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Emerg Med J. 2007 December; 24(12): 808.
PMCID: PMC2658345

Five years on: some positives, some negatives

A King's Fund commissioned report, Our future health secured? A review of NHS funding and performance,1 published in September this year, is, as its title succinctly suggests, a timely retrospective review of National Health Service spending and performance since 2002, the year the Treasury published a Gordon Brown commissioned review of health care funding needs for the next 20 years.2 Sir Derek Wanless, a career banker, led both reviews.

The first one said that a huge increase in NHS spending demanded parallel and radical reforms to tackle problems of “excessive waiting times, poor access to services, and poor quality of care and outcomes”. The second review answers questions about the amount of money invested in recent years, where it went, what it achieved, whether it was spent wisely and what lessons can be learnt. It is 320 pages long, as comprehensive as it can be at such length, surprisingly well written, succinct, reasonably jargon free and, although balanced, does not pull its punches.

What does it say that may interest readers of this journal?

  • Funding has seen an annual real term growth of 7.4% over 5 years, real spending rising by 50%—a total cash increase of £43.2 billion (€62.2 billion, US$87.8 billion)—and the proportion of the UK's gross domestic product spent on health has grown to 9–10%, close to but not equal to the European Union average
  • Pay modernisation led to substantial new costs with few convincing signs of improved productivity, the latter point referring to hospital consultants and general practitioners, as there is no national evaluation of Agenda for Change, the new pay and grading system for non‐medical staff. The increased pay costs are only slightly higher than the assumptions made in 2002
  • The government is on track with its commitment to employ more staff (of all types); the down side is that the target numbers are still not high enough to cope with demand after 2008
  • The government is on track to meet its target for building new hospitals and modernising general practitioner premises; the down side is that the targets are not ambitious enough. Backlog maintenance is worsening rather than improving
  • Three quarters of CT and MRI scanners and linear accelerators in use are new
  • Targets for increased numbers of procedures have been exceeded
  • The largest overall growth in hospital activity has been in emergency admissions, with a net increase of 1.6 million (35%) admissions
  • A&E [sic] attendances, static between 1998 and 2002/3, have grown by more than a third to 19 million in 2005/6. Causes are changes in clinical behaviour, lower A&E waiting times and changes in GPs' out‐of‐hours cover
  • Calls to NHS Direct have plateaued at just under 7 million a year
  • NHS Direct Online, launched in 1999, receives 1.5 million hits a month
  • 75 English walk‐in centres attracted more than 2.5 million visits in 2005/6
  • Emergency calls on the ambulance service have doubled in the 10 years to 2005/6 to almost 6 million
  • A&E receives about 1.9%, NHS Direct and NHS Direct Online 0.1%, walk‐in centres 0.01% and ambulance journeys 1.4% of total NHS spending
  • Broadly speaking, the health of the population has improved with lower overall mortality rates and longer life expectancy, both continuations of long term trends
  • Cancer survival rates have increased
  • Infant and perinatal mortality rates have improved slightly since 2002, although they remain higher than for many other European countries
  • Inequalities between socioeconomic groups, measured by infant mortality and life expectancy at birth, have grown
  • Overall, the official measures of NHS productivity (defined in detail in the review) are inconclusive, there being some wins and some losses in the various subsets of productivity measurement
  • Attempts to measure whether the quality of care is improved suggest significant gains but it is hard to be sure due to a lack of routinely collected data; in addition some data are at the softer end of the spectrum.

The review finishes with a list of recommendations, many interrelated and high level. One such (not a surprise to many readers) is that the government must strengthen its analytical capacity to monitor the effectiveness of its policies; another one, even less surprising, is that it must strengthen its capacity to link clinical and service objectives with the resources needed to achieve them.

If this were a school report, the teacher scoring the pupil's progress and proficiency would give an at best overall score of 5 out of 10.


Competing interests: None declared.


1. Wanless D. King's Fund Commission Report, September 2007.
2. Wanless D. HM Treasury Report, April 2002.‐

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