By Ruth Thorlby and John Appleby
22 April 2010
The NHS is a priority issue for voters in the general election. So how successful have the reforms and high levels of investment been over the past 13 years – and what challenges will a new government face? Ruth Thorlby and John Appleby of the King’s Fund review the evidence
The NHS is once again being held up as a critical election issue by the main political parties, which all promise more reform. It is perhaps not surprising that the opposition parties argue that the health service needs to be fixed – by them. But even Labour argues that the NHS needs to change from ‘good to great’.
Given the sustained and unprecedented levels of funding growth that have gone into the service since 2000, voters might be forgiven for being confused, especially as satisfaction with the NHS is at an all-time high. Why does it still need fixing? Has it not become better? How good is it now? How much more change does it need?
In an attempt to answer these questions, the King’s Fund has reviewed the progress made since 1997 in transforming the NHS in England into a high-performing health system. We focused on England as health policy has now diverged sufficiently between the devolved administrations to make comparisons complicated.
This was not an attempt to judge whether the government had met its own targets and objectives – it has been successful in many of them. Rather, the aim was to sum up what all the white papers, legislation, new organisations and initiatives have amounted to over the period and to set out the challenges for an incoming government.
Assessing whether the NHS is high performing is not straightforward as there is no single health care system that can be held up as the definitive example. But, as a minimum, a good health system would need to function well in terms of access, safety, health promotion, clinical effectiveness, patient experience, equity, efficiency and accountability.
For our study, we drew on official published data and reports from government, regulators and academic research.
One lesson hit home immediately as we attempted a brief synopsis of the situation before 1997, revisiting the white papers and other official documents from the mid-1990s. This was a world with no National Institute for Health and Clinical Excellence, no national regulator, no national patient experience surveys or national safety agency and with a much more limited data set on NHS performance and productivity. Vastly more data are collected and published about the NHS today. In addition, the business of government and the way it is communicated has changed almost beyond recognition. Where there were once short white papers, perhaps with a few black and white photos, for major government initiatives such as the Next Stage Review, now there are full colour, long documents filled with graphics and photos, dedicated websites, YouTube broadcasts and Twitter accounts.
There has been a great deal of policy activity since 1997: 26 green and white papers, 14 Acts of Parliament and a huge number of initiatives and policies. The broad narrative since 1997 is now well known: faltering progress on waiting lists led to the NHS Plan and the momentous decision to boost NHS spending to European averages. Increases in capacity, staff and new buildings followed, accompanied by reform using (in order of importance) a combination of targets, financial incentives, choice and competition.
The period has been rounded off, most recently, with an appeal to local clinical leadership to revolutionise the quality of care, building on the foundations of national service frameworks and Nice clinical guidance.
An overlapping combination of levers has been constructed and pulled to get results since 1997, including targets, stringent performance management, financial incentives for individuals and organisations and a modest degree of competition accompanied by a very modest degree of patient choice.
There have been successes. The most striking has been hospital waiting times: median waiting times for inpatient hospital treatment fell from more than 14 weeks in 1998 to four weeks in 2009. The government also successfully tackled the problem of patients waiting for diagnostic and other tests before hospital treatment: more than 90% of patients now receive an initial outpatient appointment and tests within 18 weeks of being referred by their GP for a hospital admission. Waiting times have also been reduced for emergency care (most people are seen or discharged within four hours of arriving at A&E) and for cancer diagnosis and treatment.
There has been much retrospective criticism of the focus on waiting times and the targets used to drive them down, not least the effect of channelling so much resource and energy into only one aspect of quality – speed of access. But long waiting times were the most obvious quality failing of the NHS in the 1990s and could be lethal for some: it was not irrational for the government to spend so much effort on putting them right. The big challenge will be maintaining these short waiting times in the future, particularly if targets are no longer favoured and finances are under pressure.
There are other positives: the creation of national evidence-based clinical standards have yielded better quality care for heart disease, cancer and acute mental ill health. Despite local controversy over individual decisions, Nice is held in high regard internationally, where it has been seen as a pioneer and model for other countries. National Service Frameworks, released from 1999 onwards for clinical conditions such as cancer, heart disease, mental health and diabetes, have set evidence-based national standards for prevention and care, earmarked funds and set timetables for reporting progress.
Mortality rates from cardiovascular disease and cancer have continued to fall, but attributing this directly to government policy is always tricky. Long-term mortality trends have been downwards regardless of which government has been in power. However, it is likely that the reduced waiting times, specialisation of surgery and implementation of best practice for care of conditions such as stroke have – at the very least – contributed to maintaining the decline in mortality.
In mental health, the creation of specialist community teams to intervene early for those with acute ill health has reduced admissions and reforms are under way to improve access to services for those with common mental health disorders. But in all these areas, variations in quality exist across the country despite national standards.
A future government will have to ensure that national standards continue to evolve in line with the best evidence and are fully implemented locally.
The NHS has progressed in terms of patient safety and measuring patients’ experiences – both have emerged internationally as major dimensions of good health care systems.
The National Patient Safety Agency has established national systems of error reporting and learning from mistakes. But there is still some way to go before incidents are comprehensively spotted and reported (especially in primary care) and a culture of safety is embedded in the NHS. The national patient survey programme is one of the largest of its kind: patient ratings of different aspects of care are generally high. But there has been little change over time and some groups, such as users of inpatient mental health services, often report poorer experiences.
There have been disappointments too: health inequalities have widened and overall the challenge of prevention has not been successfully met. The number of smokers continues to fall and will probably decline faster in the wake of the 2007 ban on smoking in public places. But rates of obesity and excess alcohol consumption continue to rise. Comprehensive policies to tackle these are relatively recent and, for most trusts, investing in prevention has been well down the pecking order since 1997.
There have been plenty of smaller-scale initiatives to manage the health of those with long-term conditions, such as the use of community matrons for those with complex needs and the expert patient programme, but the evidence of effectiveness is still limited. Chronic conditions are now better managed in primary care thanks to the Quality and Outcomes Framework incentive scheme for GP practices. But there needs to be much more emphasis on and investment in community-based services to meet the challenge of an older population and reduce avoidable admissions to hospitals.
In the case of prevention and better management of chronic conditions, the biggest challenge facing any future government will be shifting the balance of investment and energy in the NHS away from the acute sector. This problem has been diagnosed many times in the past, but no-one has yet succeeded in fixing it.
The regulatory landscape has changed almost beyond recognition since 1997, with the creation of the Care Quality Commission (and its predecessors), Monitor for foundation trusts and an overhaul of professional regulation. But there are real concerns that the burden of regulation outweighs the benefits it can bring to the public in terms of safer, more accountable, services and this will need action from an incoming government.
The most pressing problem is the need to make the NHS more efficient. Measurement of productivity was poor before 1997 and has been improved since. Though imperfect, it tells the story of NHS outputs failing to keep pace with inputs. Productivity has fallen steadily until recently and this long-term trend will need to be reversed if the NHS is to meet the challenge of rising demand in the future. Potential efficiencies have been identified – shorter lengths of stay, reducing avoidable admissions and the use of generic drugs, for example – but the NHS will need to substantially up its game to achieve this.
So is the NHS now high performing? In some respects, it is. But the challenges are changing, as they are for health systems in other countries. The changing demography of England over the next few decades, with more older people and more people with chronic conditions, requires a different kind of health system.
It is not clear whether the NHS is fully prepared to meet these challenges. If the same energy that was devoted to improving hospital waiting times and improving hospital care could be channelled into meeting these future challenges, then the NHS would rightly rank as one of the world’s high-performing systems.
Ruth Thorlby and Professor John Appleby are respectively fellow and chief economist at the King’s Fund. Thorlby is also co-author of A high performing NHS? A review of progress 1997–2010, which is available to download on www.kingsfund.org.uk/publications/a_highperforming_nh.html
22 April 2010
The NHS is a priority issue for voters in the general election. So how successful have the reforms and high levels of investment been over the past 13 years – and what challenges will a new government face? Ruth Thorlby and John Appleby of the King’s Fund review the evidence
The NHS is once again being held up as a critical election issue by the main political parties, which all promise more reform. It is perhaps not surprising that the opposition parties argue that the health service needs to be fixed – by them. But even Labour argues that the NHS needs to change from ‘good to great’.
Given the sustained and unprecedented levels of funding growth that have gone into the service since 2000, voters might be forgiven for being confused, especially as satisfaction with the NHS is at an all-time high. Why does it still need fixing? Has it not become better? How good is it now? How much more change does it need?
In an attempt to answer these questions, the King’s Fund has reviewed the progress made since 1997 in transforming the NHS in England into a high-performing health system. We focused on England as health policy has now diverged sufficiently between the devolved administrations to make comparisons complicated.
This was not an attempt to judge whether the government had met its own targets and objectives – it has been successful in many of them. Rather, the aim was to sum up what all the white papers, legislation, new organisations and initiatives have amounted to over the period and to set out the challenges for an incoming government.
Assessing whether the NHS is high performing is not straightforward as there is no single health care system that can be held up as the definitive example. But, as a minimum, a good health system would need to function well in terms of access, safety, health promotion, clinical effectiveness, patient experience, equity, efficiency and accountability.
For our study, we drew on official published data and reports from government, regulators and academic research.
One lesson hit home immediately as we attempted a brief synopsis of the situation before 1997, revisiting the white papers and other official documents from the mid-1990s. This was a world with no National Institute for Health and Clinical Excellence, no national regulator, no national patient experience surveys or national safety agency and with a much more limited data set on NHS performance and productivity. Vastly more data are collected and published about the NHS today. In addition, the business of government and the way it is communicated has changed almost beyond recognition. Where there were once short white papers, perhaps with a few black and white photos, for major government initiatives such as the Next Stage Review, now there are full colour, long documents filled with graphics and photos, dedicated websites, YouTube broadcasts and Twitter accounts.
There has been a great deal of policy activity since 1997: 26 green and white papers, 14 Acts of Parliament and a huge number of initiatives and policies. The broad narrative since 1997 is now well known: faltering progress on waiting lists led to the NHS Plan and the momentous decision to boost NHS spending to European averages. Increases in capacity, staff and new buildings followed, accompanied by reform using (in order of importance) a combination of targets, financial incentives, choice and competition.
The period has been rounded off, most recently, with an appeal to local clinical leadership to revolutionise the quality of care, building on the foundations of national service frameworks and Nice clinical guidance.
An overlapping combination of levers has been constructed and pulled to get results since 1997, including targets, stringent performance management, financial incentives for individuals and organisations and a modest degree of competition accompanied by a very modest degree of patient choice.
There have been successes. The most striking has been hospital waiting times: median waiting times for inpatient hospital treatment fell from more than 14 weeks in 1998 to four weeks in 2009. The government also successfully tackled the problem of patients waiting for diagnostic and other tests before hospital treatment: more than 90% of patients now receive an initial outpatient appointment and tests within 18 weeks of being referred by their GP for a hospital admission. Waiting times have also been reduced for emergency care (most people are seen or discharged within four hours of arriving at A&E) and for cancer diagnosis and treatment.
There has been much retrospective criticism of the focus on waiting times and the targets used to drive them down, not least the effect of channelling so much resource and energy into only one aspect of quality – speed of access. But long waiting times were the most obvious quality failing of the NHS in the 1990s and could be lethal for some: it was not irrational for the government to spend so much effort on putting them right. The big challenge will be maintaining these short waiting times in the future, particularly if targets are no longer favoured and finances are under pressure.
There are other positives: the creation of national evidence-based clinical standards have yielded better quality care for heart disease, cancer and acute mental ill health. Despite local controversy over individual decisions, Nice is held in high regard internationally, where it has been seen as a pioneer and model for other countries. National Service Frameworks, released from 1999 onwards for clinical conditions such as cancer, heart disease, mental health and diabetes, have set evidence-based national standards for prevention and care, earmarked funds and set timetables for reporting progress.
Mortality rates from cardiovascular disease and cancer have continued to fall, but attributing this directly to government policy is always tricky. Long-term mortality trends have been downwards regardless of which government has been in power. However, it is likely that the reduced waiting times, specialisation of surgery and implementation of best practice for care of conditions such as stroke have – at the very least – contributed to maintaining the decline in mortality.
In mental health, the creation of specialist community teams to intervene early for those with acute ill health has reduced admissions and reforms are under way to improve access to services for those with common mental health disorders. But in all these areas, variations in quality exist across the country despite national standards.
A future government will have to ensure that national standards continue to evolve in line with the best evidence and are fully implemented locally.
The NHS has progressed in terms of patient safety and measuring patients’ experiences – both have emerged internationally as major dimensions of good health care systems.
The National Patient Safety Agency has established national systems of error reporting and learning from mistakes. But there is still some way to go before incidents are comprehensively spotted and reported (especially in primary care) and a culture of safety is embedded in the NHS. The national patient survey programme is one of the largest of its kind: patient ratings of different aspects of care are generally high. But there has been little change over time and some groups, such as users of inpatient mental health services, often report poorer experiences.
There have been disappointments too: health inequalities have widened and overall the challenge of prevention has not been successfully met. The number of smokers continues to fall and will probably decline faster in the wake of the 2007 ban on smoking in public places. But rates of obesity and excess alcohol consumption continue to rise. Comprehensive policies to tackle these are relatively recent and, for most trusts, investing in prevention has been well down the pecking order since 1997.
There have been plenty of smaller-scale initiatives to manage the health of those with long-term conditions, such as the use of community matrons for those with complex needs and the expert patient programme, but the evidence of effectiveness is still limited. Chronic conditions are now better managed in primary care thanks to the Quality and Outcomes Framework incentive scheme for GP practices. But there needs to be much more emphasis on and investment in community-based services to meet the challenge of an older population and reduce avoidable admissions to hospitals.
In the case of prevention and better management of chronic conditions, the biggest challenge facing any future government will be shifting the balance of investment and energy in the NHS away from the acute sector. This problem has been diagnosed many times in the past, but no-one has yet succeeded in fixing it.
The regulatory landscape has changed almost beyond recognition since 1997, with the creation of the Care Quality Commission (and its predecessors), Monitor for foundation trusts and an overhaul of professional regulation. But there are real concerns that the burden of regulation outweighs the benefits it can bring to the public in terms of safer, more accountable, services and this will need action from an incoming government.
The most pressing problem is the need to make the NHS more efficient. Measurement of productivity was poor before 1997 and has been improved since. Though imperfect, it tells the story of NHS outputs failing to keep pace with inputs. Productivity has fallen steadily until recently and this long-term trend will need to be reversed if the NHS is to meet the challenge of rising demand in the future. Potential efficiencies have been identified – shorter lengths of stay, reducing avoidable admissions and the use of generic drugs, for example – but the NHS will need to substantially up its game to achieve this.
So is the NHS now high performing? In some respects, it is. But the challenges are changing, as they are for health systems in other countries. The changing demography of England over the next few decades, with more older people and more people with chronic conditions, requires a different kind of health system.
It is not clear whether the NHS is fully prepared to meet these challenges. If the same energy that was devoted to improving hospital waiting times and improving hospital care could be channelled into meeting these future challenges, then the NHS would rightly rank as one of the world’s high-performing systems.
Ruth Thorlby and Professor John Appleby are respectively fellow and chief economist at the King’s Fund. Thorlby is also co-author of A high performing NHS? A review of progress 1997–2010, which is available to download on www.kingsfund.org.uk/publications/a_highperforming_nh.html
