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BRIEFING: Pre-election briefing on health care and the NHS

James Gubb, May 2010

Health: the NHS

As a precursor to the election, this briefing explains the NHS today, and the Labour government’s performance over the past decade, in figures. It also explains what the Conservatives are proposing.

The Position Today

England 2008/09 unless otherwise stated.

Expenditure on the NHS [1]: £102.7 bn [2009/10]

Life expectancy at birth [2]: 77.9 yrs (male); 82.0 yrs (female)

Total staff numbers [3]: 1,368,693 (of which 701,323 are clinical, including 133,662 doctors – 37,213 of which are GPs – and 408,159 nurses)

Average (mean) total pay [4]: Consultant: £121,700; GP: £99,436; Nurse (Band 5): £28,400

Total available beds [5]: 159,386 (of which 100,892 are acute)

Activity: 300.4m GP consultations [6]; 35.9m imaging and radiodiagnostic examinations or tests [7]; 18.8m ‘new’ attendances in A & E [8]; 18.7m ‘first’ outpatient appointments[9]; 16.2m ‘finished consultant episodes’ in inpatient care.[10]

Waiting times [11]: 92.8% of patients admitted for elective operations, and 97.7% of patients not admitted, are treated within 18 weeks [Nov 2009]

Mortality rate [12]: Cancer: 1,349 (m), 995 (f); Heart disease: 1,211 (m), 562 (f); Stroke: 468 (m), 442 (f) (/m, age standardised) [2008]

Mortality considered avoidable through good health care [13]: 95.8 (/m, age standardised)[2008]

MRSA [14]:2,935 cases (0.79 cases per 10,000 bed days)

C-difficile [15]: 36,095 cases (0.56 cases per 1,000 bed days)

Cancelled operations [16]: 63,644

In the 2008 inpatients survey, conducted by the Healthcare Commission, 43% of respondents rated their care as ‘excellent’; 35% ‘very good’; 14% ‘good’; 5% ‘fair’; and 2% ‘poor’.[17]

Emergency re-admissions to hospital within 28 days of discharge (16+yrs)[18]: 468,723 (10.7% of admissions, costing c.£1.5bn) [2007/08]

Emergency admissions to hospital for conditions usually managed in primary care:
Acute [19]: 222,847 (426.74 /100,000) [2007/08]
Chronic [20]: 91,217 (178.39 /100,000) [2007/08]

Labour’s Record

Under Labour, expenditure on the NHS increased dramatically- from £41.3bn in 1999/2000 to £102.7bn in 2009/10, a real terms increase of 95%.[21] Broadly speaking, in areas specifically targeted by the government, significant improvement has been registered:

Waiting times: In October 1999, 497,500 had been waiting for longer than 13 weeks for a first outpatient appointment and 526,867 for inpatient treatment.[22] In November 2009, 92.8% of people were treated within 18 weeks of a referral.[23]

Cancer: The 3-year average mortality rate/m for under-75s has fallen from 1,287 in 1999-2001 to 1,140 in 2006-08.[24]

Coronary heart disease: The 3-year average mortality rate/m for under-75s has fallen from 1,145 in 1999-2001 to 748 in 2006-08.[25]

Capacity: Numbers of professionally qualified clinical staff have increased from 540,792 in 1999 to 701,324 in 2008;[26] 304 hospital/health centre building schemes have progressed.

However, in areas not given so much attention, improvement has been less impressive.

Stroke: Death rates in hospital are higher vis-a-vis the OECD average for both ischaemic (9.0% vs. 5.0%) and hemorrhagic stroke (26.3% vs. 19.8%).[27]

Chronic disease management: Admission rates to hospital are significantly higher than the OECD average for asthma (75 vs. 51) and diabetes (32 vs. 21) /100,000.[28]

Dementia: Only a third of people with dementia are formally diagnosed; and 32 months is the reported time to diagnose Alzheimer’s disease from first symptoms.[29]

Inequalities in health: The gap between the life expectancy of ‘routine and manual’ groups and the population as a whole has widened over the last ten years, by 4% for men and 11% for women.[30]

Overall NHS productivity – the amount of output achieved per unit of input, adjusted for quality -declined by 4.3% between 1997-2007.[31]

Labour’s approach to the NHS has changed throughout its time in government. Alongside the traditional approach of central targets, three means have been put in place to drive performance:

Regulation: New national institutions such as the Care Quality Commission (the national regulator of quality of care) and NICE (that appraises drugs and technology and disseminates clinical guidelines) help set minimum standards of care.

Competition: The NHS now functions on the basis of a market. Primary Care Trusts (PCTs) are expected to meet the health needs of their populations through buying (‘commissioning’) care from whoever can offer the best value service, NHS or non-NHS. In elective (planned) care, patients can choose which provider they wish to go to.

Financial incentives to drive quality: Since 2004, up to 20% of GP income has been linked to attaining specified standards of quality; and, under the CQUIN scheme, up to 1.5% of contract value in secondary care is now conditional on meeting certain quality targets.

Currently, the emphasis of the Government is shifting away from competition towards a reliance on financial incentives and applying best practice ‘systematically’ across the NHS. In September 2009 Labour announced NHS bodies are to be its ‘preferred provider’ of services.

Labour’s core election pledge thus far is for dedicated one-to-one nursing to be provided for all cancer patients in their homes.

The Conservative plan

Whereas Labour has said ‘front-line spending will increase in line with inflation’ until 2013/14, the Conservatives remain committed to modest real-term increases. Given the state of public finances, this could entail real-term cuts to other departments of up at least 3.4%.

In terms of policy, the Conservatives are set to continue with the overall framework for the NHS put in place by Labour, but the emphasis is on using competition to drive performance through:

Scrapping ‘politically motivated’ process targets in favour of publishing the outcomes of care, such as survival rates.

Scrapping NHS organisations’ status as the ‘preferred provider’ of services and opening the NHS up to the independent and voluntary sectors.

Handing GPs ‘hard’ budgets to take more responsibility for commissioning from PCTs.

The Conservatives expect these moves, alongside as yet unspecified cuts to quangos, to cut the cost of NHS bureaucracy by one third.

The most significant structural change proposed is to create an ‘independent’ NHS board of experts at the helm of the NHS. The aim here is to prevent politicians from micro-managing: ‘to ensure that political interference does not result in the distortion of clinical priorities’.

This move is also intended to free the Department of Health (to be re-named the Department of Public Health) to focus on prevention. The Conservatives intend to ring-fence an as yet unspecified amount of NHS funding as a public health budget to be devolved to local authorities (LAs), with a ‘Health Premium’ used to divert resources to areas with the poorest health. LAs will be paid ‘success payments’ if they succeed in tackling social problems such as childhood obesity.

There are a number of tensions in Conservative health policy:

They have pledged to scrap ‘politically motivated targets’, but they have set targets of their own such as increasing the number of single rooms in hospital.

They have pledged to ‘remove politicians from day-to-day decision-making’, but also have a high-profile moratorium on hospital and A&E closures.

They wish to increase personal responsibility for health, but appear to be relying on LAs ‘nudging’ people in the right direction.

Time will tell how these play out.

Notes to Editors

Full references with web links are found in the pdf version found above.
[1] DH, Departmental Report, 2009, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_100667

[2]ONS, http://www.statistics.gov.uk/pdfdir/liex1009.pdf

[3] NHS Information Centre

[4]NHS Information Centre

[5] Beds Open Overnight, Performance data and statistics, Publications.

[6]NHS Information Centre

[7]Imaging and Radiodiagnostics 2008/09, DH

[8]A&E Attendances, DH,

[9]First Attendances 2008-09, Hospital Episode Statistics.

[10]Headline Figures 2008-09, Hospital Episode Statistics

[11]18 Weeks Referral to Treatment Statistics, DH

[12]Mortality Statistics: Deaths Registered in 2008, ONS, Series DR. http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15096 NB Two populations with the same age-specific mortality rates for a particular cause of death will have different overall death rates if the age distributions of their populations are different. Age-standardized mortality rates adjust for differences in the age distribution of the population by applying the observed age-specific mortality rates for each population to a standard population.

[13]Age-standardised mortality rates adjust crude mortality rates for differences in the age distribution of the population, thereby allowing proper comparison. Mortality Statistics: Deaths Registered in 2008, ONS, Series DR. http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15096

[14]Health Protection Agency, Results from the mandatory surveillance of meticillin resistant Staphylococcus aureus (MRSA) bacteraemia http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1254510675444?p=1191942169773; Second statistic: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1229502458494

[15]Health Protection Agency, Mandatory C. difficile infection (CDI) surveillance scheme http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1179746015058

[16]Cancelled Operations, DH

[17]Survey of adult inpatients 2008, National NHS patient survey programme.

[18] NCHOD, Indirectly age, sex, method of admission, diagnosis, procedure standardised percent,

[19]NCHOD, Number of Admission Continuous Inpatient Spells – Numerator, Indirectly age and sex standardised rate per 100,000 http://www.nchod.nhs.uk/

[20]NCHOD, Number of Admission Continuous Inpatient Spells – Numerator, Indirectly age and sex standardised rate per 100,000 http://www.nchod.nhs.uk/

[21] DH, Departmental Reports, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_100667. Real Terms Increase calculation made using HM Treasury GDP Deflator.

[22]Hospital Waiting Times/List Statistics; DH. http://www.performance.doh.gov.uk/waitingtimes/index.htm

[23]Commissioner Data, 18 Weeks Referral to Treatment Statistics, DH.

[24]However, 5-year relative survival rates are poor; the survival rate for breast cancer during 2002-2007 was 78.5% in England compared to 90.5% in the US. DH, Mortality Target Monitoring, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_106776

[25]DH, Mortality Target Monitoring, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_106776

[26]NHS Information Centre

[27]OECD, Health at a Glance 2009, http://www.oecd.org/document/11/0,3343,en_2649_37407_16502667_1_1_1_37407,00.html

[28]OECD, Health at a Glance 2009, http://www.oecd.org/document/11/0,3343,en_2649_37407_16502667_1_1_1_37407,00.html

[29]NAO, Dementia: International Comparisons

[30]Health Committee, 3rd report: Health Inequalities Session 2008-09

[31]Phelps M. Total public service output and productivity. UK Centre for the Measurement of Government Activity, Office for National Statistics, 2009 c