Doctors For Reform- NHS is failing and unsustainable
We once believed the NHS was the finest healthcare system in the world. Today few healthcare professionals would make that claim. Britain is the world’s fourth largest economy. But it does not enjoy standards of healthcare consistent with its status.
The best international evidence on medical outcomes has been collected for cancer patients. It shows that British cancer patients have a significantly lower chance of survival after diagnosis than patients in other developed countries as well as poorer access to cancer drugs.
On other measures such as life expectancy, infant mortality, premature mortality and cancer survival rates the UK continues to perform poorly compared to other countries and there is a significant gap with the best performing countries.
For example the UK’s rate of infant mortality is roughly a quarter higher than in France and Switzerland. The UK’s 5-year cancer survival rates are amongst the worst in Europe and over 10 per cent lower than France, Germany and Switzerland.
Waiting lists, standing at just under one million, are far longer than in other Continental countries such as France and Germany. Many patients’ conditions deteriorate further while on the waiting list. One study has shown that 21 per cent of lung cancer patients became unsuitable for curative treatment during the wait for their radiotherapy.
Despite large spending increases and rises in the number of medical students, numbers of medical staff in this country still remains below that of other Continental countries. The latest figures show that the UK has a third less practicing physicians per 1,000 population than France, Germany or Switzerland and roughly half as many general practitioners as France.
A recent study found that while the total headcount number of midwives had increased between 1994 and 2004 the number of actual number of midwife hours worked had fallen by 14 per cent to the great detriment of mothers.
This is likely to remain the case in the medium term. Noting that the number of doctors cannot be raised as quickly as spending the OECD recently stated: “When health spending reaches 9.5 per cent of GDP in 2007/08, there will only be about 2.4 practising physicians per 1 000 population (up from 1.9 in 1999), compared with currently 3.1 to 4.1 in Belgium, Italy, Netherlands and Sweden, which have a comparable spending level and 3.4 in Germany and France, which spend slightly more.”
The NHS was conceived more than half a century ago, at a time of rationing and considerable poverty. It aimed to provide a uniformly high standard of care to the whole population. But as the Prime Minister himself has said, it has produced a "deeply unequal" system where the most affluent in society opt out while the poorest too often receive the worst healthcare.
The current system of healthcare provision leads to the poorest in society facing the worst healthcare and the worst health outcomes. Following a heart attack, intervention rates of coronary artery bypass grafts or angiography are 30 per cent lower in the lowest socioeconomic groups than in the highest. Hip replacements are 20 per cent lower among the lower socio-economic groups despite roughly 30 per cent higher need. Males in East Dorset live on average over eight year longer than in Manchester.
Health inequalities have worsened in recent years. Between 1997-99 and 2001-03, the relative gap between life expectancy in England as a whole and in the lowest fifth of local authorities increased by 2 per cent for males and 5 per cent for females. The infant mortality rate among the “routine and manual” group was 19 per cent higher than in the total population in 2001–03, compared with 16 per cent higher in 2000–02 and 13 per cent higher in 1997-99.
The Government sought to address these inequalities – particularly in primary care – in the White Paper, Our health, our care, our say which noted that “there are persistent and particular problems in deprived areas which have long been under-served”.
We welcome the substantial increase in resources for the NHS committed by the current Government. But it is becoming clear that simply bringing up our level of health spending to the European average or beyond will not be sufficient to achieve the necessary standards of care.
Since 1999-00, NHS spending has been growing well above inflation. UK health spending reached the European average this year. By 2007 it will have reached the level of countries such as the Netherlands and France.
These increases have led to some marginal improvements, such as a reduction in maximum waiting times and some increase in capacity. But the nationalised monolithic structure of the NHS simply does not allow the effective transmission of resources to frontline services.
There are few indicators showing unambiguous improvements in outcomes over and above trend improvements that were already apparent before the surge in spending. For example, mortality rates from cancer and hear disease have declined since 1999, but only at the same rate as the existing trend.
Despite the large increases in spending performance is still poor. One Department of Health measure for average waiting times shows a 25 per cent increase since 1999-00. The Royal College of Radiologists has shown that waiting times for cancer treatment are “substantially worse” now than in 1997. The current target – a wait of 2 months from referral to first treatment – would be unacceptably long in most European countries and result in litigation in the USA.
Instead of improving care the extra money has gone into higher costs across the service such as higher pay for NHS staff, higher drugs costs and the costs of large hospital building schemes. The King’s Fund estimates that for the last three years roughly three-quarters of every year’s spending increase has gone on cost pressures. For this year the figure was 87 per cent.
Doctors are beset with political targets and central direction, distorting clinical priorities.
The Government has recognised the need to move away from a target led system of healthcare. Speaking before the election last year Tony Blair described them as a “blunt instrument” and admitted that there are “too many” of them. But the reality of life in the service is that the target culture has bedded down and become entrenched
The creation of foundation hospitals and the limited extension of choice in the NHS are steps in the right direction, but such changes fall far short of the necessary degree of reform.
Where choice has been tried in the NHS it has had a dramatic effect. London Patient Choice Project – which gave patients choice of an alternative provider after a certain period – dramatically reduced waiting times in the specialities it was piloted in. Researchers also found that improved performance and waiting times benefited all patients not just those that opted for an alternative. 60 per cent of patients who were offered a choice took it and of those who did 97 per cent said they would recommend the scheme to others.
Very limited patient choice of elective surgery providers was introduced at the start of this year. Choice of any provider – compared to the four or five available now – will not be on offer until 2008. Other countries do not have such limits on patient choice.
No healthcare system is perfect. But we have much to learn from other countries.
Other countries have both a diverse range of healthcare suppliers and mixed funding systems, such as social insurance, which empower patients and offer real choice to all, including the most disadvantaged in society.
In Britain, nearly all resources for healthcare are collected through general taxation. According to the Wanless Review, tax financing provides too great an incentive for governments to limit spending, with the result that the UK has under-invested in healthcare compared to other countries over many years. Other countries have been able to spend more by raising health funds from a variety of sources.
Tax financing provides relatively limited choice for patients. Under social insurance systems, in contrast, health contributions are paid to third party insurers who (unlike governments) are under an obligation to serve customers. Such systems also provide a universal guarantee of high quality care for all in society. Governments pay the premiums of those unable to do so. Payments are regulated so that people with higher health risks are not penalised.
We do not advocate any particular system. But the French, German and especially Swiss health systems have advantages from which Britain can learn.
France
Under the French system of social insurance, citizens enjoy very wide choice over healthcare providers but not over their health insurer. Membership of the 18 insurance funds, all independent of government, is determined by occupation. Money follows the patient, which gives financial incentives to supply high standards of care.
Three quarters of all funding is provided from contributions from employers and employees. The balance is provided by hypothecated taxation (recently introduced), private payment at the point of use (with exemptions for the poor) and supplementary insurance. A third of all hospitals are non-state owned.
The major weakness of the French system is that it has poor incentives to achieve value for money. Prescription drug use and the seeking of second opinions, for example, are much higher than in other countries. The system has been facing financial problems.
Germany
Around three quarters of German citizens have mandatory insurance through a statutory system of social insurance. Some groups such as the self-employed are excluded and usually choose to purchase private insurance. High income earners can choose between statutory insurance and private health insurance.
The social insurance benefits package is laid down by law. Citizens have the right to choose their insurer and there are approximately 450 sickness funds which are independent of government. Patients also have a choice of provider. Half of all hospitals are non state-owned.
Treatment capacity is high and waiting lists are virtually unheard of since competing providers usually treat all patients. Germans enjoy high levels of healthcare and outcomes. However the system contains elements which drive up costs, for example the requirement for all insurers to contract with all willing providers.
Switzerland
In Switzerland, it is compulsory to pay for a basic insurance plan defined by law. About 100 private insurers compete for customers, offering a mandatory and comprehensive package which is set at the national level. Community rating of the compulsory package means that everyone pays the same premium in the same region with the same insurer, irrespective of their own risk. Unlike France and Germany, employers do not make contributions towards healthcare costs, which could be seen as advantageous in Britain.
Around one third of Swiss citizens receive premium subsidies and the poor have virtually all the full premium paid for them, but the principle of payment is regarded as important. Premiums vary with a wide range of deductibles, co-payments and managed care options.
Switzerland is one of the most attractive models of healthcare. With a wide choice of insurers and providers, the Swiss enjoy a degree of choice unrivalled outside the US. But as in Germany, efficiency is compromised as sickness funds have to contract with all providers.
USA
The USA is a mix of voluntary private insurance and public funding, with private funding accounting for 55 per cent of total healthcare spending. Nearly three quarters of the population have private insurance. Government programmes fund healthcare for retirees and the disabled (Medicare) and the poor (Medicaid).
We do not advocate the US model of healthcare. Insurance tends to be bought by those with higher risks, driving up the cost of premiums. For smaller businesses, the self-employed and those between jobs, the pricing of insurance can be prohibitive.
The time has come to look at new ways to supply and fund healthcare.
The NHS cannot meet public expectations today. It is highly unlikely that it will meet them tomorrow. Future generations will seek rapid access to care, greater choice and more information about their treatment. We need a healthcare system which is equal to rapidly rising costs and demand, and which enables professionals to retain the essential bond of trust with their patients.
The NHS fails to meet it pledge to provide care for all. Despite large funding increases areas of the service severely underperform. The average wait for hearing aid is nearly a year and can be three times that in some parts of the country. In the six months after their discharge only half of stroke patients receive the vital therapies and treatment they need to recover fully. This falls to a fifth in the 6-12 months period.
The spending increases of recent years and rapid advances in medicine will themselves increase patient expectations. Already new types of drugs and treatments are appearing that patients demand but the NHS cannot afford to provide. One study has shown that cancer care alone may cost three times more than the current cost of the NHS in two decades’ time.
As Lord Winston, the Labour peer, recently said: “The rising cost is absolutely massive and there is no sign of that regressing. I am not convinced that any political party is realistic about the costs of the NHS …. We need a real debate about how we are actually going to pay for the NHS.”
Rising demand and expectations cannot be met solely by the taxpayer. Sir Derek Wanless recently advocated a mixed funding system for social care. There is no reason why it wouldn’t be beneficial for all health care. There has been a recognition that we cannot carry on in this way be some within Government.
A commission on health services in the mid 1990s, Deputy Chaired by Patricia Hewitt, concluded: “We are committed to general taxation being maintained as the principal source of funding health services. However we believe it is not possible to expect the continuing gap between resources and demand to be closed through increased tax funding alone. Increased tax funding may play a part, but it seems that the gap will be effectively reduced only by a combination of strategies which include a clearer definition of what services will be provided free at the point of use and raising the proportion of healthcare funding provided by individuals through options such as user charges and / or patient co-payments.”
http://www.doctorsforreform.com/page.asp?pid=92
The best international evidence on medical outcomes has been collected for cancer patients. It shows that British cancer patients have a significantly lower chance of survival after diagnosis than patients in other developed countries as well as poorer access to cancer drugs.
On other measures such as life expectancy, infant mortality, premature mortality and cancer survival rates the UK continues to perform poorly compared to other countries and there is a significant gap with the best performing countries.
For example the UK’s rate of infant mortality is roughly a quarter higher than in France and Switzerland. The UK’s 5-year cancer survival rates are amongst the worst in Europe and over 10 per cent lower than France, Germany and Switzerland.
Waiting lists, standing at just under one million, are far longer than in other Continental countries such as France and Germany. Many patients’ conditions deteriorate further while on the waiting list. One study has shown that 21 per cent of lung cancer patients became unsuitable for curative treatment during the wait for their radiotherapy.
Despite large spending increases and rises in the number of medical students, numbers of medical staff in this country still remains below that of other Continental countries. The latest figures show that the UK has a third less practicing physicians per 1,000 population than France, Germany or Switzerland and roughly half as many general practitioners as France.
A recent study found that while the total headcount number of midwives had increased between 1994 and 2004 the number of actual number of midwife hours worked had fallen by 14 per cent to the great detriment of mothers.
This is likely to remain the case in the medium term. Noting that the number of doctors cannot be raised as quickly as spending the OECD recently stated: “When health spending reaches 9.5 per cent of GDP in 2007/08, there will only be about 2.4 practising physicians per 1 000 population (up from 1.9 in 1999), compared with currently 3.1 to 4.1 in Belgium, Italy, Netherlands and Sweden, which have a comparable spending level and 3.4 in Germany and France, which spend slightly more.”
The NHS was conceived more than half a century ago, at a time of rationing and considerable poverty. It aimed to provide a uniformly high standard of care to the whole population. But as the Prime Minister himself has said, it has produced a "deeply unequal" system where the most affluent in society opt out while the poorest too often receive the worst healthcare.
The current system of healthcare provision leads to the poorest in society facing the worst healthcare and the worst health outcomes. Following a heart attack, intervention rates of coronary artery bypass grafts or angiography are 30 per cent lower in the lowest socioeconomic groups than in the highest. Hip replacements are 20 per cent lower among the lower socio-economic groups despite roughly 30 per cent higher need. Males in East Dorset live on average over eight year longer than in Manchester.
Health inequalities have worsened in recent years. Between 1997-99 and 2001-03, the relative gap between life expectancy in England as a whole and in the lowest fifth of local authorities increased by 2 per cent for males and 5 per cent for females. The infant mortality rate among the “routine and manual” group was 19 per cent higher than in the total population in 2001–03, compared with 16 per cent higher in 2000–02 and 13 per cent higher in 1997-99.
The Government sought to address these inequalities – particularly in primary care – in the White Paper, Our health, our care, our say which noted that “there are persistent and particular problems in deprived areas which have long been under-served”.
We welcome the substantial increase in resources for the NHS committed by the current Government. But it is becoming clear that simply bringing up our level of health spending to the European average or beyond will not be sufficient to achieve the necessary standards of care.
Since 1999-00, NHS spending has been growing well above inflation. UK health spending reached the European average this year. By 2007 it will have reached the level of countries such as the Netherlands and France.
These increases have led to some marginal improvements, such as a reduction in maximum waiting times and some increase in capacity. But the nationalised monolithic structure of the NHS simply does not allow the effective transmission of resources to frontline services.
There are few indicators showing unambiguous improvements in outcomes over and above trend improvements that were already apparent before the surge in spending. For example, mortality rates from cancer and hear disease have declined since 1999, but only at the same rate as the existing trend.
Despite the large increases in spending performance is still poor. One Department of Health measure for average waiting times shows a 25 per cent increase since 1999-00. The Royal College of Radiologists has shown that waiting times for cancer treatment are “substantially worse” now than in 1997. The current target – a wait of 2 months from referral to first treatment – would be unacceptably long in most European countries and result in litigation in the USA.
Instead of improving care the extra money has gone into higher costs across the service such as higher pay for NHS staff, higher drugs costs and the costs of large hospital building schemes. The King’s Fund estimates that for the last three years roughly three-quarters of every year’s spending increase has gone on cost pressures. For this year the figure was 87 per cent.
Doctors are beset with political targets and central direction, distorting clinical priorities.
The Government has recognised the need to move away from a target led system of healthcare. Speaking before the election last year Tony Blair described them as a “blunt instrument” and admitted that there are “too many” of them. But the reality of life in the service is that the target culture has bedded down and become entrenched
The creation of foundation hospitals and the limited extension of choice in the NHS are steps in the right direction, but such changes fall far short of the necessary degree of reform.
Where choice has been tried in the NHS it has had a dramatic effect. London Patient Choice Project – which gave patients choice of an alternative provider after a certain period – dramatically reduced waiting times in the specialities it was piloted in. Researchers also found that improved performance and waiting times benefited all patients not just those that opted for an alternative. 60 per cent of patients who were offered a choice took it and of those who did 97 per cent said they would recommend the scheme to others.
Very limited patient choice of elective surgery providers was introduced at the start of this year. Choice of any provider – compared to the four or five available now – will not be on offer until 2008. Other countries do not have such limits on patient choice.
No healthcare system is perfect. But we have much to learn from other countries.
Other countries have both a diverse range of healthcare suppliers and mixed funding systems, such as social insurance, which empower patients and offer real choice to all, including the most disadvantaged in society.
In Britain, nearly all resources for healthcare are collected through general taxation. According to the Wanless Review, tax financing provides too great an incentive for governments to limit spending, with the result that the UK has under-invested in healthcare compared to other countries over many years. Other countries have been able to spend more by raising health funds from a variety of sources.
Tax financing provides relatively limited choice for patients. Under social insurance systems, in contrast, health contributions are paid to third party insurers who (unlike governments) are under an obligation to serve customers. Such systems also provide a universal guarantee of high quality care for all in society. Governments pay the premiums of those unable to do so. Payments are regulated so that people with higher health risks are not penalised.
We do not advocate any particular system. But the French, German and especially Swiss health systems have advantages from which Britain can learn.
France
Under the French system of social insurance, citizens enjoy very wide choice over healthcare providers but not over their health insurer. Membership of the 18 insurance funds, all independent of government, is determined by occupation. Money follows the patient, which gives financial incentives to supply high standards of care.
Three quarters of all funding is provided from contributions from employers and employees. The balance is provided by hypothecated taxation (recently introduced), private payment at the point of use (with exemptions for the poor) and supplementary insurance. A third of all hospitals are non-state owned.
The major weakness of the French system is that it has poor incentives to achieve value for money. Prescription drug use and the seeking of second opinions, for example, are much higher than in other countries. The system has been facing financial problems.
Germany
Around three quarters of German citizens have mandatory insurance through a statutory system of social insurance. Some groups such as the self-employed are excluded and usually choose to purchase private insurance. High income earners can choose between statutory insurance and private health insurance.
The social insurance benefits package is laid down by law. Citizens have the right to choose their insurer and there are approximately 450 sickness funds which are independent of government. Patients also have a choice of provider. Half of all hospitals are non state-owned.
Treatment capacity is high and waiting lists are virtually unheard of since competing providers usually treat all patients. Germans enjoy high levels of healthcare and outcomes. However the system contains elements which drive up costs, for example the requirement for all insurers to contract with all willing providers.
Switzerland
In Switzerland, it is compulsory to pay for a basic insurance plan defined by law. About 100 private insurers compete for customers, offering a mandatory and comprehensive package which is set at the national level. Community rating of the compulsory package means that everyone pays the same premium in the same region with the same insurer, irrespective of their own risk. Unlike France and Germany, employers do not make contributions towards healthcare costs, which could be seen as advantageous in Britain.
Around one third of Swiss citizens receive premium subsidies and the poor have virtually all the full premium paid for them, but the principle of payment is regarded as important. Premiums vary with a wide range of deductibles, co-payments and managed care options.
Switzerland is one of the most attractive models of healthcare. With a wide choice of insurers and providers, the Swiss enjoy a degree of choice unrivalled outside the US. But as in Germany, efficiency is compromised as sickness funds have to contract with all providers.
USA
The USA is a mix of voluntary private insurance and public funding, with private funding accounting for 55 per cent of total healthcare spending. Nearly three quarters of the population have private insurance. Government programmes fund healthcare for retirees and the disabled (Medicare) and the poor (Medicaid).
We do not advocate the US model of healthcare. Insurance tends to be bought by those with higher risks, driving up the cost of premiums. For smaller businesses, the self-employed and those between jobs, the pricing of insurance can be prohibitive.
The time has come to look at new ways to supply and fund healthcare.
The NHS cannot meet public expectations today. It is highly unlikely that it will meet them tomorrow. Future generations will seek rapid access to care, greater choice and more information about their treatment. We need a healthcare system which is equal to rapidly rising costs and demand, and which enables professionals to retain the essential bond of trust with their patients.
The NHS fails to meet it pledge to provide care for all. Despite large funding increases areas of the service severely underperform. The average wait for hearing aid is nearly a year and can be three times that in some parts of the country. In the six months after their discharge only half of stroke patients receive the vital therapies and treatment they need to recover fully. This falls to a fifth in the 6-12 months period.
The spending increases of recent years and rapid advances in medicine will themselves increase patient expectations. Already new types of drugs and treatments are appearing that patients demand but the NHS cannot afford to provide. One study has shown that cancer care alone may cost three times more than the current cost of the NHS in two decades’ time.
As Lord Winston, the Labour peer, recently said: “The rising cost is absolutely massive and there is no sign of that regressing. I am not convinced that any political party is realistic about the costs of the NHS …. We need a real debate about how we are actually going to pay for the NHS.”
Rising demand and expectations cannot be met solely by the taxpayer. Sir Derek Wanless recently advocated a mixed funding system for social care. There is no reason why it wouldn’t be beneficial for all health care. There has been a recognition that we cannot carry on in this way be some within Government.
A commission on health services in the mid 1990s, Deputy Chaired by Patricia Hewitt, concluded: “We are committed to general taxation being maintained as the principal source of funding health services. However we believe it is not possible to expect the continuing gap between resources and demand to be closed through increased tax funding alone. Increased tax funding may play a part, but it seems that the gap will be effectively reduced only by a combination of strategies which include a clearer definition of what services will be provided free at the point of use and raising the proportion of healthcare funding provided by individuals through options such as user charges and / or patient co-payments.”
http://www.doctorsforreform.com/page.asp?pid=92
posted by Dr Search- Principal Consultant at the Search Clinic at
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