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Health Reform

NHS performance

After decades of under investment in the UK's health system, the NHS Plan (July 2000), acknowledged that the NHS had been 'left with insufficient capacity to provide the services the public expect', and pledged sustained amounts of extra cash for the NHS.

But is this extra money working? The following graphs and statistics provide a useful overview of the facts:*

Spending ¦ Physical inputs ¦ Physical outputs ¦ Health outcomes ¦ Productivity ¦ Useful publications

*All statistics apply to the NHS in England, unless stated.

Spending

Public spending on the NHS in England has increased from £39.8bn in 1998/99 to £90.7bn in 2007/08; an increase of 82 per cent in real terms. [.xls data]

Physical Inputs

Staff numbers have risen rapidly across the board since the publication of the NHS Plan in 2000; the NHS now employs nearly 250,000 more staff in 2007 compared with 1997. The biggest increase has been in the number of qualified nurses, of which there are now 322,000. [.xls data]

New buildings. The NHS has invested an estimated £10.6bn in both primary and secondary care, though significant amounts have been financed through PFI under the Hospital Building Programme and Local Improvement Finance Trust (LIFT) scheme. [.xls data]

Key diagnostic areas. Capacity has been increased; for example there are now at least 7.5 CT scanners per million of the population in the UK, compared with 4.5 in 2000. Increasing amounts are also being carried out in the private sector. [.xls data]

Hospital beds. The average number available per day has decreased in both acute and general wards, with the exception of day case. This has caused undercapacity in maternity care, but there are wider efficiency gains to be made by treating more patients in primary care. [.xls data]

Physical Outputs

GP consultations, after dipping between 1997 and 2000, have risen by 16.2 per cent to 181.6 million in 2006. Patients are also seeing nurse practioners much more often, with 97.1 million appointments made in 2006 compared with 48.2 million in 1997. [.xls data]

Drugs dispensed in primary care increased from 500.2 million prescriptions in 1997 to 752.0 million in 2006; equivalent to an annual expenditure of £6.4bn. Increased prescribing of statins accounted for a significant part of this. [.xls data]

Diagnostic activity increased commeasurably with increased capacity; over twice as many MRI and CT scans were carried out in 2006/07 compared with 1998/99, although waiting lists remain. [.xls data]

Hospital activity has increased despite the fall in beds with over 3 million more first outpatient appointments and finished consultant episodes in 2006/07 compared with 1997/98. A&E attendances also rocketed by over 5 million, although this could be seen as evidence of access barriers and inefficiency. [.xls data]

Health outcomes

Waiting times

Outpatient waiting times, have fallen quite dramatically; in 1999/00 nearly 500,000 people waited over 13 weeks at any given time for an outpatient appointment. Now virtually no-one does. [.xls data]

Inpatient waiting times have also fallen; waiting lists are half that in 1999/00. However, at the last count, just over 50,000 had still waited over 13 weeks; median waiting times are actually higher now than prior to the large increases in funding. [.xls data]

Diagnostic waiting times were the victim of New Labour's focus on inpatient and outpatient waiting times. When first measured systematically in April 2006, 25 per cent - or 203,000 people - had waited over 13 weeks, although this has now fallen to virtually no-one. [.xls data]

Referral to treatment. Patients are now expected to receive treatment within 18 weeks of initial referral from their GP. Steady progress has been made, with 69 per cent of patients now within this target as of January 2008. However, 16,000 still endured waits of over a year. [.xls data]

Mortality rates

Mortality rates for all causes (age-standardised) fell faster in the period 2001-06 than in previous five-year intervals, at a rate of 12.3 per cent compared with 10.8 per cent between 1996-2000. [.xls data]

Mortality rates for diseases specifically targeted by the government (age-standardised) have registered greater improvement than those not. Whereas death rates from ischaemic heart disease (IHD) between 2001-06 fell by 5.3 percentage points more than between 1996-2001, death rates from chronic obstructive pulmonary disorder (COPD) fell by 1.2 percentage points less. [.xls data]

Avoidable mortality is a better measure of the performance of a health system, isolating those conditions where death should be preventable by good medical care. Avoidable mortality from circulatory disease is accelerating downwards, but worringly the rate of improvement in cancer has fallen year-on-year since 1999. [.xls data]

Deaths within 30 days of a hospital procedure have fallen at a fairly constant rate of 0.5 per cent per annum, with the most improvement registered for myocardial infarction. Improvement has also been registered for deaths within 30 days of an emergency admission, particularly for strokes, although performance is static for fractures of the proximal femur. [.xls data]

Patient safety

Rates of MRSA and C-difficile remain very high. While the rate of MRSA has fallen from its peak in 2003/04, it is still 1.67 per 10,000 bed days. C-difficile is proving just as difficult to contain; at the end of 2006 the rate was 2.39 per 1,00 bed days just in over-65s. [.xls data]

Patient safety has been measured most comprehensively by Dr Foster. Using indicators developed by AHRQ, they reveal considerable variation between the performance of NHS trusts. For example, where the national crude rate for decubitus ulcers per 1,000 is 8.16, in some trusts it is as high as 30.79. [.xls data]

Patient satisfaction

The British Social Attitudes Survey reveals a marked decline in net satisfaction with all NHS services since 1999, with the exception of inpatients. Net satisfaction with the entire NHS was just seven points in 2004. [.xls data]

Patient experience is perhaps a better measure of patient-centred performance than 'satisfaction', which is subject to external influences. Surveys by the Health Consumer Powerhouse and the Picker Institute show few signs of improvement. In the former, the UK ranked 17th out of 29 European countries on patient-centred measures in 2007. [.xls data]

Health inequalities

Infant mortality rates have fallen across the board from 1994 to the present, but at a faster rate for managerial and professional classes than routine and manual. The relative gap between them is now 69.7 per cent compared with 52.4 per cent in 1996-98. [.xls data]

Life expectancy shows a similar trend, increasing across the board but more rapidly for those living in affluent areas. In 1994/5 the gap between males living in the most deprived and the least deprived areas was 8.1 years; it is now 10.1 years. [.xls data]

Inequalities in death rates have also widened, most poignantly in the case of circulatory disease, where the relative gap has grown from 58.7 to 71.0 per cent between 1995-97 and 2004-06. [.xls data]

Inequitable provision. The source of health inequalities goes far beyond the reach of health care, but there is mounting evidence that the NHS is exacerbating the situation. For example, hip replacements are far more common in higher-income groups than the lowest, in contrast with need. [.xls data]

Productivity

Productivity in the NHS across the UK, according to the latest estimates by the Office of National Statistics (ONS), has fallen by 2.5 per cent per annum over the past five years and by 1.0 per cent per annum over the past ten. This has no regard to increased quality, but the ONS estimates this would only decrease the fall by 0.5 percentage points from 2000. [.xls data]

Pay deals

Increased pay is estimated to have consumed some one third of the increase in NHS expenditure, but the benefit to patients has on the whole yet to be realised.

Consultant contract. In 2005-06 the average annual pay of consultants was £110,000, an increase of over a quarter in three years. But the average number of hours they reported working for the NHS decreased from 51.6 to 50.2 hours. The National Audit Office (NAO) concluded there was little evidence that the intended productivity gains or benefit to patients had been realised. [.xls data]

GP contract. In 2005-06 the annual average pay of a GP partner was £113,614, an increase of 58 per cent since 2002-03. While the number of consultations with patients has increased, GPs are working on average seven hours less per week than in 1992 and there is little evidence to suggest that patients' health has improved as a result of Quality and Outcomes Framework (QOF). The NAO concluded extra costs had outweighed the benefits. [.xls data]

Agenda for Change pay settlements have cost an estimated £2.2bn and were over budget by £220 million in 2004/05 alone. A King's Fund analysis showed,'there are few signs yet that it has delivered increased productivity', citing a lack of focus on longer-term benefits such as higher quality of care and career progression. [.xls data]

Use of resources

Sir Derek Wanless (King's Fund, 2007) estimated that the NHS could have performed an extra one million elective and emergency operations in 2005/06 alone if it had registered the efficiency gains that he thought reasonable in his 2002 review for HM Treasury.

Department of Health. The capability of the department on leadership, financial management and outcomes-focus has been heavily criticised by the Cabinet Office. This is reflected in the NHS' budgetary position which has fluctuated from a deficit of £547m in 2005/06 to a projected surplus of £1.8bn over the last three years. [.xls data]

NHS Trusts and Primary Care Trusts. The Audit Commission asigns Use of Resource scores for financial performance based on financial standing, financial management and value for money. In total 104 organisations received 'Level 1'; or 'inadequate performance' in 2006/07, indicating a very high level of inefficiency; only six scored 'Level 4'. [.xls data]

Micro-inefficiency

Length of stay is shortening across the NHS for most key procedures, with the exception of CABG, where the mean length of stay has increased from 11.2 to 12.9 days. This should be a sign of increased efficiency and quality but... [.xls data]

Day case rates have remained fairly constant in recent years, fluctuating between 28-29.5 per cent; though the absolute number has increased alongside the increased number of Finished Consultant Episodes. [.xls data]

Emergency re-admissions to hospital are on the increase; suggesting a decline in the quality of care. In 2005/06, 9.83 per cent of patients were re-admitted to hospital following a procedure, compared with just 7.84 per cent in 1998/99. For strokes the picture is worse; 10.59 per cent vis-a-vis 7.53 per cent. [.xls data]

Emergency admissions for conditions properly managed in primary care shows a similarly worrying trend, with admissions for acute conditions worsening from 384 to 392 cases per 100,000 and admissions for chronic conditions staying approximately static between 1998/99 and 2003/04. [.xls data]

Cancelled operations are no lower now than in 1997/98. In Quarter 3 of 2007/08, 15,599 operations were cancelled at the last minute for non-clinical, compared with 12,476 in 1997/98. On a more positive note, only 720 waited longer than 28 days after this to have their operation, as opposed to 1,891 ten years ago. [.xls data]

Useful publications:

For useful assessments of where the NHS has got things right and wrong; and for possible solutions see: