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Slow progress on public health may need more health spending
The review of National Health Service (NHS) funding and performance since 2002 published this week, which has been led by Derek Wanless, has something for everyone.1 2 The government's supporters will focus on progress made in appointing extra staff, modernising buildings, buying new equipment, cutting waiting lists and waiting times, and improving priority areas of service provision such as cancer and cardiac care.
The government's critics will emphasise the failure to improve productivity and the high cost of the new contracts for general practitioners, consultants, and other staff. Independent observers will note that progress on reform of the NHS and on the wider public health agenda falls well short of the most optimistic “fully engaged” scenario set out in the original Wanless reports.3 4 The implication of this shortfall is that government may need to increase planned spending on the NHS to enable it to meet future demands.
While the review provides a comprehensive and even handed assessment of NHS reform, two factors need to be borne in mind in drawing conclusions. The first concerns the lack of reliable information to assess progress in some key areas.
Most importantly, incomplete data on the range and quality of services delivered for the increase in resources made available to the NHS make it hard to accurately assess changes in productivity since 2002. This is important because estimates of future resource requirements are particularly sensitive to improvements in productivity.
While work is in hand to fill gaps in data and to develop a measure of productivity that reflects quality of care and the full range of services provided,5 the extent to which extra spending has improved performance is uncertain, as the review emphasises. Arguments that further major increases in funding are needed should therefore be treated with caution.
The second factor relates to the scale of the challenges involved in the NHS reform programme. Transformational changes of this kind rarely proceed in a linear fashion, so that performance often deteriorates before it improves.
The review says nothing about this problem and offers a “before and after” assessment of progress, rather than a more nuanced account. Failure to analyse the rhythm and pace of change means that it is not clear whether reform is on a rising or declining trajectory. If the progress noted is accelerating, then the review's verdict on the state of the NHS today is more positive than it would appear.
Looking to the future, Wanless argues that the policy direction taken by the government is right, notwithstanding the disruptive effects of organisational change. In making this point, the review emphasises that the most notable improvements have been driven centrally through national service frameworks, guidance from the National Institute for Health and Clinical Excellence, and government targets.
It is all the more surprising therefore, that the report lends qualified support to patient choice, provider competition, and commissioning as drivers of change in the next stage of reform. These policies have been implemented too recently to have been evaluated properly, and it is not clear that they will be more effective than other approaches in bringing about change.
To take just one example, much hinges on general practitioners and primary care trusts becoming “world class commissioners,”6 yet evidence from other countries shows how difficult it is to commission health care effectively.7 On this matter, the authors' aversion to further lurches in policy direction has outweighed a more considered assessment of the evidence.
The review is on sounder ground in its criticisms of the policy making process. Specifically, it notes that the pressure to produce quick results has led to some policies and initiatives being introduced without adequate preparation.
It also argues that the government has failed to take full account of how the various elements of its reforms fit together. There are strong echoes here of the Cabinet Office's capability review of the Department of Health and its criticisms of the quality of policy making in government.8
However, the review sounds the loudest warning bells on public health. Despite continuing progress in increasing life expectancy and reducing infant mortality, considerable threats for the future are identified in widening health inequalities and increasing rates of obesity.
The review reiterates the need for a comprehensive framework for public health and criticises the raiding of public health budgets to help tackle the financial deficits that emerged in the NHS in 2005. During a week in which the new secretary of state for health chose public health as the subject of his first major speech, it may be that the review's message will be heeded this time round.
If there is a surprise about the review, it lies less in its analysis and recommendations, and more in the muted reaction of politicians. At least for now, there seems to be broad political consensus on the future funding of the NHS and the policies that need to be put in place to deliver further improvement.
The pessimistic view is that this reflects the poverty of thinking in the political class. A more generous interpretation is that it stems from the challenges involved in turning around a major organisation like the NHS and the realisation that no quick fixes are on offer. The opportunity this creates is for the NHS to build further momentum for improvement, relatively sheltered from the shifting winds of political debate.
Competing interests: CH was director of the strategy unit in the Department of Health between 2000 and 2004.
Provenance and peer review: Commissioned; not externally peer reviewed.