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Greater spending on the NHS over the past five years, by more than £43bn (€63bn; $87bn), has failed to deliver improvements in productivity that could have led to better health care for all, an independent review has concluded.
The review by Derek Wanless, which has been carried out for the independent health think tank the King's Fund, follows up his 2002 report Securing Our Future Health (BMJ 2002;324:998 doi: 10.1136/bmj.324.7344.998), which was commissioned by Gordon Brown, then Chancellor of the Exchequer.
Although the extra spending on the NHS has led to many important improvements in healthcare infrastructure, staffing levels, and care provided for some conditions, the new report says, the opportunity to deliver better public health has been missed—with the prevalence of obesity in particular now higher than the worst case scenario forecast in the 2002 report.
“The extra resources, accompanied by fundamental reform, have undoubtedly improved patient care over the past five years,” said Sir Derek, former chief executive of the NatWest Group. “But what is equally clear from this review is that we are not on course to deliver the sustainable and world class healthcare system and, ultimately, the healthier nation that we all desire.
“Without significant improvements in NHS productivity—and much greater efforts to tackle obesity in particular—even higher levels of funding will be needed over the next two decades to deliver the comprehensive, high quality services envisaged by my original review. Such an expensive service would undermine the current widespread support for the NHS and raise questions about its long term future.”
Waiting times have fallen significantly since 2002, life expectancy and cancer survival have improved, and better care is being provided for people with heart disease, stroke, and mental health problems, and the number of smokers has fallen, the review found. However, the gap between the health of the rich and the poor has widened, and 23% of men and 35% of women in 2005 were obese—four times the number predicted in 2002.
The improvements in productivity anticipated in the 2002 report have also not been realised. Although the cost of providing hospital and other services has increased, there is no evidence that quality has improved.
The biggest increase in hospital activity has been in emergency care (up 21%) and attendances at accident and emergency departments (up 33%), which could be due to poor out of hours services being provided in the community, said Sir Derek. He also expressed concern that non-elective admissions had grown more rapidly than elective admissions, again possibly reflecting over-reliance on improved emergency services and raising doubts about how demand in the health service is being managed.
Sir Derek also complained that although increases in pay across the NHS had absorbed an estimated £18.9bn, or 43% of the increased input costs, “there was a dearth of robust evidence of significant productivity or other benefits arising from the new contracts [for GPs and consultants] and pay deals.”
Sir Derek gave a “guarded tick” to the present structure of the NHS, but he said it had been a “slow journey,” with unnecessary disruption resulting from the countless reorganisations. He insisted that the levers were now in place to achieve value for money but that outcomes had to be monitored more closely and data on outcomes collected more robustly.
If the NHS was going to meet the “fully engaged” scenario outlined in his 2002 report, where services were significantly more productive and people took greater responsibility for their own health, spending on the NHS would have to increase from an estimated £68bn in 2002-3 to £154bn by 2022-3 (at 2002-3 prices), says the report.
To tackle public health more effectively Sir Derek called for an independent body to be set up to advise the government. The report also recommends developing better estimates on long term healthcare needs, research into workforce planning and the effect of new staff contracts, and a framework for public health.
Nigel Edwards, director of policy at the NHS Confederation, the body that represents most NHS organisations, welcomed the report. He said: “We are pleased the report recognises that health policy is moving in the right direction. While there are clearly lessons to be learnt in terms of policy implementation, there have been many successes at a local level. Effective clinical engagement and demand management must be led by health service leaders at a local level.
“The current measure of productivity in the NHS used by the Office for National Statistics is too simplistic and potentially acts as a perverse driver. Official figures show that waiting lists and times have dramatically improved since 2002, despite the fact that the NHS has been facing a legacy of underinvestment. In addition, the NHS Confederation believes that we need to radically overhaul the current approach to measuring productivity by putting patient satisfaction at the centre.”
Commenting on the report, Jonathan Fielden, chairman of the BMA's Central Consultants and Specialists Committee, said that doctors needed to be free to innovate to improve productivity.
He said, “In the last few years the government has been so determined to balance the books and bring down NHS debt that doctors have been prevented from introducing innovative practices to improve productivity. Hospital go-slow policies have meant that patients have had to wait longer for their operations, despite the fact that doctors and their professional colleagues have been willing to carry them out. Doctors want to do more for their patients but need the freedom to be able to innovate and become more productive.”
Dr Fielden added that the BMA has called for tough action to tackle childhood obesity. “Of course, health professionals have an important role to play in helping their patients make healthy choices, but it is essential that people take responsibility for their health and follow advice about eating healthily and exercising.
“The UK faces an obesity time bomb that the public—led by health professionals—must face up to. The government must act with us to change unhealthy eating patterns and enhance activity in all our lives.”
Laurence Buckman, chairman of the BMA's General Practitioners Committee, said, “Doctors' productivity can only be measured in the longer term, as their ability to influence people's health outcomes improves. The GPs' quality framework has already had an impact in reducing illness; this is the best measure of the way we work.”
Our Future Secured? A Review of NHS Funding and Performance can be seen at www.kingsfund.org.uk.