroenterologists are on average treating 82% of patients in time, whereas just 33% of patients waiting for trauma or orthopaedic surgery have their operation within 18 weeks of first visiting a GP.

Responding to the government's changes, Liberal Democrat health spokesman Norman Lamb said: "Ministers will struggle to convince a public already sceptical about government statistics that this change isn't merely providing political cover because of fears they will fail to achieve their target."

5 years on, a mixed review from man behind the masterplan

In any given year, scores of reports of varying authority and insight will pass judgment on the state of the National Health Service. But in 2007, few carried more weight than the one by Derek Wanless.

Wanless is of course the man commissioned by the Treasury in 2002 to put together a strategic plan for how the NHS should evolve over the ensuing twenty years.

The resulting report was remarkable for the clarity with which it set out priorities – and what was made especially clear was that more money was needed to improve the service. The Wanless report was the green light the then Chancellor Gordon Brown needed, and it was followed a few days later by tax rises that would pay for a rapid boost to NHS spending.

Fast forward just five years into the 20-year vision set out in the report, and Wanless had teamed up with the King's Fund to review the progress to date.

Overall, Wanless's assessment of the NHS in 2007 was mixed: while the overall health of the nation has improved, and patients services have got better, he concluded that the NHS has failed to fully capitalise on its extra resources.

The 2007 Wanless report summary

Outputs: an overall assessment

With increased resources, the NHS has been able to do more work in most areas. Elective Admissions increased by 7% between 2002/3 and 2005/6 and outpatient attendances by 3%. There have also been very large increases in emergency care (+21%) and accident and emergency attendances (+33%). Three-quarters of the 20% increase in prescription items dispensed between 2002/3 and 2006/7 is due to just ten drugs. Lipid-regulating drugs (statins) account for nearly a fifth of the total increase and are on target for achieving the 2002 review's recommendations at a lower-than-expected cost.

Overall, in terms of outputs, this places the NHS between slow uptake and solid progress.

Health outcomes and determinants of health: an overall assessment

The 2002 review's vision was that health would improve through a combination of better and more responsive health care services and changes in health-seeking behaviour. On broad measures, the health of the population has improved. Tackling the causes of ill health is an ongoing long-term task. Continuing reductions in smoking and improvements in levels of physical activity and diet suggest a future close to the solid progress scenario.

But over-optimistic targets – such as those relating to obesity – make it difficult to assess engagement levels in relation to the 2002 review scenarios. In addition, tackling recent financial difficulties in the NHS by raiding public health budgets has not been in the long-term interests of the public health of the nation.

Overall, the evidence suggests that the population is a long way short of the fully engaged scenario and is on a path between slow uptake and solid progress.

Productivity: an overall assessment

Official measures of NHS productivity provide inconclusive evidence of improvement.

The 2002 review's productivity assumptions of annual unit cost reductions of 0.75-1% between 2002/3 and 2007/8 have not been achieved; broadly, unit costs have increased for all hospital services.Although indicative measures of quality, such as waiting times and patient satisfaction, suggest improvement, 'hard' measures of quality, valued in monetary terms, are not available to compare with the review's assumption that the quality of care would improve year on year.

Some evidence suggests that the failure to reduce unit costs may have been partially offset by improved quality. However, the NHS has failed to generate the relatively modest improvements in unit cost productivity that might have been expected and were assumed by the 2002 review.

Overall, in terms of productivity, this places the NHS closer to the slow uptake scenario.

Will the health service ever be set free from politicians?

In May, doctors leaders put together a list of radical reforms they claimed would stop any government undermining the NHS in England and fragmenting the care it provides.

The BMA proposed appointing an independent board of governors to oversee a written constitution and holding a public debate on what the health service can afford to provide.

The idea of an independent board to manage the NHS seemed to gain widespread support in late 2006 and 2007, with Gordon Brown and the Conservative leader David Cameron also expressing support for variations on the idea.

BMA chairman James Johnson said: "As the ultimate guardians of the public purse, politicians and parliament should decide the high-order questions around setting priorities and funding. When it comes to the day-to-day running of the NHS, the role of national politics should be significantly reduced."

Then in June, the Conservatives unveiled their vision for the NHS, including the scrapping of targets for GPs as well as their take on the independent board idea.

In a deliberate break with Conservative policies of the past, David Cameron said, if elected, the party would enshrine in law the free-at-the-point-of-care status of the NHS, and turn its back on past policies which encouraged greater use of private healthcare.

He also pledged "each year we will increase spending on the NHS", but would not provide further detail on the scale of any rise in budgets.

Patricia Hewitt, health secretary until June, had dismissed the idea of making the NHS fully independent from politicians, even though the idea had been proposed by prime minister-in-waiting Gordon Brown a few months earlier.

"The NHS is four times the size of the Cuban economy and more centralised," she told an audience at the LSE.

"That is part of its problem, and the problem can't be solved by proposing that a modern health service be run like a 1960s' nationalised industry."

Hewitt's intervention followed similar comments made by Tony Blair, who dismissed Mr Brown's idea of an independent NHS board, claiming it would hamper reform and stop difficult decisions being taken on the future of the health service.

Anticipating her dismissal just days later, Hewitt took her chance to speak out against the idea, and Brown seems to have backed off from the most radical version of the reform.

Nevertheless, Brown looks set to bring in at least some of the proposed changes.

He will give the NHS a gift in time for its 60th birthday in July by creating a new NHS Constitution, a move currently being evaluated by the Next Stage review, which is due to issue its report in June 2008.

Are polyclinics the future ?

A review of the NHS in London recommended in July setting up a network of 150 'polyclinics' to take on much of the work currently done by hospitals.

The London report, led by the then newly-appointed health minister Professor Ara Darzi, is significant because it is likely to be used as a blueprint for the rest of England's health services.

The radical reorganisation would give local hospitals the bulk of routine work, freeing up major acute hospitals for complex and specialist procedures.

But Prof Darzi's proposals have not generally been well received.

The prime minister was forced to deny they would lead to hospital closures and doctors leaders warned polyclinics – combinations of GP surgeries and a variety of other services – may not be in patients' best interests.

Prof Darzi's report concluded there was a compelling case for change and that polyclinics would best fill the gap that currently exists between primary care and hospital care.

But the BMA said polyclinics could destabilise and fragment existing hospital and GP services.

Chairman of the BMA's London Regional Council Dr Tiz North said: "It seems odd to invent a new model for healthcare when there is already a successful and proven system of general practice which is highly-rated and trusted by patients."

If the proposals are adopted polyclinics could provide up to half of all hospital outpatient treatment by 2017.

Darzi's report found more favour with the NHS Confederation. It represents more than 90% of NHS organisations, and hailed the report as a vision which will revolutionise care in London".

Private, keep out

Lymington New Forest Hospital became the first NHS facility in England to be run entirely by the private sector in January.

It was widely expected that Lymington would be the first of many deals, and part of an inevitable push towards outsourcing health provision into the private sector.

But since Gordon Brown moved into Number 10 in June, government policy on using the private sector in the NHS has shifted subtly but significantly.

While the government has reiterated its commitment to increasing competition in primary care by allowing new private sector providers to rival GP practices, it has cut back dramatically on the role for private contractors in surgery and secondary care services.

Six new clinics which had been planned and another which was already operational were axed in November after health secretary Alan Johnson said the schemes did not represent good value for money.

The government will have to pay compensation to the private providers, but Johnson said Care UK's mobile diagnostic service for the West Midlands would have to be cut because of "unacceptably low rates of use".

The government said the move was not an overall change in policy, and while it proved popular with many in the NHS, others accused Brown's government of losing its nerve on reforming the NHS.

The Confederation of British Industry, representing the interests of the private healthcare companies called it a "hugely disappointing decision", and said the government had shown itself to be a customer in whom investors may have limited confidence.

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