Civitas Blog

Today, the HSJ reports on the departure of two chief executives recently deposed of their positions at two of London's biggest trusts - Barts and the London, and West Middlesex University. Here are some of the quotes from its sources:

‘Food Glorious Food’ sing fellow inmates of the workhouse in which the young Oliver Twist finds himself incarcerated at the start of Lionel Bart's musical named after the hero of Dickens' famous novel similarly named after him. A half a century on, the same startling discovery seems once again to have been made by the tv chef who also bears that same name.

On the basis of a report by the CMO, Sir Liam Donaldson, the government has recommended that no child should drink before the age of 15; and that children between the 15-17 years should only drink under the supervision of adults.

So, the NHS Constitution has been released after almost a year of negotiations, at a reported cost of around £1 million of taxpayers’ money. Was it worth it? Will it really make a difference to patient care?

Trawling over the health press I’d missed in a week’s holiday yesterday, this headline has got to be the winner: ‘Deaths from hospital blunders soar 60% in two years as NHS staff 'abandon quality of care to chase targets' says the Daily Mail. Really?

Disney is ranked number one in Fortune Magazine’s most admired entertainment industry category for 2008. It was also ranked number three across all US companies for people management and is one of the top performing companies in the world in terms of customer satisfaction. Key to Disney’s success is the clarity of its vision: safety, courtesy, the show and efficiency.

It’s not often that you read a document produced by a regulator that actually has genuine feel behind it, but The State of Healthcare published by the Healthcare Commission today does. The dynamic of the text is a lesson, almost, in making a subtle political point. The tone is reflective and conciliatory (though, inevitably it’s managed to ruffle the BMA’s feathers) but powerful: why are you getting rid of us when there’s so much left to do?

'Quality', wrote Lord Darzi in his recent Next Stage Review of the NHS, 'is improved by empowered patients and empowered professionals. There must be a stronger role for clinical leadership and management throughout the NHS'. A raft of measures to encourage its development has been proposed, but will they be effective? Is this a new dawn, or merely a false beginning? Last Wednesday, around 100 delegates debated this topic at a debate organised by Civitas.

The Nursing & Midwifery Council has been all over the news the last couple of days with its advice that nurses should no longer use terms such as ‘love’ when communicating with the elderly. Seems harmless enough, but is it really a good place to be if we need government or official bodies to tell us how best to behave?

The Quality and Outcomes Framework (QOF) has lofty aims. In linking up to a third of general practice income to achievement against a series of quality indicators, it hoped to deliver significant increases in quality to patients. Has it succeeded?

It’s illuminating reading the DH’s two most powerful policy documents under New Labour, The NHS Plan (2000) and Lord Darzi’s recent review of the NHS, High Quality Care for All (2008). The latter is certainly more refined and less concerned with quantity, not making attempts to dictate the need for x more staff, equipment, buildings etc. Instead, it sets quality of care as the 'irrevocable' first. But are they actually that different?

This Tuesday, a forum at Civitas heard the ideas of Bartley J. Madden, an independent researcher in the US. His big idea is a dual-track system that aims to speed up the time from trial to licensing for new medicines. Topical, given the recommendation of Mike Richards' review on top-up payments this week to consider how PCTs can be better supported to make decisions on funding off-label drugs, Madden argued that drugs that have passed Phase I safety tests should be subject to two regimes...

The Quality and Outcomes Framework (QOF) - the framework that offers GPs financial incentives for meeting certain standards of care - has been accredited with improving clinical quality across general practice and cutting health inequalities for certain core diseases. But, as ever, we should be concerned with unintended consequences.

Continued at bmj.com.

‘The number of people who will die as a result of diabetes is forecast to rise from one in ten to one in seven in less than 20 years unless obesity rates can be reduced significantly. Costs to the NHS of treating the disease are expected to rise by a third by 2025 as the number of people suffering from diabetes reaches a record level. The figure is forecast to rise to £12 billion, before inflation, by 2025,’ says Diabetes UK. All true; it fact, if the NHS’ current productivity trends are to continue, it will probably be worse....unless, of course, we start working in a completely different way.

The Annual Health Check of NHS organisations, released today by the Healthcare Commission, presents a picture fit for the NHS’ 60th birthday bash earlier in the year. Sixty-two per cent of organisations are now rated ‘excellent’ or ‘good’ on quality of services, up from 41 per cent two years ago, and those rated ‘excellent’ or ‘good’ on use of resources are up a fantastic 45 percentage points to 61 per cent. Can we then pop open the champagne?

This blog last Thursday wrote about whether or not the government was pushing the public health agenda too far without proper debate on the implications for civil liberty. Apparently, this doesn’t seem to matter a jot to the Department of Health.

Ealing PCT’s new campaign to ‘help’ smokers quit goes to the heart of a debate too-often ignored: the proper limits of state intervention in the name of public health.

In an article for The Fraser Institute, we argue the lessons for Canada from the NHS reform programme are less that competition in health care has failed, but rather that market-based health care reforms in the UK have been crippled by the government’s unwillingness to stop directing the service from the centre. The reform programme as a whole has been 'a botched job driven by political imperative, constant reconfiguration, and central diktat'.

‘It’s simply not possible to transform health care to meet the needs of the 21st century without strong initiatives that focus on the demand side; no matter how good the regulator is’, opened Mark Britnell at the latest in Civitas' series of debates on NHS reform.

The NHS’s history, he put it, has been one of provision; never before has the NHS really done commissioning. Previous attempts have merely redefined supply and re-written contracts, with minimal impact on health.

‘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>

We can all cheer! The NHS is in surplus. Unaudited accounts released yesterday by the DoH reveal an operating surplus of £510m, a miraculous £1.37bn turnaround from the £547m deficit reported last year. Most of the press have, typically, attacked this achievement by reporting the dire consequences – as many as 70,000 job cuts, cut-backs back on elective surgery, cuts to the NHS training budget etc. But the fact is the problem of NHS deficits had to be addressed. The NHS, so long as it has finite resources by virtue of the fact is funded through general taxation, must also have a centrally agreed budget and a principle of cost containment, i.e. that its organisations either stay in surplus or balance.

The real issue is why such deficits have mounted in the first place. This is no easy question to answer, but the root cause almost certainly lies in the structure of the NHS itself.

Having an independent NHS seems to be the big idea at the moment. Cameron is all for it, Brown is pondering it and Andy Burnham, the likely successor to the embattled Ms. Hewitt, is apparently sympathetic. As are a number of influential bodies. Steve Dewar, Director of Health Policy at the King’s Fund, re-ignited the debate in 2003 with his paper ‘Government & the new NHS – Time for a new relationship?’; Fiona Godlee, editor of the BMJ has been a long-term supporter; the Health Services Management Centre at Birmingham University, including Chris Ham, argued for it in their paper ‘Things can only get better?’ (April 2007); the BMA followed suit this month in ‘A Rational Way Forward for the NHS’; and today the Nuffield Trust released a pamphlet by Prof. Brian Edwards reviewing the various forms independence could take.

A study released yesterday by Cancer Research UK revealed that in the past 30 years, survival rates from cancer in the UK have almost doubled from 23.6% in 1971, to 46.2% in 2000/1. OECD statistics running up to 2003 show the trend continued. In terms of deaths from cancer before the age of 70 that were potentially preventable by good medical care, the UK witnessed a 3.29% improvement.

Many, including the government’s cancer tsar, Prof Mike Richards, expect Eurocare-4 statistics, to be published later this year, to show further progress. A large proportion of the extra funds the NHS has received since 2000 has been targeted at improving cancer care through the NHS Cancer Plan; 99.9% of suspected cancer patients urgently referred by their GP are now seen by a specialist within 2 weeks, compared with just 63% in 1997; the number of cancer specialists employed by the NHS has increased by 49%; and £520m has been invested in new specialist equipment.

But a more interesting point will be to see whether improvements in the UK (assuming there will be improvements), outstrip those in other countries.

Since 2000, the NHS has witnessed a huge, and unprecendented, increase in funding. Public spending on the NHS has risen from £46.0bn in 2000/1 to an estimated £84.4bn in 2006/7, representing an increase of 83.5% in cash terms and over 50% in real terms.

This has been accompanied by reforms that on the one hand point towards a more patient-centred and primary-care led 'internal-market' for healthcare. Primary Care Trusts and GP practices now purchase secondary care from NHS Trusts (or private providers) on behalf of patients, who can exercise some choice over where they are treated. NHS Trusts will be paid for the work they carry out; money should in theory follow the patient. But on the other hand, the government has created a whole raft of central bodies to provide 'the impetus for reform' and, more often than not, set targets that NHS bodies are expected to meet on anything from patient records to waiting times.

Last week, Alcohol Concern, ‘the National Agency on Alcohol Misuse’, managed to generate a significant amount of media coverage with its recommendation to ‘make it illegal to provide alcohol to anyone under the age of 15.’ The reasoning behind this was that since unsupervised consumption of alcohol is spiralling, along with associated anti-social behaviour, among young people, the natural solution is to imprison parents who offer a thimble of wine to their child at the dinner table.

When faced with that as a consequence of their proposal on the BBC’s Today programme, Alcohol Concern’s spokesperson argued that the change in the law was still necessary in order to ‘send a message’. I am not sure what sort of message about this society would be sent out if Jewish Passover services (where every family member is encouraged to drink a traditional sweet red wine throughout the evening) were raided by the police, but I doubt the delinquents in town centres will see the relevance to them. The alternative 'message', that such laws won't be enforced to the letter so best to work out one's own interpretation of justice would be the likely unintended consequence.

Today the National Institute for Health and Clinical Excellence (NICE) released guidance that calls on firms to help smokers quit, particularly in the run up to the public ban on smoking that comes into force in England on 1 July. This includes more uncontroversial advice such as employers providing information on where staff can go for help in quitting, and the possibility of NHS ‘stop smoking’ services being held on large firms’ premises if there is the demand. Evidence suggests that 3 in 4 smokers want to quit – if this is the case then making services to help them more accessible should probably help. One criticism also often loaded at the NHS is that it is too heavily focused on treating illness rather than helping to prevent them in the first place. There is little doubt that smoking is linked to any number of different, and serious conditions, that cost the NHS huge sums of public money. So, if such measures do help to prevent illness by stopping people smoking, then we may justifiably support them. Industry would also be glad – smoking is estimated to cost them £5bn in lost productivity, absenteeism and fire damage. Incredibly, evidence suggests that smokers have, on average, 8 days more off work sick than non-smokers.

But this does not justify NICE’s more radical proposal – that employers allow smokers to attend anti-smoking clinics during work time.

It is reported in today’s Times that, despite of music being a compulsory subject in school until age 14, less than an hour a week is devoted to it in most primary schools and that only 13 per cent of primary pupils learn an instrument. Apparently, a major contributing factor behind the current dearth of music teaching in our primary schools is the fact that student primary teachers receive no training in the teaching of music.

You may well be wondering, sad though the dearth of music is in our primary schools, what the early learning of music has to do with social cohesion. Well, Plato and Aristotle certainly both thought it has a great deal to with it.

Continued at the Centre for Social Cohesion blog.

Dr Crippen delivers a steady drip feed of episodes that demonstrate quite how ridiculous and dangerous hospital bureaucracy has become. This diary entry from yesterday was exemplary.

Tuesday 27th March

Ah!

The NHS remains in crisis. More catastrophes barely make an impression on the British public. They no longer seem to make a difference: the NHS limps on with the efforts of the doctors and nurses that still treat medicine as a vocation. Some targets are hit, others are missed, and amid the crushing burden of admin and the monthly crop of scandals, hospitals and surgeries force through some limited health provision.

The NHS has always been Labour’s favourite child, representing its now faded and tattered dream of fully socialised public services. Grown old and decrepit, for some years now it has been reliant on ever more potent injections of government cash to keep it in proximate working order, a course of treatment now shortly about to end as basically the medicine has run out.

The treatment has not worked. The patient continues steadily to decline and the hour is surely approaching when the hard decision will have to be made to take it off life-support and replace it with a new system more reliant on patient choice and consumer sovereignty, albeit one that preserves protection for all against medical catastrophe regardless of means.

How sick the patient is indicated by the results of on-line poll of over 3,000 doctors currently working for the NHS conducted by the Times and published in today’s issue. A majority denied any improvement in the NHS had occurred since 2002, denied the increased funding on the NHS had been well-spent, and denied that their own specific area of medicine had benefited in any way.

That almost double the number of the doctors polled thought the NHS would fare better under David Cameron than Gordon Brown suggests a truly profound level of doctor disillusion with New Labour’s approach to health care.

In the run up to the next election, the Conservatives have a window of opportunity to develop a policy on health care that would put in place the ground-work for an appropriate system for the 21 century. Let us hope they do not squander it.

An article in the Financial Times last week reported the former commercial director of the Department of Health, Ken Anderson, saying EU law will soon force the NHS to open up many more of its services to bids from private sector companies. His argument is basically that that the government’s policy of slowly introducing more competition into healthcare is “increasing the likelihood that NHS services may be subject to EU single market and competition rules”. Probably true. In which case could the EU, finally, be doing the UK a favour?

Have you wondered why City workers and others in the financial services sector are enjoying such huge annual bonuses this Christmas? Well, it seems they are doing so courtesy of the hard-pressed tax-payer.

Today’s Times reports the first independent breakdown of the costs to the public sector of hiring external consultants, published by the National Audit Office. It discovered a huge recent increase in such forms of expenditure: in the last three years, it rose by a third from £2 billion to £3 billion.

Anyone, like the present author, who spent the bulk of their working life in the public-sector will know just how demoralising and counter-productive has been the recent imposition upon it of a managerialist culture.

Formerly self-regulating professions like medicine and teaching have been reduced to box-ticking exercises carried out by hordes of fearful and demoralised zombies desperately counting out the days before they could retire from the monstrously overblown regimes of excessive and unneeded managerial oversight to which they know their once genuine forms of service to the public have been reduced.

Like ships in a convoy forced to sail at the speed of their slowest, this cumbersome and time-consuming method of management has been imposed on schools, hospitals and universities, often in response to purely local instances of malpractice that could have been remedied more easily and expeditiously at a corresondingly purely local level.

Well, this culture of bureaucratic over-management and over-regulation has not been without enormous personal cost for those working in this sector. A glimpse of just how much it has cost them personally has been given this week by a consultant psychiatrist at the Priory Clinic in Surrey.

Best known as the refuge of burnt-out over-partied show-biz celebrities like Robbie Williams and Pete Doherty, the clinic now apparently regularly provides sanctuary for burnt-out public-sector professionals, such as doctors and teachers, whose stay is being funded, reading between the lines of a report about this matter on the BBC News website, by the NHS that has driven so many of them there.

Since, and because, the government down-graded Cannabis to a class C drug, its use among young people has substantially increased. So claimed Roger Davy, a West Yorkshire magistrate and national spokesman on youth courts, according to a a reort in today’s Times entitled ‘Cannabis is linked to rising child crime and harder drugs’.

Britain is now among the worst European nations for drug misuse. It tops the European league table for cocaine use, not only among 15 to 34-year olds (over 10% have tried it), but also among the 15-24 year olds (6% have tried it). In the last year for which figures are available (2003), Britain also topped the European league table for heroin seizures, came second after Spain for cocaine and cannabis seizures, and was top for seizures of Ecstasy.

The scale of human tragedy indicated by these figures is truly appalling. Yet what do we read in an adjacent report but that, to meet government targets to reduce the waiting times for treatment of hardened drug addicts, they are being increasingly palmed off with comparatively inexpensive but largely ineffective methadone programmes and day centres, rather than placed in more expensive but far more effective residential drug rehabilitation centres. Only 3% of addicts kick their habit after a methadone programme; nearly a third do after rehab in a residential centre.

Should Pete Doherty ever find himself banged up for possessing hard drugs, he would soon discover that incarceration had not remotely put them beyond his reach. This is especially so, should he have been incarcerated north of the border.

According to a report in yesterday’s Times, so easy has it become for inmates in Scottish prisons to gain access to illict hard drugs while inside them, and so awash with drugs have they become, that they are shortly all to be given personal drug-taking kits, complete with syringes, swabs, filers, and a sharps disposal box.

I was only surprised to read that a gram or two of heroin or coke is not be thrown for good measure.

Having chosen to occupy the same centre ground New Labour has monopolised to such electoral effect these last ten years, David Cameron is busy re-positioning his party to present the public with a far more friendly and caring image of it than has appeared for many a long year.

Meanwhile, the goverment sinks steadily deeper into the immigration morass it has equally as carefully long cultivated but which now appears to be its undoing.

The new Tory party leader is cultivating his new image for his party by focusing on quality-of-life issues as against straightfoward economic ones.

Earlier this month, after a well-publicised dash to the pole, he spoke about the environment. This week he has chosen to highlight the work-life balance.

I commute daily to work in the centre of London by tube, as I did on July 7th last year.

Since that eventful day, I have to confess hardly a day has gone by when I have set out on that journey without wondering whether it would prove to be my last.

Am I just being paranoid?

Well, to adapt what was said of Harold Wilson after he persisted in claiming, when Prime Minister, that he was under surveillance by British intelligence: I may be paranoid, but it doesn’t prove that Islamist fanatics are not out to get me and all my non-Muslim compatriots who are as unwilling as I am to convert to Islam or accept dhimmitude.

‘Some comfort/pleasure from Barney the dinosaur/Teddy and his awareness of his family are all that MB has. But… these assets are precious and real.’

So said Mr Justice Holman in the High Court yesterday in explanation of his decision to withhold legal permission from doctors who had sought it to withdraw life-support from an eighteenth-month boy in their care, identified in the case only as ‘MB’, suffering from acute muscular atrophy and with a life expectancy of only a year.

Had Mr Justice Holman been less able than his quoted remark reveals him to have been to put himself imaginatively into the acutely painful shoes in which the baby boy currently languishes in a hospital somewhere in the north of England, then doubtless today the boy would no longer be on a respirator there but in its morgue.

On the same day as the media are full of stories about the sad predicament in which the current leader of the Lib Dems finds himself as a result of the power of demon-drink, the Times carries a report about the findings of a European-wide comparative study of the effects upon health of excessive consumption of alcohol.

The study was undertaken by Professor Robin Room, of Stockholm University’s Centre for Social Research on Drugs and Alcohol. Its findings were recently published in the Lancet and have been summarised in today's report about them in the Times.

Until recently Mr Cameron had given the impression that he was going to take a long, careful look at policy issues and wait for commissions to report before making final decisions. In the last few days, however, he has shut down the health and education debates and pre-judged social security reform. In today's Daily Telegraph I have tried to explain why. Let me know if you think I'm wrong.

I love it when this government gets its knickers in a twist. Goodness knows it’s got itself tangled up in so many problems it deserves to be tripping over. The attempt to legislate virtually every aspect of public and private life is proving complicated for the classroom swat Ruth Kelly, the priggish Patricia Hewitt and the haughty Baroness Scotland. They’re not alone, but they’ll do for today. You see, Kelly’s trying to keep bossy Blair happy by doing exactly what he tells her, Hewitt’s having her pigtails tugged by that naughty Johnny Reid, and as for Baroness Scotland, she’s been pushed around in the playground of the Lords.

Two vignettes from today’s Times reveal how much of the rank-and-file opposition in the Labour party to the government’s plans to increase private-sector delivery of NHS treatment is grounded in sheer prejudice and how badly greater private-sector involvement is needed.

First, in yesterday’s debate at its annual conference on these plans, a nurse is reported to have questioned whether for-profit companies could be motivated by patient care in the delivery of such NHS routine services as district nursing, health visits, occupational therapy, cancer screening, asthma and diabetic clinics. Mm, pursuit of profit in conditions of competition and customer-care are incompatible, that’s an interesting notion I don’t think.

Second, it is reported elsewhere in the same issue that an elderly couple from Portsmouth who have been attending the same g.p. surgery for a total of between them 137 years have been ordered to move to another practice within 28 days because it has apparently just been discovered they live outside the catchment area for that practice. That’s patient-care public-sector monopoly style for you.

Last month, according to a report in today’s Times, saw a massive increase in muggings on the streets of London and of such suburbs as have loaned it uniformed police officers to help patrol its public transport system in wake of the heightened security concerns triggered by the terror bombings at the start of that month there.

The threat of further terror strikes in the capital has not abated. Indeed, if anything it has intensified and shows no signs of going away for the foreseeable future.

It can then hardly be the right moment for the government to be embarking on a social experiment likely to stretch police resources still further away from what should be their normal task of protecting the law-abiding against criminal predators.

However, it is on such a foolhardy course that the present government seems intent by pressing on with its plan to relax current licensing laws to allow very much longer opening times for pubs and off-licenses.

It seems intent on continuing with this course, despite severe criticism by police and judges who have said that extending hours will merely add further alcoholic fuel to the already raging fires of drunken violence that nightly turn our city centres into no-go areas, save for all intent on taking part in what seems to have become the new national past-time for Britain’s young of binge drinking.

In a piece of insane reasoning worthy of a character from Lewis Caroll’s Through the Looking Glass, the government justifies its policy by claiming that, by keeping pubs open for longer, urgency will be removed from drinkers to get down a few before closing time. It claims the current fast-track to drunken disorderliness will make way for a gracious meandering lane to quiet inebriation apparently the fashion on the continent where extended open hours are said to encourage less frantic alcohol consumption.

It would be interesting to know upon exactly what evidence, if any, the government bases its surmise that, by extending British opening hours, it will reduce drunkenness.

The notion that it is likely to do any such thing seemingly flies in the face of the overwhelming evidence to the contrary provided by the annual spectacle of young British holiday makers in Europe displaying their legendary propensity for getting drunk. They seem unmoved by Europe’s longer opening hours to moderate their native approach towards drinking which may best be described as drink-as-much-as-you-can-as-fast-as-you-can-and–then-knock-over-everything- in-sight-that-moves-until-you-pass-out-in-a-drunken-stupor.

The general short-sightedness and complete lack of intelligence displayed by the present government’s approach towards dealing with social problems, or at least those it considers such, of which its approach towards the problem of binge-drinking is but an instance, is never better illustrated than by the findings released this week by the Office of National Statistics on social inequality which reveal how little progress the government has made since 1997 in its multifarious efforts to close the gap between rich and poor. Despite all its initiatives and special measures since gaining office to reduce inequality, it turns out it has had next to no effect in achieving that goal.

The principal reason it has failed to do so is something on which it chooses not to dwell. Setting aside the special problem posed by endogenously generated radical Islamism among Britain’s disaffected young Muslims which has an entirely different and peculiar cause, what primarily lies behind practically all of Britain’s present current social problems, from binge-drinking, through anti-social behaviour to relative deprivation, is the collapse of the two parent family. For this collapse has left large numbers of young males, especially those from the lowest social classes where single parent families are most frequently found, inadequately socialised and unmoored by claims of familial responsibilities.

The government refuses to address this problem – or even to acknowledge that it really is one, let alone how much of a principal cause it is of all those that it does identify as such.

If we stand back and ask what must be done to put the genie of deracinated, demoralised, out of control drunken, violent and disorderly British young males back in the bottle of domestic responsibility, the search for an answer must surely take us back, beyond the 1960’s radical feminism that did so much to undermine the family and to inform present social policy of new-Labour, to a much deeper cause.

“Why in the 21st century are we still so poor at involving patients in their care?”. So asks Simon Williams, director of policy at the Patients Association, according to a news report by the BBC, in light of the disturbingly low level of NHS patient involvement in their own treatment that is announced by the Healthcare Commission in its annual report on the state of NHS published today.

Indicative of this low level of patient involvement are the following findings of the Healthcare Commission published in its report:

· A third of patients’ diagnostic tests are not explained to them in a way that is understandable to them.

· A fifth of patients left hospital confused as to what their drugs were for.

· Only 22% of coronary bypass surgery patents were told of alternative treatments.

· The UK ranked lowest for patient involvement in their primary care among five countries surveyed.

May I proffer the following answer to Mr Williams’ question?

Britain remains poor at involving patients in their own healthcare because, under the present system of socialised provision, patients lack any genuine consumer power that alone can be provided by their having a genuine choice between providers who are allowed to compete between themselves for custom.

In the absence of genuine patient choice, there will be no competition between providers, or hence any incentive on their part to inform and involve patients fully in their treatment, should it be more costly and inconvenient for them to do so, which undoubtedly it is in a great many cases.

Tentatively, the government is feeling its way to providing greater consumer choice but healthcare providers are likely to howl if the result have the intended effect of exposing defective forms of provision.

According to a report from the Picker Institute, an international think tank that has surveyed nearly a million NHS patients since 1998, the NHS has improved when subjected to government targets, but not otherwise. In some cases the service has become worse. Quoted in The Times, Angela Coulter, chief executive of the charity, said: “The most disappointing thing is that all the rhetoric about creating patient-centred care hasn’t led to improvements across the board. Only where specific targets have been set — in waiting times and in cancer and heart disease — are we seeing big improvements. Where there are no targets, in areas such as cleanliness and access to a GP, the service has not improved and in some cases has got worse. Many aspects of patients’ experience still need urgent attention.”

Scottish experience has been similar. The Scottish Assembly has not targeted waiting lists, but focused more on public health issues. In Scotland waiting lists are going up, suggesting that hospital managers respond to direct pressure by focusing effort on target compliance at the expense of services or activities not visible to the target setters.

What is missing is a constant, unrelenting pressure to provide the best service for customers. Public sector monopoly with targets is an improvement on public sector monopoly with no such targets, but a system based on competition would be better still. The imperfections of the human condition mean that without pressure to perform, the producers are likely to settle for a quiet life. More important still, by allowing scope for invention and experimentation, a competitive system allows standards to improve through a process of mutual emulation.

Now that the election date has been announced, we will be publishing some guides to the main public policy issues: initially crime, the NHS, education and welfare. The briefings will be fully referenced so that everyone can check the facts for themselves. The first one is here.

In January 2002 Tony Blair said that his government may stand or fall on the reform of the NHS: ‘things are starting to get better, and they will be dramatically improved. I am so confident of that, let me say this: if the NHS is not basically fixed by the next election, then I am quite happy to suffer the consequences. I am quite willing to be held to account by the voters if we fail’. Here is our update of progress so far. (It's a PDF file and may take a minute to download.)

On the face of it, the government set itself a target and achieved it: the reduction of waiting times and lists may be one of the more significant achievements in the NHS since its inception almost sixty years ago. By the end of this year, according to Niall Dickson in a recent article for the Sunday Times, nobody should wait more than six months for anything. Mr Dickson, chief executive of the King’s Fund, an independent charitable foundation, did point out, however, that these figures disguise ‘hidden waits, because the NHS does not measure the gap between a first outpatient appointment and being put on the inpatient list for treatment.’ The fact is that the NHS has a distinguished history of fiddling waiting list figures, and investigations such as those by the National Audit Office, the Audit Commission and the King’s Fund, testify that confidence in current waiting list figures may well be misplaced. Nevertheless, everyone, and not least Mr Dickson, who’s foundation has just produced a highly positive Audit of the NHS, seems to believe NHS waiting has remarkably improved.

What if, just for the sake of argument, we consider the possible negative consequences of reducing waiting lists in such a target obsessed way? A&E departments have reached a stage, hospitals say, where 96% of patients are dealt with in four hours. But at what cost?

Today’s newspapers carry forecasts by city economists that the pre-election spending-spree announced by Gordon Brown in his budget-speech yesterday will lead to a £10-12 billion shortfall in public finances. To meet it would require a 3% rise in the basic rate of income tax.

Soon after the election, assuming the bribe works and New Labour are returned, the public will be made to pay.

You can be sure those made to pay will not come from the ranks of the vast army of low-paid public sector workers whom New Labour has created while in office and who, being entirely dependent on public-sector pay, pensions and income support, form the core of that party’s ever expanding band of natural supporters.

The day after the election, assuming the bribe successful, my bet is that whoever becomes Chancellor will claw back the needed revenue to cover the current spending spree by announcing that gains on the sale of primary residences will become liable to CGT.

Just like Gordon Brown’s raid on private pension funds in 1997, the prudent will be punished to reward the profligate. Ever more numbers of people will be made to depend on the state rather than able to fend for themselves by having their hard earned capital-assets expropriated by the state.

However, it is not the national tragedy of yesterday’s budget about which I wish to write here, but, rather, an altogether more personal and minor tragicomedy played out in the small hours of Budget Day.

It was then I was awakened from my slumbers by the sound of my wife calling my name, followed by a resounding crash.

How good is the NHS? How does it compare with other systems? Here is a survey of the evidence that we'll update as new material emerges. Read on (PDF file).

“They don’t know it, but we’re bringing them the plague”, reputedly quipped Sigmund Freud to the two fellow psycho-analysts who accompanied him on his first trip to the USA as their boat approached New York harbour in August 1909.

They had gone there after the head of a Massachusetts university had invited Freud to lecture on his revolutionary new form of psychotherapy about whose supposedly miraculous efficacy rumours had started to circulate in the US.

Ignorance of their own very much other than metaphoric highly contagious disease is not an excuse that can be pleaded by the many TB carriers from overseas who have seemingly been entering Britain of late to gain the benefits of free NHS treatment for their condition. Their numbers would undoubtedly have helped to make Britain the world’s capital for health tourism and significantly have contributed to the startling rise of reported cases there of this disease in recent times.

Nor can ignorance be the plea of either the Government or Opposition of the risks to which they seem willing to continue to expose the country by failing to advocate that all would-be entrants to it from countries in which TB is prevalent be made to undergo prior screening and found clear of the disease before being allowed to enter.

According to the NHS Board Room Pay Report 2005, the pay of NHS chief executives rose 70 per cent in ten years, while nurses’ pay only went up by 50 per cent. The NHS accounts in the year to March 2004 show that the average salaries of chief executives in England was £107,500, with the fattest cat of them all being the chief executive of Hammersmith Hospitals who takes home a tidy £212,500 each year. Meanwhile, many nurses are struggling to make £18,000. Union leaders are not the only ones who should be concerned.

Not entirely surprisingly, there’s strong evidence to suggest that increased spending on medical resources has a beneficial impact on medical outputs. In particular, researchers at the OECD have repeatedly demonstrated that higher doctor numbers are significantly associated with lower mortality, and in its 2003 report International Health Comparisons, the NAO declared that the number of doctors per 1,000 of population is the second most important measure after occupation in terms of explaining variations in premature mortality.

‘The most seriously ill NHS patients should be allowed to die so that the money can be better used elsewhere, the Health Department is expected to tell the Court of Appeal. John Reid, the Health Secretary, is expected to refer to the cost of keeping coma patients alive with food and water.’

So ran the opening sentences in a report in yesterday’s Times.

Anyone intrigued to know how NHS resources might be better deployed than on keeping sick people alive need only wait to today’s Sunday Times for an answer. Here a damming front-page report on current (lack of) cancer care in the NHS opens by informing readers that: ‘The government’s £2 billion scheme to revolutionise the treatment of British cancer sufferers has failed, with much of the money wasted on creating 400 bureaucrats.’

It is reassuring to see that, in a world in which so much else is changing so fast, New Labour remains wedded to Labour's public-sector traditions -- unless you happen to be seriously ill or not rich enough to be able to pay twice for health insurance.

Due to the recent enforced closure of the Merseyside-based firm that supplied the NHS with flu-vaccine and diamorphine, it is reported in today’s papers that the country’s hospitals face the prospect of running out of supplies of the painkiller in a mere matter of weeks.

This is no laughing matter, since diamorphine is used in the analgesic treatment of cancer patients and others with serious and terminal painful conditions.

The Government thinks we eat too much, drink too much and smoke too much, and it's going to use the full weight of the law to put a stop to any further irresponsibility. But a consistent puritan would want gambling stopped too, and yet the Government wants us to gamble more. This inconsistency helps us to see more clearly the motivation of New Labour.

Today’s Times carries a report that a private health insurance company, PruHealth, intends to charge a lower premium to customers who maintain a healthy life-style by not smoking, regularly visiting the gym, etc.

Surely, the Treasury could and ought to consider offering comparable kinds of rebate in connection with NHS charges? At present the Government seeks to encourage healthier life-styles but without offering the taxpayer any real inducements to do so beyond making smokers and drinkers pay extra taxes for indulging their taste for tobacco and alcohol.

Chocolate bar manufacturers in the UK are doing away with so called ‘king-size’ bars, ostensibly to do their part for the war against obesity and, no doubt, to reduce the pressure from health and safety groups clamouring for further regulation. Super-size Snickers and Twix bars may be a thing of the past as early as next year.

The industry’s Food and Drink Federation deputy director general Martin Patterson defended the move, claiming that the companies have to do their part and encourage people to eat less junk. (I was under the impression the company was doing its part by making great snacks and creating wealth for its shareholders, but perhaps I simply don’t have enough compassion for my nougat-addicted countrymen.)

Eliminating these bars isn’t enough for Sustain, the food and farming group pushing for tougher regulations regarding snack foods: ‘[This move] is half-hearted, and the industry won't be able to claim it is behaving in a responsible way until it stops its aggressive advertising of unhealthy foods to children.’

Thank goodness Sustain can save all these sugar-crazed youngsters; it must take enormous pressure off parents to actually do their jobs.

The Guardian reports how several local hospitals have been prevented by Whitehall from improving their services. Why? Because the changes would look bad in the run-up to a general election. Hospital improvements often involve closing an old building and starting again in a new and better one, but defenders of the old service are often able to kick up sufficient fuss to make politicians back away.

As a result, hospital managers throughout the country have been told that it is the ‘wrong time’ for change. The interference is affecting maternity services in North London, and emergency services in Hartlepool and Edinburgh, among others. Nigel Edwards, policy director of the NHS Confederation, which represents NHS managers and trusts, is quoted as saying that political pressure now means that managers are only ‘able to change anything during an 18-month window between elections, or in safe seats’.

The remedy, not recommended by the Guardian, is de-politicisation. All NHS hospitals should be removed from political control to the management of wholly independent local trusts, able to serve the interests of patients without interference borne of electoral calculation.