Quality | 2010.01.11
Come off it, Dr Cameron | John Appleby
There\'s a problem with the changes pledged by the Tories for the NHS: they\'ve happened already
As David Cameron\'s foreword to the Conservatives\' draft manifesto on health , what\'s needed is "change": "This is no time for business as usual. This is no time for more of the same. There is only one way out of this mess, and that is massive change."
So, things are going to be very different for the NHS. Or are they? First, there is a commitment to increasing NHS funding – but no numbers. Just to cope with changes in the population over the next few years will need an increase in funding in real terms of 1% to 1.5%. And to match the recommendations of a 2002 review on NHS funding (carried out for Gordon Brown) would require an annual increase of 3-5%.
The problem any government will face is how it will pay for such commitments. Recent analysis by the King\'s Fund and the Institute for Fiscal Studies pointed out the bleak choices ahead: a 1% real increase in funding for the next three years for the NHS would mean real cuts of over 12% in all other spending departments.
Funding aside, the list of "massive changes" looks much like what\'s already happened, or is happening in the NHS. Choice of hospital for patients? Yes, since 2005. Semi-autonomous hospitals (foundation trusts)? Yes, since 2004. Financial incentives for hospitals? Yes, since 2004. Publishing data on performance of NHS organisations? Yes, since 1998. Linking GPs\' pay to the quality of results they deliver? Yes, in one form or another, since 1990. More choice in and coordination of maternity services? As the Royal College of Midwives states, this is already happening. And it hardly seems worth going to the trouble of appointing an independent board to distribute the global NHS budget to local primary care trusts – a computer that allocates 80% of the NHS budget (one of the most sophisticated formulas for allocating public money anywhere in the world) could carry out this job.
Perhaps what is new is a commitment to provide separate public health funding to local authorities rather than the NHS. This money – again, a sum unspecified, but presumably not unadjacent to the £3bn or so the NHS is estimated to spend on public health – will be allocated on the basis of need with poorer and less healthy areas getting more money. The aim of this spending is laudable – to eradicate health inequalities. But as governments have found for half a century or more, reducing (let alone eradicating) disparities in life expectancy and mortality is a wicked problem and one not simply solved through public health activities or dividing up the NHS cake according to need.
A real commitment to reducing health inequalities requires something of the scale advocated by Sir Michael Marmot\'s strategic review of health inequalities that involves action not just in healthcare, but in tax, incomes, education and the environment.
A promise presumably popular with some consultants will be the scrapping of "politically driven process targets", which apparently stop professionals doing their jobs properly. The use of targets – most notably to reduce waiting times – has received a bad press; but interestingly, research (as opposed to opinion) suggests that targets combined with a few sticks and carrots have reduced waiting times, with limited or no detriment to the quality of care.
The National Institute for Clinical Excellence (Nice) – one of the most admired NHS organisations internationally – gets a bit of rough treatment; "unaccountable bureaucrats" apparently deny the British public their rightful access to effective treatments. But the manifesto does not advocate the abolition of Nice (it would only have to be reinvented) – it suggests that drug companies be paid according to the "value" of their produce. Sounds good, but "value-based pricing" experiments – such as beta interferon, for multiple sclerosis – suggest it may not be the best way of getting value for the NHS budget.
Perhaps the most surprising omission in the Conservatives\' health manifesto is any mention of how the NHS will improve productivity. If there\'s one message that\'s been drummed into the noggins of managers over the last year by the Department of Health, it is the absolute and overriding need over the next few years to make every healthcare pound go further. Cutting bureaucracy (as every putative government promises) is one thing, but pales into insignificance compared with the scale of the productivity challenge facing the NHS.
For more information, please visit
http://www.guardian.co.uk/commentisfree/[...]n-changes-nhs-happened-already
