So, if you read the original article (not just the abstract), targets and patient choice combined seem to have done the trick. Indeed introducing patient choice coincided with reduced waiting times and improved equality of provision even though activity increased. Sounds awfully like a Tory, market driven policy! Oh dear.

[2] “targets and patient choice combined seem to have done the trick – sounds awfully like a Tory, market driven policy”.

Why not try comparing levels of NHS funding under NuLab compared to the dark days of the Tories – perhaps that might have something to do with it as well, eh?

2: Whichever reason, Labour at least seem to have made the decisions that have improved waiting times. The Tories didn’t when they had the chance.

The NHS, according to the BMJ, has improved massively since 1997.

It certainly should have. Public spending on the NHS is now three times higher compared with 1997, a fact that the BMJ glides over. The important issue is whether healthcare in terms of patient outcomes is now three times better or whether much of the increase in spending has been absorbed by increases in the pay of clinicians – reportedly now the best paid in Europe – and in an inflated bureaucracy.

According to estimates by the Office of National Statistics, productivity in the NHS has been going down:

“The NHS has seen a year-on-year fall in productivity despite the billions of pounds of investment in the service, latest figures show. The data from the Office for National Statistics showed a fall of 2% a year from 2001 to 2005 across the UK.”
http://news.bbc.co.uk/1/hi/health/7610103.stm

Several NHS Primary Care Trusts are reporting that top earning GPs are getting over £300,000 a year remuneration. Also, several media reports say that higher pay for NHS staff has absorbed some 70% of the extra financial support put into the NHS by the government since 1999. I believe these are major factors explaining why NHS productivity is assessed by ONS as having shrunk.

“NHS hospitals in England are rife with waste and inefficiency, consultants McKinsey and Company have told the Department of Health in a confidential report, seen by HSJ.

“It says up to £2.4bn could be saved if hospitals with the lowest levels of staff productivity pulled themselves up to nearer the average performance. The management consultants argue that doctors and nurses in the worst 10 per cent of trusts deal with less than a fifth of the volume of patients that those in the best 10 per cent handle.

“As well as staff productivity, the report identifies inefficiencies in the patient pathway. For example, it sets out how around 40 per cent of patients in a typical hospital do not need to be there at any one time. . .

“It says up to £200m could be saved a year if unnecessary diagnostics were cut and another £600m if new and follow-up outpatient appointments were limited. . . ”
http://www.hsj.co.uk/news/acute-care/mckinsey-cost-saving-proposals-focus-on-waste-in-acute-sector/5005785.article

It seems to me that the BMJ is engaging in just another propaganda exercise for the benefit of the gullible. Someone will shortly wheel out again that old canard: the NHS is surely wonderful because the American healthcare system is so awful.

[4] He, hee, Lee, remember the Tory mantra? – “the NHS safe in our hands”

A little synopsis of their disastrous legacy on health.
http://news.bbc.co.uk/1/hi/health/background_briefings/your_nhs/85952.stm

At three times the cost it bloody well should have improved!

With that amount of money, even I could have improved it.

The question is, has it improved as much as it should have done?

[7] “The question is, has it improved as much as it should have done” – definitely not is the short answer, but ………..

As a % of GDP the increase is nothing like three times as much.
GDP was 6.7% in 1998 (thanks to years of Tory underfunding)
http://www.bmj.com/cgi/content/extract/320/7235/640

It rose to a still relatively modest 8.4% by 2007
http://www.oecd.org/dataoecd/46/4/38980557.pdf

Check the co-author and the not-so-hidden agenda. It’s Julian ‘marketise/privatise’ Le Grand.Managerialists like him ain’t ever going to admit that the biggest blight on the NHS is managerialism.The internal market wastes vast amounts of money, abolish it, together with all the staff needed to run it. Marketisation of the NHS increases costs at a much faster rate than it improves care, after all there are a lot of shareholders to be paid.
Opening up public services to a “free” market won’t necessarily save money. Private firms cherrypick the profitable bits, leaving the costly bits to the public service. And someone has to police the contracts for service, which is costly in terms of highly paid consultants, accountants and the rest.
And if you don’t award contracts for long periods, the renegotiation of contracts, and possible change of contractors leaves problems of continuity.
You could talk of Labour investment, but so much of of it hasn’t been:Look at the immorally high costs of PFI where the taxpayer, having bailed out the banks, is now paying almost twice as much as it should for some PFI hospitals through high rates of interest and returns to shareholders. The total money raised from private finance so far is £12.27bn but the NHS will pay out £41.4bn for the availability of buildings and a total of £70bn over the life of the contracts.
When people talk about investment in the NHS I wonder if there’s some reliable data on how much capital investment has been planned, centrally funded and delivered by Labour over the last 12 years?
I wouldn’t be suprised if, removing the PFI schemes, the actual amount of infrastructure and capital investment is only marginally greater than during the currency of the last Parliament under the Conservatives.
There’s no doubt that they’ve spent £Billions extra but much of this will have been wasted on management consultants, IT systems that have failed etc.

NewLab had a golden chance to sustainably rescue the NHS, but they blew it. Big style.

[9] hard to disagree with any of that, Alisdair – well said.

“Many people feared that the government’s NHS reforms would lead to inequity”

Mostly that would be people on the inside, the BMA for example. It’s much the same issue as the police association being against elected police chiefs. The quangos lobby for their own interest rather than the interest of those using the service they provide.

Back to the article – If I recall the report credited the internal market reforms with a large chunk of the improvement in service rather than the increase in funding. Despite the funding increase though, I still hear stories from my girlfriend (who works in a BUPA care home) of residents having to go to hospital for a few days and coming back in a far worse condition than they went in (and also being fitted with a catheter even though they are perfectly capable of going to the toilet themselves if only someone would help them out of their bed).

It’s important to note that where the study is talking of improvements, it’s about waiting times. Discuss to death other aspects of the NHS but it won’t be relevant to this here.

In Monday’s (7 September 2009) news:

“Health and overseas aid budgets will not be spared from a programme of public spending cuts that will be rolled out by ministers over the next two months, the Guardian has learned. . .

“Though Labour will not ring-fence any government department’s spending programme, it will focus on ‘protecting activities and priorities’ such as education and fighting child poverty.”
http://www.guardian.co.uk/politics/2009/sep/06/new-labour-strategy-cuts

Evidently, protecting the NHS is no longer a Labour priority. Curiously, Cameron has already promised to protect spending on health and overseas aid. What is not widely appreciated is that the NHS budget is in surplus according to this news report in August last year:

“The NHS in England is heading for an estimated surplus of £1.75bn in the current financial year, official estimates predict.”
http://news.bbc.co.uk/1/hi/health/7584868.stm

Interesting what Le Grand said in a Guardian piece about the report:

“During the same period that we examined waiting times in England in our study, Scotland and Wales, which both explicitly rejected market-driven reforms, have spent more per patient but have seen much smaller decreases in waiting times.”

http://www.guardian.co.uk/commentisfree/2009/sep/04/nhs-cost-cutting-patient-care

Markets work…..who knew?

We should also remember that improvements in many areas have been slower than in more marketised health systems in parts of Europe. Still, I think we should give some credit to Labour on this one. Their reforms have meant that the increased funding hasn’t been as inefficiently used as it would have been under a more bureaucratic system.

@ Tim Worstall. Waiting lists are not a good metric. Le Grand’s notions often don’t bear scrutiny.
Quality of health outcome is not really mentioned. Nor is provision for extra capacity for major emergencies or epidemics and, in fact, an effective bias against such provision by requiring maximum number of patients with the same amount of resources.Also, if every hospital is running at full efficiency and
capacity (his ideal) how does the market operate?
Also note that more spending in Scotland and Wales is on-balance sheets (fewer PFIs etc). How do you marketise the preventative function of the NHS, too. Oh, and the usual metrics don’t take into account complexities of need:Healthcare shouldn’t be about the maximum numbers of people treated with finite resources, it’s about treating the greatest needs. NOT the same thing.
Let’s give you an example from the field of mental health in which I work: there is a national programme called IAPT (Improving Access to Psychological Therapies).
A huge debate has ensued within this about the case mix.
There is a large number of very mild MH problems or cases (if indeed we even dub it MH, and not some other phrase like emotional resilience/wellbeing) which is a bottomless pit of ‘need, but better termed ‘want’: not need in a strict clinical sense, but folk want a service to stop their unhappiness. the nearest match in their eyes are the already stretched MH services, so thats who they ask for help. Should MH services be dealing with such folk? Id most certainly say no and focus resources on severe and enduring problems,others may disagree.
However, the real temptation for managers, one to which many have succumbed, egged on by the ludicrous pronouncements of management consultants is to divert clinical time to the not-very or barely distressed because the throughput of resolved cases looks hugely impressive. Until you realise that most of these folk would have got better in time anyhow, and that the more severe and enduring, difficult cases have been neglected by contrast.

#9: “the biggest blight on the NHS is managerialism”

For a change, let’s look at the facts on NHS staff numbers:

701,831 NHS medical staff, including 37,213 GPs; 84,595 hospital doctors; 408,160 nurses; 11,854 dentists and dental staff; 142,558 other medical staff and 17,451 members of ambulance crews.

666,863 Non-medical staff, including 355,010 clinical support workers; 179,151 administrators; 39,913 senior managers; 353 other non-medical staff and 92,436 non-medical GP surgery staff.
http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-should-sack-137000-of-its-staff-1780891.html

Apparently, pure administrators and managers are in a minority.

My impression as an outpatient and from what I’ve gleaned in talking with clinical staff at my local hospital trust is that clinical work is in serious need of more, not less, administrative support. Friends of about the same age group concur reflecting the difficulty of making hospital appointments, cancelled appointments, chasing correspondence, recurring problems in getting reports of diagnostic tests etc etc. A couple of years back, I received a letter in August from my local hospital asking me to return so they could take more blood for a blood test as insufficient had been taken at my “recent” visit. The “recent” blood test was, in fact, in April. Mercifully, the test did not relate to anything critical.

Btw as for history, try this news report of 11 April 1997:

“Half a dozen chief executives of NHS trusts are being paid more than the Prime Minister, according to a salary survey published today. The review, by Income Data Services, underlines Labour and Liberal Democrat complaints about the rocketing costs of administration, which have risen by more than £ 1bn since 1989-90.”
http://www.independent.co.uk/news/salary-study-fuels-row-over-nhs-fat-cats-1266384.html

And this oddity:

“NHS is world’s biggest employer after Indian rail and Chinese Army”
http://www.timesonline.co.uk/tol/news/uk/health/article1050197.ece

@ Bob B I said managerialism, not the number of managers per se.
Managerialism:http://en.wikipedia.org/wiki/Managerialism

Thanks to Alisdair Cameron for putting the real facts forward.

For the amount of money thrown at the NHS – there has NOT been a corresponding rise in ‘effectiveness’.

Too many managers, targets, pointless diktats and one hell of a farcical IT system which cost millions and doesn’t work.

That’s the reality of 12 years of CRAP LABOUR GOVERNMENT.

That’s why Labour will be T O A S T come the General Election.

This is one of the reasons why we need to question whether the sheer size of the NHS is dysfunctional:

Pay is centrally negotiated because the NHS is managed by the Department of Health and provides what is verging on a monopoly of healthcare services in Britain. But centrally negotiated pay means hospitals and other supply units can’t respond to local labour market conditions.

LSE researchers predicted that the ensuing difficulty of recruiting and retaining nursing staff in regions with strong labour markets would have worse medical outcomes than regions with weak labour markets where it is easier to recruit and retain nurses. And that is what they found:

“Hospitals in the north gain from a more stable pool of nurses. Southern ones have to lean on temporary agency nurses, who can be paid more but tend to be less experienced, less familiar with the hospital and less productive. Do southern patients suffer as a result?

“The economists look at the proportion of patients aged 55 or more, admitted to hospital after a heart attack, who die within 30 days. They find a strong link between this ratio and local private-sector wages. The higher the private wage, making it harder to get good nurses in the NHS, the higher the death rate: to be precise, if the private wage is 10% higher in one area than another, the death rate is 4-5% higher.”
http://www.economist.com/world/britain/displaystory.cfm?story_id=E1_TDVGGRSS

The original LSE research is posted here:
http://www2.lse.ac.uk/ERD/pressAndInformationOffice/PDF/CanPayRegulationKilll.pdf

By independent assessments, other west European countries have healthcare systems which yield better patient outcomes without monolithic structures like the NHS. I am becoming increasingly alarmed at the poor intellectual quality of arguments mounted on behalf of the NHS by professional clinicians working in the NHS. Frankly, it leads me to doubt their capabilities for rational analysis and making objective judgements in diagnosis.

[22] “I am becoming increasingly alarmed at the poor intellectual quality of arguments mounted on behalf of the NHS by professional clinicians working in the NHS. Frankly, it leads me to doubt their capabilities for rational analysis and making objective judgements in diagnosis” – and NHS staff grow weary of critics who question why the NHS is not better than the aggregation of all that is best across a vast territory like Europe.

Any comparative arguments is undermined by the fact the phenomena we are being asked to measured is virtually meaningless when couched in these terms.

There is no such country as Europe, Bob B.

Tell us which country has the best system – then we can look at how much it costs while comparing a RANGE of outcomes (including waiting times, infant mortality, life expectancy, and performance for key diseases, etc).

Most of the apparent difference is largely a matter of perception in my opinion (coloured by political persuasion, of course) allied to the fact that outcomes are, to a certain extent, independent of the system provided.
Look at the USA and its problems with obesity – only one state has a prevalence rate of less than 20%, no wonder their life expectancy is worse than ours, while even the best performing country in Europe shows only a marginal difference compared to the NHS when it comes to how long we live.
http://www.cdc.gov/obesity/data/index.html

“Apparently, pure administrators and managers are in a minority.”

No shit, sherlock.

@Worstall “Markets work…..who knew?”

#23: “There is no such country as Europe, Bob B”

Check out the league tables of an independent Swedish think-tank – Health Powerhouse – for healthcare systems in other west European countries:
http://www.healthpowerhouse.com/files/canadaIndex03.pdf

The NHS has regularly rated as fairly mediocre in its annual league tables.

The obvious reservations about spending even more public monies on boosting the NHS are:

- the NHS budget was in surplus last year and is officially predicted to be in surplus this year as well

- without reforms, the extra spending will just get swallowed up through falling productivity in the NHS, more waste and inefficiency – as per the recent McKinsey report – and even higher salaries for NHS clinicians, who are already reckoned to be the best paid in Europe

What I believe many of us would really like to know is how do healthcare systems in other west European countries manage to achieve better patient outcomes without massive, monolithic structures like the NHS – as reported: the NHS is the largest employer in the world after India Rail and the Chinese army.

“Markets work…..who knew?”

Really? Just what caused all those failing banks last year and the ensuing financial crisis then?

@18 Bob B
“clinical work is in serious need of more, not less, administrative support.”

Or…. perhaps less administration. There is so much red tape in the NHS that the admin staff will be overworked for a great deal of the time. If you cut down their job requirements to the bare minimum you can reduce the number of man hours required to administer the health service.

“Really? Just what caused all those failing banks last year and the ensuing financial crisis then?”

Longterm low interest rates, set by governments that hold a monopoly in fiat currency.

#28: “There is so much red tape in the NHS that the admin staff will be overworked for a great deal of the time.”

What I’m talking about is pretty basic, such as letters informing patients of the results of diagnostic tests at hospitals – which patients are legally entitled to know – without the need to keep chasing hospital departments. Also, letters from hospital consultants to GPs about changes in treatment, which I’ve had to chase up several years running.

I started to get paranoid about this until my GP told me that any number of patients have similar problems. On talking to clinical staff, I was told that from their perspective, there is too little basic administrative support.

The claimed problems of NHS bureaucracy are probably a function of the sheer size of the organisation – the NHS is the largest employer in the world after India Rail and the Chinese army. There is also the evidently growing problem of clinical errors, which doubtless generate much paperwork:

“Thousands of patients are feared to be dying needlessly every year because of poor communication between hospital staff, faulty equipment and a lack of skills.”
http://www.timesonline.co.uk/tol/life_and_style/health/article2141382.ece

“Accidents, errors and mishaps in hospital affect as many as one in 10 in-patients, claim researchers. The report in the journal Quality and Safety in Health Care said up to half of these were preventable.”
http://news.bbc.co.uk/1/hi/health/7116711.stm

I only wish we had more information from researchers and think-tanks on how all this compares with experience of healthcare systems in other west European countries.

29#: “Longterm low interest rates, set by governments that hold a monopoly in fiat currency.”

Not so. In 1997, Parliament declared the Bank of England independent with the remit of applying monetary policy to maintain a specific annual inflation target of +/- 1%. In February 2004, the annual inflation target was switched from 2.5%, as measured by the Retail Price Index minus mortgage interest (RPIX), to 2% as measured by the Consumer Price Index (CPI). The RPIX includes mortgage repayments and hence reflects an element of house-price inflation or deflation. The CPI is a more narrowly based index and excludes house prices. There is an active and unresolved policy controversy on both sides of the Atlantic over whether the monetary policies of central banks should explicitly address asset-price bubbles.

Btw: “American house prices rose 124% between 1997 and 2006, while the Standard & Poor’s 500 index fell by 8%; half of US growth in 2005 was house-related. In the UK, house prices increased by 97% in the same period, while the FTSE 100 fell by 10%.” Robert Skidelsky: Keynes – The Return of the Master (Allen Lane 2009) p. 5.]

Last year, John Redwood was quoted as saying in the Conservative Home forum that the cause of the recession was because the government had kept interest rates too high for too long.

The latest tweak in NHS policy options:

NHS hospitals could become charities: Foundation hospitals may want to become charities in order to raise income from private patients and escape government interference, trust hospital network suggests
http://www.guardian.co.uk/society/2009/sep/09/nhs-hospitals-charities-private-patients

@ Bob B (31) Made my feelings about that very clear on the Guardian site itself…

It wouldnt have improved at all under the conservatives. I want my taxes spent on healthcare and other socially beneficial areas. I dont want all my money to myself so i alone can benefit at the expense of others and society as a whole. Ask GPs and nurses, has it improved under Labour. Ask teachers the same thing. I believe the answer is yes.