Civitas Blog

‘Until last month’, writes Jenni Russell in The Guardian, ‘it had been years since I'd been inside [A&E]. In the intervening time I assumed that the money poured into the NHS would have made a visible difference to A&E too.’ In her view, it hasn’t; ‘barbaric’, ‘no-one to help’, ‘inhuman’ are powerful words. Yet sadly, it’s an all too familiar tale.

The NHS might be seeing some five million more in A&E now than in 2000 and rushing the majority through in under four hours, but the experience of patients all too often remains unchanged. ‘At a time when the government is increasingly concerned about how people interact with one another in public places’, Russell continues, ‘it seems perverse that institutions run by the state should abdicate their responsibility for setting more civilized norms.’ Perhaps true, but has the state ever been particularly good at this? By extending its regulatory capture ever further, is it not becoming part of the problem?

It was a theme that ran throughout Lord Darzi’s final report, published earlier this week. ‘High quality care cannot be mandated from the centre – it requires the unlocking of the talents of frontline staff....where change is led by clinicians and based on evidence of improved quality of care, staff who work in the NHS are energised by it and patients and the public more likely to support it’, he wrote. Never a truer word.

But this is precisely what the system doesn’t like to countenance.

Lord Darzi today publishes his eagerly awaited Next Stage Review of NHS policy.

Ostensibly it heralds the end of the top-down era; a shift away from central targets to more self-sustaining means of driving performance, based on user-empowerment, information, choice and competition - but the system will work against it.

The Conservatives made a first small step in the right direction on NHS policy yesterday, reaffirming their pledge to scrap the endless targets that have - to not put too fine a point on it - bludgeoned the life out of the health service over the past decade or so; and instead focus on outcomes. As this blog has written many times - such as here and here - targets are a sure way to demoralise staff and distort clinical priorities like none other. Outcomes are what we should be looking at.

The press is littered today with references to a new report on system reform in the NHS produced jointly by the Audit Commission and the Healthcare Commission – two well respected watchdogs. It concludes ‘the [competitive] reforms [in the NHS] have not yet delivered the desired change’, adding that ‘there is no evidence from our fieldwork that choice policy has so far... led to an improvement in the quality of service offered’.

Lord Darzi’s Healthcare for London report, published last July, outlined ambitious proposals to introduce a series of polyclinics in the capital. While the national Next Stage Review currently being conducted may not take the London report as a template, it is likely that polyclinics are to form a part of Lord Darzi’s conclusions once again.

But what is there likely impact? Are polyclinics the emperor’s clothes – it’s certainly a new, untried, model – or could they serve as a means to the integrated care we all crave? At a debate hosted by Civitas last week, the medical profession and leading academics had their say.

Perhaps one of the biggest misnomers in the NHS at present is payment by results, quite simply because it isn’t payment by results at all. It’s payment by caseload.

For an operation from the same health resource group, whether you bungle it and leave the patient ridden with MRSA and disabled for life or whether you’ve done a world-class job that Lord Darzi himself would be proud of, you’ll get paid the same.

‘The potential for social enterprise and not-for-profit organisations to contribute to health and well-being remains almost completely unrealised’, surmised Harry Cayton, at a debate hosted by Civitas in the House of Commons last week.

The question is why? Social enterprise – as shown in personal examples such as SELDOC and Stahcom, led by Mo Girach, and Knowledge into Action, the brainchild of Sir Muir Gray – has much to offer.

Yesterday, the world renowned health economist and ‘father’ of managed competition, Professor Alain C. Enthoven of Stanford University, gave a lunchtime seminar at Civitas, in which he advocated the development of genuine patient-centred health care, based on integrated delivery systems and individual (cost conscious) choice in the NHS.

Those calling for integrated systems of finance, delivery, primary and secondary care are getting louder across the UK, but, according to Professor Enthoven, they must be competing: 'Kaiser Permanente leaders recognise their money and livelihood comes from the money of satisfied members/patients who have a choice. Service improvements are driven by a recognition they could go elsewhere. Kaiser recognises they are a competitor and they welcome competition'. Listen again or view his slides here.

Is summer now the season for publications pushing increased government intrusion into private conduct? The warm air has been accompanied by the somewhat chillier sensation of the release of two reports with some joyously Orwellian titles: The Politics of Public Behaviour from Demos and Creatures of Habit? The Art of Behavioural Change from the Social Market Foundation. From the mechanisms discussed in both these titles, it seems that the aspiration to get the state more involved in people’s lives remains as strong as ever among many policymakers, but combined (perhaps dangerously) with fresh research into behavioural economics.

In a head-to-head debate in the British Medical Journal, we argue that instead of backing away from the reality that supplementing of NHS care with private treatment is already widespread – and will become even more so as the finite budget of the NHS becomes less able to cover the medical care that people want or require – the government should instead work towards creating an equitable framework for top-up fees. This would allow access to new drugs and treatments to all, rather than just the wealthy as is the case currently.

Writing in the British Medical Journal in February 2008, Allyson Pollock and Sylvia Godden lambasted the quality of care provided in independent sector treatment centres (ISTCs). They are right to raise concerns over data quality and collection, but a report released this week by the LSHTM and the Royal College of Surgeons allay many of the fears they proclaim.

The NHS Confederation today publishes a report looking at polyclinics, widely anticipated to be recommended as part of the conclusions of Lord Darzi’s Next Stage Review in the summer.

The Confed puts a pretty strong case for them, describing the principles behind them as ‘in line with the way that healthcare is developing across the world’ and listing the potential benefits: larger groupings of primary care professionals, economies of scale, a reduction in expensive hospital activity, better integration of services and space created for community health care. It thinks, with all this laid out, that the proposal has ‘generated a surprising level of opposition’. Really?

If anyone ever wanted a clear exhibition of the damage this government has done to the medical profession, look no further than this post by Dr Crippen. Doctors' professionalism and sense of intrinsic reward replaced by crude economic calculation of value leads, unsurprisingly, to inferior service. Here, it's out-of-hours care...I'm sure there are many more.

The irony is that the DH now has a 'Social Enterprise Unit' to encourage the very ventures, such as the one he describes, it has crushed by central direction and 'one-size-fits-all' policy. And it's the patient that suffers.

The British Medical Association (BMA) have just released a survey today confirming a point I remember being made in no uncertain terms to me last year by one of the figureheads of the junior doctor pressure group, Remedy UK. The European Working Time Directive (EWTD) coming into effect next year will cut junior doctors' maximum week to 48 hours; a fact, he said to me, risks serious shortcomings in patient care. It seems his colleagues agree. Two in three (64 percent) believe the EWTD will have a "negative overall effect" on their training.

The Department of Health took a blasting a few weeks back from the Statistics Commission for lack of clarity, accuracy, objectivity, professionalism, use of simple language and ease of use in its publication of data. And with good reason; much seems about as clear and accessible as mud.

But here’s an attempt to add a bit of clarity to it. A few days of painful number crunching, data extraction and presentation of various DH and government sources across the spectrum of value for money – spending, inputs, outputs, outcomes and productivity – can be found here.

Some measures the NHS can be reasonably proud of; some it certainly won’t be. Has the 82 per cent real terms increase in funding since 1997 really been worth it?

The Guardian features two blogs on health inequalities that are, to be frank, almost completely non-descript. They do a good job at listing the damning evidence – that life expectancy for those in poverty has been falling further behind the national average over the past decade, that infant mortality 19 per cent higher for "routine and manual groups" than for the total population, and that this is worse than it was in 1997-99 when it was just 13 per cent – but offer no real assessment of the problem, let alone posit a solution.

Disagreement is still evident over the exact role of competition in healthcare, but a consensus is emerging that the ‘type’ of competition being pursued in the NHS is too narrowly focused and must facilitate greater service integration and clinical leadership.

That was the finding of a high-profile seminar organised by Civitas last month, which debated one of the key drivers of system reform in the NHS: competition.

A new report, published in the latest edition of the Civitas Review, argues NHS performance on efficiency, quality and - most damagingly so far as its ideals are concerned - equity, has flailed badly over the past ten years despite record increases in funding.

The problems are systemic. The undeniable talents of doctors, nurses and health care professionals working in the NHS are being stymied by perverse incentives created by Whitehall.

The NHS needs to be considering more radical options than those under review by Lord Darzi: it should be looking to Europe, and particularly the Netherlands, for better ways of providing universal and comprehensive health care. To read the report click here.

But not quite. His latest article on Comment is Free is headlined ‘Making GPs more accessible is just a disguised concession to big business’. Although his ideology is almost unparalleled in its economic illiteracy, it looks on the face as if he might have happened upon something important. He starts off well, pointing out that the government’s move to force GPs to open out-of-hours, lacks the significant public backing that is claimed, with evidence cooked up by a cabinet office report and a CBI poll.

The Times today reveals the Conservatives are equally, if not more, committed to throwing yet more money at the NHS than Labour. The Shadow Health Secretary, Andrew Lansley has boldly so he thinks, and completely foolhardily so many of the public will think, pledged to increase spending on it by £28 billion per year to around 11 per cent of GDP.

Richard Vize writes what can only be described as a vitriolic attack on the BMA in his editorial in the Health Service Journal this week, describing them as resorting to ‘sabotage to block the modernisation of our primary care services’ and ‘crass, childish behaviour’.

His particular gripe is that the BMA’s GP Committee has, very unhelpfully it must be said, advised practices they are within their legal rights to withhold data being requested by Primary Care Trusts (PCTs) on practice opening hours and the availability of appointments as part of an audit ordered by the Department of Health (DH). In this sense, Mr Vize is entirely correct in his attack, quite rightly pointing out that ‘GPs cannot take state money then refuse to be held to account for the services they provide’. But then, in the context of the whole debate on extended opening hours one can feel slightly sympathetic.

When the DH slashed the second wave of independent sector treatment centres (ISTCs) last year, it reasoned ‘they were unlikely to provide acceptable value for money’. This was based on capacity assessments by the new Director General of the Commercial Directorate, Chan Wheeler.

But now it appears a separate, independent, review concluded exactly the opposite. Nick Timmins, writing in the FT, reveals how the DH actually suppressed the findings of an independent assessment – conducted as part of the ‘gateway’ process – which rated the project’s chance of success as ‘green’, described the planned ISTCs as ‘well-matched to the [NHS’s] requirement’ and described the programme as ‘suitably tailored to regional needs’. Key stakeholders, such as strategic health authorities (SHAs), in fact told the review the deals were ‘appropriate and very welcome’. Strange indeed, then, that most are not going ahead.

The Swiss health care system – while certainly not cheap at €4,270 per head – receives international acclaim for achieving both universal coverage and a very high quality of care for all, without the constrained resources that tend to characterise government-controlled systems such as the NHS. Waiting times for treatment are short or non-existent and the uptake of new technology and drugs is high. For example, whereas only three NHS centres provide the latest intensity-modulated radiotherapy routinely to significant numbers of cancer patients, the Swiss do this as standard. Patient satisfaction is, perhaps unsurprisingly, excellent. As this Civitas study shows, there is much the NHS could learn.

Based on a recent report by Civitas, analysis of referral-to-treatment waiting time statistics show that while at the latest count, from October 2007, 59.9 per cent of patients received treatment within the targeted 18-weeks, many NHS Trusts still have a long way to go. Importantly, many of these are are in PCTs that have been most reluctant to embrace patient choice.

Reading John Carvel’s interview with Alan Johnson in Society Guardian this week, one could be forgiven for supporting this government on the NHS. He does seem, at least on the superficial level, to get it. It’s funny how every recent Secretary of State for Health has gone into the job with a very ‘nicey-nicey’ approach to the NHS and then, six months to a year or so down the line, realise it’s not going to reform itself and that Blair didn’t introduce competition just for kicks.

In March this year, 48% of patients recalled being offered a choice of hospital for their first outpatient appointment. Since then, in every survey the DH has conducted, this figure has fallen. In the latest survey – conducted in July – it stands at just 43%. This really is quite a feat - though not a very impressive one.

In an important new report for Civitas, Nick Seddon argues compellingly that it is out of respect for the founding principles of the NHS – to provide universal and comprehensive health care – not to mention better care, that it must embrace fundamental, market-based, reform.

Described in a foreword by Mr Bernard Ribeiro, CBE, President of the Royal College of Surgeons of England, as ‘an excellent analysis’, Seddon picks apart the recent NHS reforms and shows:

Last week, this blog wrote strongly in favour of David Nicholson’s hints that it might not be too long before choice might eventually be expanded to allow patients to choose their commissioner or PCT - and not least because it could end the postcode lottery in the NHS. If ever there is a case to support this it is the figures released today by the Conservatives on cancer care expenditure. This proves it really is a lottery, just not a very funny one. Oxfordshire PCT spends £5,182; Nottingham City PCT spends £17,028 and spending by the rest is spread right across the range in between. Clinical need alone cannot account for such wild differences.

Some will say this is the ultimate case for more central direction to ensure ‘equality’, but this would be disastrous – the last seven years have well and truly proved this approach doesn’t work. Enabling patients to vote with their feet by switching PCT if not satisfied with the outcomes of their care would be a much more effective way.

Despite Alan Johnson’s protestations in the FT that the newspaper is ‘wrong to suggest the government is reversing the NHS reforms’, few are that inclined to believe him. As Blair’s former health advisor, Julian Le Grand, has said: the government no longer seems to believe in, or at least wants to pay for, the idea of using competition to drive up standards in the NHS, following its decision to slash the second wave of the ISTC programme last week. But then along comes what might possibly more than a glimmer of light at the end of the tunnel.

A priority of the Dutch health care system, just like in the NHS, is to guarantee access to health care services in accordance with principles of solidarity and equality. As a result, health care coverage, just like in the NHS, is universal.

But, unlike the NHS, universal coverage is being achieved not through a predominantly government-run system, but through an insurance market that aims to be patient-focused and competitive. The government regulates the system and provides extra funds for the poor and those with excessive health care risks, but is neither the major provider nor funder of health care. It is patient demand, not central command that drives quality of care. As this Civitas briefing shows, there is much the NHS could learn.

Let’s get one thing straight. Hospital reconfiguration is necessary. There are too many district general hospitals (DGHs) in England. All the evidence suggests that acute care, such as A&E, cardiology, neurosurgery, liver transplantation, some cancer surgery and major vascular surgery, is more safely provided in larger hospitals where doctors have the right skills, experience and equipment to treat the sickest patients.*

But that does not mean the Department of Health should go about it by just unilaterally cutting payments – or, more specifically, not offering ‘top-up’ premiums – for specialist procedures to some DGHs they’ve decided should no longer be carrying them out, as has been revealed today by the HSJ.

A report released last Friday by Civitas, looking at trends in avoidable mortality, found real improvements had been made in England and Wales; avoidable mortality from cancer fell by 15.0% and from circulatory disease by 34.0% between 1999 and 2005. But while this compares quite favourably with improvements made in many European countries, real cause for concern does remain:

• The decline in avoidable deaths from cancer has been less step since 1999, at odds with trends since 1979; which must surely question the effectiveness of NHS Cancer Plan with all the extra money that has come with it.

• Avoidable mortality rates from circulatory disease remain far above most European countries of comparable development. Assuming the best performing country, France, made no improvements in the coming years, and the NHS continued to improve at the same rate as between 1999-2004, it would still take until about 2019 for us to catch up.

The full report may be viewed here.

Rudi Giuliani has caused just a bit of a political storm this week for citing poor UK cancer survival rates in an attempt to rile Hilary Clinton's 'socialised' healthcare proposals. So now we have hot-shots on both 'sides' of the US political debate bandying around the merits of the NHS, after the glowing reviews it received in Michael Moore's questionable polemic, SICKO. I'm not going to get into the argument either way here, but just to point out one particular irony: Alan Johnson has the nerve to tell the Times: “The British NHS should not become a political football in American presidential politics". If only New Labour could practice what he preaches in the domestic context.

This Monday, Robert Naylor, Chief Executive of UCLH NHS Foundation Trust, gave a seminar at Civitas, in which he put a powerful case for the continuation and deepening of the Foundation Trust ‘experiment’. He argued persuasively that not only has Foundation Trust status – with its associated financial and structural freedoms – provided for both greater efficiency in use of resources, but also higher quality and more responsive care for patients. In short, it is the way forward for the secondary care sector. His presentation can be viewed here.

Professor Julian Le Grand has a radical strategy for tackling the supposed problems of ill health in the UK: smoking permits (which might require a doctor’s note), an ‘exercise hour’ for company employees, a ban on additional salt in foods, more free fruit in general and more stern notes sent to the homes of children that have been found to be obese. Le Grand calls this broad sweep of measures ‘libertarian paternalism’, claiming, perversely that none of these actually restrict individual freedom. Wouldn’t ‘libertarian paternalism’ be more normally understood as a friendly word of advice without the backing of force?

The Healthcare Commission today released its second annual health check of NHS organisations. The overall picture is a familiar one; things have got a bit better, but not by as much as one would have hoped. “Could do better” is the general feeling – not least in offering patients a choice.

This blog has written many times of the damaging effects that targets and excessive top-down instruction has had on patient care by distorting clinical priorities and removing patient focus. It is also something the Healthcare Commission has reported many times, and yet again today.

One of Lord Darzi’s key recommendations in his interim report released today is the creation of a Health Innovation Unit – with a budget of £100m ‘to help the NHS develop and deploy hi-tech health care such as medical devices and diagnostics’.

But it is wholly unclear that a new central body is what is required to drive innovation in the NHS. The NHS already has such a body – the National Institute for Innovation and Improvement – and its lack of impact has been noticeable.

A report released today by Civitas argues that a Health Innovation Unit will only help if the NHS follows its reform agenda to the full and embraces diversity and competition; PCTs must be empowered as strong commissioners, providers must be autonomous and patients must have real choice. Central direction needs to end.

Full press release
Full report

The ambiguous messages coming out of the government on the NHS have the potential to be highly damaging. Happily munching my cereal yesterday morning, the Today programme introduced a discussion with the Health Secretary, Alan Johnson, and I confess my initial reaction was, oh no, ‘here we go again’. But, while there was the compulsory dose of ministerial squirming, I actually came away reasonably optimistic that the reforms in the NHS weren’t going to be rolled back after all. Even the reverse?!

The HSJ runs a headline article on Lord Darzi’s series of citizens’ juries, the first of which was held last week and attended by both the PM, Gordon Brown, and Alan Johnson, the Health Secretary. On the subject of these consultations, the enlightened Mr. Johnson said: “our principle aim is to get away from this view that the NHS is Whitehall – and DH-led – we want to get away from this top-down approach”. And then: “we want to create a healthcare system that is completely focused on patient care and moves away from structural change”. About time, one might think.

But then comes the shocking story narrated to a colleague of the consultant blogger, Dr Ray, who managed to attend this first ‘citizens’ jury’. Turns out it’s not a ‘citizens’ jury’ at all, more of a show trial for the NHS staged by the government. Afraid of something coming up you don’t like, what better solution than to hand-pick the audience and pay the ‘jury’ to say what you want to hear? One can only hope that Lord Darzi, a new-comer to the shady world of NHS politics, didn’t know this was happening.

The Lib Dems have today proposed scrapping PCTs and SHAs and replacing them with elected local health boards, that would also be allowed to raise extra money for local services through a local income tax. The NHS must be shuddering at the prospect of yet more organisation. On the plus side, it would undoubtedly be a step towards solving the well-documented accountability issues currently besetting PCTs: dissatisfied patients would at least be able to kick out commissioners who aren’t providing a decent local service. But it is unlikely to be a satisfactory response to the NHS’ woes.

When questioned on Sunday AM yesterday on the subject of the report by Sir Derek Wanless , released last week by the King’s Fund, on how effectively the NHS had spent its money the Health Secretary, Alan Johnson, referred to a recent study by the Commonwealth Fund:

“There was a recent study by the Commonwealth Fund which is the independent organisation in America that compared six health services in the developed world - Canada, Australia, US, Germany and New Zealand and ourselves. We came out top. We came out top on efficiency. We came out top on quality. We came out top on fairness, on equity.”

In honesty, Sir Derek Wanless’ ‘review of NHS funding and performance’, released on Tuesday by the King’s Fund, tells us little we didn’t know already: that while there may have been ‘some clear and notable improvements’, the NHS, overall, is not getting much bang for its buck. ‘The NHS has failed to generate the relatively modest improvements in unit cost productivity that might have been expected’, concludes Wanless – much the same as that of previous King’s Fund publications, that of the QQUIP team at the Health Foundation, that of Reform, and even that of a tome by the author of this blog.

The EUROCARE-4 study of cancer survival rates released yesterday by the Lancet Oncology journal does not make for comfortable reading for anyone in the UK, least of all the government. In a league of 22 European countries between 2000-02, England comes out 7th bottom, Northern Ireland 5th bottom and Scotland 3rd bottom in terms of the number of patients alive 5 years after diagnosis – much closer to the slightly inferior performance of countries such as Poland and the Czech Republic than the best performing countries such as Sweden, Finland and Switzerland. Cancer survival rates in these countries are some 10 to 15 percentage points better than the countries that make up the UK. The same trend is observed for individual conditions – survival rates from stomach cancer, for example, are as much as 86% higher in Germany than in England.

More worryingly still, is the picture painted over time. A second article, also released in the Lancet Oncology, performs a similar study for the years 1995-99. Comparing the two shows that while cancer survival rates have improved across the board, and the gap between those with the best and worst survival rates is narrowing, those in the UK remain ‘stubbornly low’. Tellingly, this study also found that the UK (along with Denmark) seems to be the exception to the broad trend that those countries that spent the most on health care generally get the better survival rates. So what’s gone wrong?

The DH sent out a press release today entitled ‘Statistical press notice: Patient choice survey and A&E statistics’. The content’s as bland as the headline; the section on the patient choice survey merely reads: ‘Report on the National Patient Choice Survey, March 2007 England and provisional headline results of the May 2007 Survey’. Yet these are often the ones that are the most interesting; the ones that aren’t spun. You’d better your bottom dollar that if the results had been worth shouting about, the release would’ve been much juicier and, at the very least, actually contained some of the statistics. The fact of the matter is that those on patient choice are a cause for concern.

The BBC reported yesterday ‘that the number of serious complaints made against GPs over out-of-hours care has soared in recent years’. Complaints received by the Medical Defence Union (MDU) increased from 30 new cases in 2003 to 100 in 2006, and by the Medical Protection Society (MPS) from 120 in 2002, to 182 last year.

This may seem relatively insignificant, but when one considers that they only get involved in the most complex cases, ‘such as those that involve deaths, compensation claims, or issues involving the GMC’ (simpler complaints are dealt with by GP practices or PCTs), it is anything but so. Laurence Buckman, chairman of the BMA’s GP committee, tried to gloss over this rise by offering the following remark: “It is a fact that patients are annoyed when they cannot see their normal doctor and I think it is more likely to make them complain”. But, for one, you would then expect the overall number of complaints to the MDU and MPS to have increased, which has not been the case – the total number of complaints they have received each year has remained steady at around 3,500 p.a. And, more poignantly, the statistic on serious complaints is just the latest worry in a whole string of concerns over out-of-hours care since the GP contract caused 90% of GP practices to opt-out of provision.

Reports released this week by the King's Fund on Agenda for Change, by the Information Centre for Health regarding the GP contract, and earlier in the year by the NAO on the consultant contract have all shown little evidence that any of the contracts have had a positive impact on productivity.

But none of this should come as too much of a surprise, according to an online briefing released on Tuesday by Civitas. Instead, the findings should be seen as symptomatic of deep-seated inefficiencies in NHS staff planning, largely caused by 'pressures to meet an explosion of central direction that has forced a focus on targets and (later) financial pressures, thereby creating an upward-looking service with short-term goals, rather than one that is truly patient-centred and able to match supply and demand'.

There is a theory in management, pioneered by Douglas Macgregor in the 1960s, which say that when it comes down to it management basically takes one of two forms.

Theory X management is based on the belief that people will give their best only when under external pressure – they prefer to be directed, have little ambition, don’t like work and don’t want responsibility. A manager’s role must therefore be a preoccupation with coercing and controlling employees in order to get them to do what’s best. Theory Y management, on the other hand, assumes that people will give their best when they are given genuine responsibility and are able to have a sense of pride in their work – people have potential, like working and want to use their natural abilities. A manager’s role is then completely different – to develop potential in employees and help them release their potential for creativity, ingenuity and imagination.

The government and the Department of Health (DH) love to think they go in for Theory Y. It’s the public service ethos. I don’t think you’ll ever hear either of them saying they think NHS staff are fundamentally lazy and don’t really care about patient care unless they have to. But in reality while they pay a lot of lip-service to Theory Y – and may even think they believe it – they somehow can’t resist extending their tentacles. Actions speak louder than words. And the actions have more often than not been symptomatic of Theory X.

A theatre on Broadway. A Hollywood actor starring at a blockbuster show. Demand is high and a waiting list is building up. But there it seems there aren’t enough ushers to put on a matinée performance, so the cast go and put on the show in a private members’ club instead – those who can’t afford to join are forced to wait, and wait…and, yes, wait, until they finally get to see the evening show on Broadway. Now think of the NHS…sound a familiar story?

John Petri, an orthopaedic surgeon, formerly under the employment of James Paget NHS Foundation Trust, is adamant that NHS waiting lists can, and should, be eliminated. But the problem is that no-one is asking the obvious question: why do we have waiting lists? It’s surely the lack of resources and the lack of doctors and nurses, right? Wrong.

Just as you think some kind of consensus has emerged to let things be in the NHS for the moment, another bombshell comes along. ‘Localise where possible, centralise where necessary’, runs the catchy slogan to the latest reform package aimed at the NHS. The report, undertaken by Sir Ara Darzi, the new junior health minister, looks at the state of healthcare in London recommends what can only be described as a dizzying array of service transformations for the capital. But this one, if properly interpreted, isn’t all bad.

Alan Johnson yesterday launched an ‘unprecedented’ review of the NHS, to advise on how to meet the challenges of delivering health care over the next decade. In particular this will examine how the NHS can provide better access to safer, high quality care for all, whilst delivering value for money for taxpayers. Sounds great, but while this may be unprecedented for Mr Johnson in his week-long tenure as Secretary of State for Health, it is hardly unprecedented in the recent history of the NHS – there have been two in the last five years, both of which have been very general in their nature.

A new online briefing released today by Civitas looks in detail at statistics relating to government performance on waiting times, in particular those recently released on the 18-week referral to treatment target. It argues that a number of statistics hidden in the data suggest the NHS has a massive, and probably insurmountable, challenge to meet the 18-week RTT target by 2008 without compromising patient care. In particular that:

- A substantial number of patients are still waiting significantly longer than 18 weeks;
36% are waiting beyond 26 weeks and 12% are waiting beyond a year.

- There are real variations in the time waited by patients both geographically and across medical specialities. For example, just 25% of orthopaedic patients are seen within 18 weeks, compared with 79% of those receiving thoracic medicine; and just 33% of patients in the South East Coast SHA are treated within the target compared with 60% in the East Midlands SHA. It will be incredibly difficult for those with low proportions of patients treated within the target to turn this around in little over a year.

-The NHS remains some way off meeting the goal that patients receive all diagnostics within 13 weeks of their first outpatient appointment, which will have to be considerably less if the 18-week pathway is to be met. 109,694 people were still waiting beyond 13 weeks as of March 2007.

Moreover, despite the improvements in cutting waiting times for inpatient and outpatient appointments, median waiting times have actually increased and 700,000 people are still on waiting lists for inpatient treatment with over 950,000 waiting for an outpatient appointment.

And NHS patients are still waiting much longer than those in other health systems. According to surveys conducted in 2005 and 2006 by the Commonwealth Fund merely 6% of primary care physicians in the UK thought their patients 'rarely or never experience long waiting times for diagnostic tests', compared with 76% in Germany; and 41% of respondents in the UK reported waiting longer than 4 months for elective surgery, compared with just 6% in Germany and 8% in the US.

There are aspects of the new Conservative White Paper on health to applaud, but they are, by and large, pretty much restricted to the supply-side. That advocated for commissioning is quite a different matter.

Improving patient safety was identified as a key goal for the NHS in the DoH report, Building a Safer NHS for Patients (2001). This built on the seminal report, An Organisation with a Memory (2000), which estimated that adverse events in which harm is caused to patients happen in an unnerving 10% of admissions to NHS hospitals (c.850,000 cases a year) costing at least £2bn p.a. The report considered around half these incidents to be preventable. A new online briefing released today by Civitas looks at how the NHS been doing since. <click here>