The climbdown came after the DoH was forced to acknowledge claims by strategic health authorities and primary care trusts that more elective capacity was not needed in their regions.

This week the DoH also announced plans for an independent clinical audit of the first wave of the ITC programme following surgeons’ concerns over the clinical quality of many operations carried out at the sites.

And the news comes as a high-profile independent sector company bidding to provide a practice in the North West pulled out, criticising delays in the process.

In September the DoH sent a ‘pre-qualifying questionnaire’ to prospective private healthcare providers, setting out the 24 elective surgery contracts on offer across the country. HSJ understands that many of the bidders had already been invited to negotiate with the DoH for the work.

However, last week companies bidding for the work received letters from the DoH’s commercial directorate telling them that seven of the contracts had been scrapped.

The letter said: ‘It has become clear for a variety of reasons that the detailed make-up of the schemes needs to be reviewed and that these schemes will not go ahead as part of the phase-two procurement programme. We are currently exploring options to replace the capacity of these schemes.’

HSJ understands that the DoH has told private providers that the monetary value of the schemes – £550m worth of work per year – will still be guaranteed. Meanwhile the other 17 remaining schemes have been delayed for up to a year.

A DoH spokesperson said: ‘We have responded to the changing needs of a small number of health authorities.

‘We continue to work with each of these SHAs to ensure that they have plans in place to deliver better services to patients using the independent sector’.

NHS Confederation policy director Nigel Edwards said: ‘What is becoming increasingly clear is that the level of surgical elective capacity is enough, if not too much. The problem is now one of patient flow rather than capacity, and there has been a growing anxiety that too much capacity had been procured and this has become a big issue.’

He said that the private providers would be ‘pretty disappointed that they have put in so much work’ and suggested that they may want their costs reimbursed. ‘The private sector providers will be pretty aggrieved.’

NHS Alliance chair Dr Michael Dixon welcomed the announcement. ‘The DoH must not straitjacket commissioners into telling them what they have to commission,’ he said. ‘They desperately need the blessing of PCTs and practice-based commissioners. If they are in doubt they should delay in order to get it right for commissioners.’

The second part of the wave two contract known as the ‘extended choice network’, under which the DoH was set to buy elective services on top of the initial national schemes, has also been delayed indefinitely. However, the diagnostic element of the second wave is unaffected.

The SHAs with the cancelled projects
* County Durham and Tees Valley: multi-specialty treatment centre
* Birmingham and the Black Country: Birmingham City treatment centre to be housed on site at Sandwell and West Birmingham Hospitals trust
* South Yorkshire: cardiology treatment centre
* South Yorkshire: general surgery treatment centre
* South West Peninsula: multi-specialty mobile unit
* West Yorkshire: plastic surgery unit
* West Yorkshire: multi-specialty treatment centre

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=4703772

Nurses run out of patience with Patricia Hewitt yesterday amid a sea of protest posters and T-shirts at the Royal College of Nursing conference

“Put your speech away,” shouted the nurses as Miss Hewitt, almost repeating the address she had made to Unison in Monday, said she would help any nurses made redundant to get new jobs. “Where? Where?” they yelled.

About 15 minutes into her speech, the nurses, who had already interrupted her with derisive laughter, cries of “rubbish”, “resign” and the stamping of hundreds of feet, had finally had enough. There would be more arguments and controversy in the coming year, Miss Hewitt was saying as the shouting spread, the crescendo of stamping grew, and she was finally drowned out.

Dave Nunn, the chairman of the conference, could just be heard telling the Secretary of State that the nurses were indicating that it was time they had their say.

Patricia Hewitt displayed less than her usual composure

Miss Hewitt agreed it was always right to take questions. “Have you finished or do you want to say more?” Mr Nunn asked. “I’ve just said to you that I will,” said Miss Hewitt, displaying less than her usual composure.

Les Miles, from a foundation hospital trust in south Tyneside, wanted to know why was it that, with all this funding going into the NHS, he and one auxillary nurse were left to care alone for a ward for 14 premature babies?

It was clear they were understaffed, said Miss Hewitt, but that really was a matter for the trust. Mr Miles said later that he felt patronised.

Maureen Marshall, a nurse from south London, demanded to know if Agenda for Change, the programme to restructure pay and ways of working, had been fully funded or not. “Yes or no. Yes or no,” thundered the audience, which felt let down by a 2.5 per cent pay rise this year. It had been fully funded said Miss Hewitt, her voice rising. But it looked as if more money would be needed. More scornful laughter.

After three quarters of an hour, Miss Hewitt’s ordeal was nearly over. “I know you are angry with me and I know you disagree with a lot of what I am saying. But I really want to stress that although there may be some areas of disagreement between us, the more we can work together and the more nurses in particular are involved in difficult decisions to be made, the better.”

The conciliation failed. The audience rose and booed. Miss Hewitt quickly left the stage and nurses held aloft the campaign posters they will take to a lobby of Parliament next month.

Dr Beverly Malone, the general secretary of the RCN, said afterwards: “Blame shifting and lame excuses from the minister won’t help a single patient or save a solitary job. What nurses and patients need is long-term planning not short-term cuts.”

Sylvia Denton, the president of the RCN, said she had never seen nurses so angry in the presence of a health secretary. “I’ve been coming to congress for the last 26 years and I don’t think I have ever seen a reception like that but I think this is a symptom of nurses not being listened to.”

Miss Hewitt returned to London to put her message across to the Fabian Society. The NHS was the best medical insurance system in the world, she said.

Under Labour’s reforms, the NHS had improved and would continue to improve, she said. She accused the Conservatives of trying to undermine the service in the hope of persuading voters that state funding was not working.

http://www.telegraph.co.uk/news/main.jhtml;jsessionid=32BYYAXK5X5TLQFIQMFCFFWAVCBQYIV0?xml=/news/2006/04/27/nhew27.xml&sSheet;=/portal/2006/04/27/ixportaltop.html

The angry mood over job losses and privatisation of services was underlined when Patricia Hewitt, the Health Secretary, was given a rough ride by nearly 1,000 delegates at Unison’s health workers’ conference in Gateshead, where delegates sat in silence as she was introduced.

Despite being urged to show respect, some shouted “Rubbish” and booed and hissed as she spoke.

Miss Hewitt refused to apologise for her claim, which attracted widespread ridicule, that the NHS had experienced its “best year ever”, although she amended it to the best year ever “for patients”.

She said: “We have written a very big cheque for the NHS and we are proud of it. But it is not a blank cheque; it never has been and it never will be.”

Overspending hospitals and organisations had to put their houses in order.

The first industrial action could hit trusts that have announced job losses in recent weeks, as well as areas with plans to outsource work.

Nurses at their annual conference in Bournemouth called for an end to bed closures and job losses and spoke of low morale after a “disappointing” pay rise.

Beverly Malone, the general secretary of the Royal College of Nursing, urged the Government to stop treating nurses “like overheads to be cut”. The success of reforms depended on their goodwill.

Mr Blair said at his monthly press conference that Miss Hewitt had his confidence in driving through reforms. He indicated that more jobs could go when he said the NHS faced “a very challenging” year.

Government figures showed yesterday that the number of hospital managers had doubled in 10 years: from 20,842 in 1995 to 39,391 last year.

Overall, the NHS workforce in England has grown by 30 per cent in that time.

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/04/25/nhs25.xml

Our own review of public reporting of financial deficits by NHS organisations to RCN representatives shows an overall deficit of around £840m in Acute Trusts, £48m in Foundation Trusts and £358m in PCT’s – a total of £1.2bn. Alongside the financial picture, we have received details of a reported loss approaching 4000 WTE posts from the NHS – this figure does not include jobs which may be lost as a result of the changes described in Commissioning a Patient led NHS.

Across the UK, each country has experienced differing levels of growth in funding and expenditure but all have experienced significant increases.

In terms of the experience of financial deficits, this is quite different from country to country as the rules governing expenditure are very different; the structures in which spending occurs are different; and each country will have different priorities in terms of overall allocation and spending plans.

Country 1999/00 2003/4 2005/6 2006/7
England £33.04bn £61.3bn £74.3bn £83.8bn
Northern Ireland £1.8bn £2.9bn £3.3bn £3.75bn
Scotland £5.16bn £7.10bn £8.62bn £9.33bn
Wales £2.98bn £4.1bn £4.87bn £5.14bn

In Wales some Trusts and Local Health Boards are reporting deficits although total spending on health care will increase to £5bn in 2006/07 – this compares with the £2.98bn health budget which the Assembly inherited in 1999.

Several NHS Boards in Scotland are forecasting deficits for the current financial year. Audit Scotland produced a report in December 2005 predicting a cumulative over spend of £91m with funding gaps in excess of £183m anticipated for 2006/7 . Boards are now required to produce savings plans to fill these gaps in funding and reduce expenditure.

In Northern Ireland the levels of deficit remain relatively small in comparison to England and tend to be short-term rather than structural, being managed through the manipulation of year-on-year budgets and through occasional financial assistance from the DHSSPS. There is an increasing shift in emphasis towards value for money in reviewing services which is impacting the distribution and organisation of services.

Whilst there are different experiences in each country, there is an overall trend which can be summarised as follows ;
· There are marked increases in funding allocations to each country from 1999-2006
· The rate of increase will probably level out over 2007/8 – 2008/9 but to different degrees as some countries have historically received insufficient allocations
· Each country health department will increasingly expect evidence of efficiency in spending and evidence of improved outcomes in return for increased investment. This is particularly true for England where a series of reforms have placed increasing emphasis on strict financial management and performance reporting.

Key Facts – sources of financial pressure
The following is a brief summary of some of the issues impacting upon NHS Trusts ability to break even. It is not true to say that the reason most Trusts are in deficit is down to poor management. Similarly, whilst it is true that the NHS has enjoyed record rises in funding, it has not all come directly to Trusts and front line services.

1. Many NHS organisations already have historical deficits to repay on top of those caused ‘in year’. For some, this can amount to millions of pounds. This can arise from previous poor management of resources but can also result, for example, from the changes in the way the PCTs pay money to acute trusts under Payment by Results (see glossary of terms), or the way in which funding formulae have changed over time

2. The current average cost of providing each service is a legacy of past decisions by NHS organisations – hence the term legacy costs (see glossary of terms). The actual costs of some services may be well above or well below the average cost per unit of activity for the NHS as a whole. Unless the services are completely redesigned or stopped altogether, this legacy of high costs will impact for the life of the service. In reality it is very difficult to do this . In England as PbR rolls out, these legacy costs will become more apparent and force Trusts to consider the viability of these higher than average cost services.

3. Across the UK, Health ministers have required substantial increases in activity from the NHS as a whole in order to address waiting lists and A&E; waiting times. The additional activity when coupled with pressures on expenditure from other areas of reform has created cost pressures above and beyond the level of additional funding provided. According to the NHS Confederation, in England only 20% of the new money was spent on providing new services and only part has gone to addressing decades of chronic under funding.

4. In terms of any overspends related to staffing costs, the RCN has found that there is no significant correlation between financial deficits and the implementation of AfC. In fact some of the Trusts with the worst deficits have not even implemented AfC yet so we do not believe AfC is a key cause of deficits. There is evidence to suggest however that the substantially larger sums involved in delivering on Consultant contracts and GP contracts were not properly costed and this has had an impact on financial stability.

5. Alongside increases in activity there have also been net increases in staff numbers in certain areas to meet demand – estimated to have cost around £2bn. There has been an increase of approximately 89,000 more clinical staff employed in the NHS since 1999; 67,880 of which are nurses/midwives/health visitors .

6. Drug costs – these continue to rise and are up 5.6% on last year; by 46% since 2000

7. Total costs for IM&T; have increased to £6.2 billion over 10 years . Overspends in meeting the technical challenge of linking up thousands of different organisations from SHA’s to Hospitals to GP surgeries are commonly reported. Implementing NPfIT is estimated to eventually run to £15bn.

8. Payment by Results – this averaging out of costs undertaken in drawing up the NHS tariff has left some Trusts with up to 20% less income than they would normally receive for the same or increased levels activity. There are also some Trusts who have benefited from the same process.

9. To date over £19bn has been invested in PFI schemes to provide new buildings in partnership with private companies. However there is ample documented evidence to suggest that on-going capital repayments under PFI are affecting service development and investment.

10. The effects of the global economic slowdown on the UK economy have produced a £20bn gap in public finances. This has forced the UK Treasury to borrow more resulting in criticism from the European Union and the International Monetary Fund (IMF) which has impacted upon Govt spending decisions.

RCN General Policy Position
The actual level of deficit when compared to the total NHS budget appears to be quite small but this is only half the picture. Locally, the impact of even a small percentage change in deficits can be disproportionate, particularly when considered alongside other costs pressures where organisations are already operating on very small margins.

The RCN has been carefully tracking the deficits picture across the UK through reports from activists and Regional staff; reviewing Trust, SHA, and Board governance papers; and monitoring national and local media. We have noticed a general trend in how NHS organisations are progressively responding to financial instability as follows

· In the first instance, many organisations have instigated blanket bans on the usage of temporary staff – this places immense pressure on existing clinical staff to increase activity without a corresponding increase in resources.

· This is often followed by vacancy freezes (with vacancies being eventually removed from establishment to provide financial break even picture). This coupled with freezes on temporary staff usage, and reductions in the funding of professional development and education, can damage staff morale and recruitment and retention.

· Latterly we have seen limitations on service provision (particularly specialist services such as health visiting). For example, changing opening hours and reducing the scope of the service.

· This can be followed by more permanent mergers of departments and directorates coupled with reductions in management and support services. In some cases, NHS organisations have decided to ‘disinvest’ or close a service completely.

· At the start of this year, we have received numerous reports of many NHS organisations are actively considering redundancies in response to their worsening financial situation.

· At the end of this financial year 2005/06, our activists and staff have reported back on a large number of NHS organisations predicted deficits for the end of year 2005/06 based on projected expenditure. Whilst a proportion of the deficit may be recovered, the extent of this recovery will depend on radical recovery plans which we believe will impact upon patient services and our members’ employment.

http://www.rcn.org.uk/news/campaigns/deficits/

He was speaking ahead of the launch of A New Ambition for Old Age, the follow-up to the 2001 national service framework for older people.

Professor Philp said that while the NSF had helped improve the productivity of older people’s services – such as reducing delayed discharges – it had not done the same for patient experience, hence the new report’s focus on dignity.

‘For many chief executives running acute hospital trusts, the four-hour trolley wait is seen as totemic of the levels of quality at their trust,’ he said.

‘If we regard dignity breaches in the same way, we would see chief executives being treated the same as if they failed on their A&E; targets. So if a trust was consistently failing on dignity breaches we would expect senior management to take the rap for this.’

Care services minister Liam Byrne called on the Healthcare Commission and social care watchdogs to ‘put older people’s dignity at the centre of their investigations’.

The commission said effective arrangements to ensure that patients are treated with dignity and respect were the ‘basic standards of care’ that trusts should meet. The commission’s annual health check includes a core standard – C13 – on treating patients with dignity and respect, which the commission said would now be re-examined.

Head of strategy Jamie Rentoul added: ‘We will seek to focus increasingly on dignity in care for all people as we develop our annual health check and through our other work.’

Professor Philp said inspectorates could measure trusts’ performance on dignity by how far they tried to engage patients on the issue: ‘This is not just about inspectorates coming down hard on trusts, it is about trusts having improvement systems in place.

‘If the inspectorate is satisfied that there is a system to encourage public and patient involvement, they will not have to intervene.’

He said the commission could intervene after receiving complaints about dignity breaches. ‘The system is not intended to be punitive but supportive: the commission could offer trusts help on improving their complaints systems. But, if necessary, it will be punitive,’ he warned.

Professor Philp said work to ensure that future tariffs for payment by results reward outcomes not processes could see organisations punished for breaching patient dignity and rewarded for creating a positive patient experience.

‘It is not impossible to imagine a time when lower levels of dignity breaches or higher positive patient experience responses could be rewarded with a financial incentive,’ he predicted.

Age Concern director general Gordon Lishman welcomed the report.

‘We want its recommendations implemented as soon as possible and a commitment by the government that money to deliver services is available,’ he said.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=4677362

But with many dentists unhappy with the deal offered – they thought they would have been given more time to spend on preventative care – PCTs have been unable to open new practices to replace the ones that have gone private.

In Avon, where nearly a third of practices rejected the contract, patients are ringing help-lines and are told of practices that are accepting NHS patients.

But it is estimated four in five are not accepting new patients so instead they are being directed on to dental access centres, which provide emergency out-of-hours care.

John Boyles, consultant in dental public health to the five PCTs in the area, said: “There is a workforce problem. The dentists just are not there, there are plenty in dental school but they take time to train. It could take five years to resolve.”

A similar system is in place in Hampshire and the Isle of Wight, which was the worst affected area in the country by the introduction of the new contract.

In Coventry, more than 8,000 patients were left without a dentist, leaving the local PCT to try to convince dentists that did sign the contract to take on extra patients.

But Lester Ellman, of the British Dental Association, said: “It is just not sustainable to keep asking dentists to take on more patients. They are going to start saying no. This contract has not improved access to services and I can’t see it happening in the future.”

Last week the government insisted PCTs were coping with the walkout – which affected nearly 1m patients – by recruiting graduates and using dentists from abroad.

The reforms were meant to introduce a simpler system of fees and reward dentists for carrying out more preventative work.

It also handed responsibility to PCTs to commission services where there was insufficient provision.

But the NHS Confederation, which represents health service managers, said PCTs had been handed a “tricky challenge”.

Deputy director of policy Jo Webber said: “It is going to take a while to bed in.”

A Department of Health spokeswoman said it was unfair to judge the reform as it was “early days”.

“We are confident that in the future people will have much more access to services.”

http://news.bbc.co.uk/1/hi/health/4908250.stm

While the opposition is in the foothills of a policy review, ministers are grappling with the toughest challenge in public sector management: how to transform the NHS from a relatively simple but obsolete supply-constrained model to a patient-driven, demand-led one.

Conceptually their vision is right; but the design capability and implementation plan to realise this vision have been missing. The Department of Health began implementing a partially designed system, leaving the rest to be worked up as it went along.

The results are reminiscent of attempts by Mikhail Gorbachev, the former Soviet leader, to reform the Soviet economy. Financial deficits, overspending and tighter rationing are symptoms of underlying systemic failures.

Midway through the five-year im­plementation of payment by results – under which hospitals and other providers are paid for what they do, rather than simply for being there – the ab­sence of proper commercial costing systems means cost data are unreliable and misleading. If financial management is weak in the acute sector such as hospitals it is worse in primary care.

Pushing economic power closer to doctors and patients with practice-based commissioning is a great idea, but one that will end in chaos if data, management skills and incentives are not properly aligned. NHS managers are drowning in policy documents and guidance notes, each pushing a new initiative. Their impact on each other has not been thought through. As the system is loosened, financial pressures and rationing are likely to intensify.

Can internal markets work? The answer is empirical rather than ideological. It depends on the circumstances and on the quality of system design.

Despite all Labour’s extra money, the Conservatives’ internal market reforms, started in the late 1980s and reversed in Labour’s first term, brought average waiting list times down faster and generated NHS output growth almost double that of Labour’s first six years.

Things started going wrong for Labour’s reforms after the departure of Alan Milburn as health secretary in 2003 and one of the prime minister’s health advisers the following year. The key factors driving change within the health department were at the political level, ministers and their personal advisers, and their vision had not been embraced by senior civil servants.

The department, like others in Whitehall, did not have the policy design capability required for system changes of such magnitude. Neither did it have the implementation skills. Without a guiding mind, there was no one person taking responsibility for implementation. The recent departure of the permanent secretary is recognition of the problem but by itself is not the answer.

As well as fresh leadership, the health department needs to remedy a traditional Whitehall failing and have its own system design and implementation capability. People also need to know where reform is heading, so ministers need to keep articulating their vision for the NHS and the improved outcomes it is meant to deliver.

There needs to be greater radicalism in aligning incentives of clinicians and other staff with improving efficiency. The government’s aim of shifting more care out of hospitals requires rationalisation of capacity. Hospital trusts sit on billions of pounds of property. Giving staff a share in the gains would facilitate capacity changes.

Regimes, it is said, are at their most vulnerable when they start to change. The NHS will not collapse of its own accord because it does not generate its own resources. By 2010, with health spending costing more than 10 per cent of gross domestic product, bailing out the NHS would have greater impact on fiscal policy and the economy than when it was 6 per cent of GDP.

But the prime minister was right in one respect. If Britain ends up with one of the most expensive healthcare systems in Europe still delivering care well below European standards, voters’ demand for an alternative model will become overwhelming.

The writer is author of The Reluctant Managers, a report on reforming Whitehall, published recently by KPMG

http://news.ft.com/cms/s/8b03111e-cf41-11da-925d-0000779e2340.html

The threat to specialist services for children was revealed by the Liberal Democrats, who released papers showing children’s trusts have told Labour ministers they will have to cut services because they claim they are facing a £22m shortfall in the new financial year.

The letter was sent by the chairs and chief executives of Great Ormond Street, Alder Hey, Birmingham and Sheffield hospitals. Together the four hospitals form the National Children’s Health Alliance, and they claim the proposed funding will damage the provision of cardiac surgery, neurosurgery and spinal surgery.

The news raises the risk of more criticism for Mr Blair’s reforms, already reeling under countrywide job losses and budget deficits approaching £800m.

In the letter to ministers, the trusts say: “We are extremely concerned that vital specialist paediatric capacity, particularly in surgical specialities, will be lost at regional and national level this year, which will lead to public concern.

“The new opportunities presented by choice and through payment-by-results should be benefiting young people and children, but quite the reverse seems to be the case. Our trusts are increasingly the only place of choice for parents whose children need specialist paediatric care.”

The trusts blame an “inaccurate and highly insensitive tariff”, something they claim they have sought to renegotiate with the Department of Health for 18 months without success.

Steve Webb, the Lib Dem health spokesman, claimed the letter showed the government was pushing its reform programme too fast on too many fronts, and the system could not cope.

The letter will add to fears that as many as 20,000 jobs will have to be cut from the NHS to cover the cost of the deficits.

But Mr Bliar argues that the “old monolithic NHS” will be replaced by a one that is “devolved and decentralised with far greater power in the hands of the patient.

The idea was and is to make reform self-sustaining, so that instead of relying on the necessarily crude and blunt instruments of centralised performance management and targets, there is fundamental structural change with incentives for the system and those that work within it, to respond to changing patient demand”.

It is this transition from one phase to the next that has created the “crunch point”. The reform contains four elements: practice-based commissioning, giving GPs an incentive to prevent unnecessary hospital referrals; payment by results for hospitals designed to allow GPs to know what they will be paying for operations and hospitals to know what they will receive; the patient’s right to choose a provider; and new independent providers of treatment and diagnostics within the NHS.

Andrew Lansley, the shadow health spokesman, claimed Mr Blair’s speech, only a week after a summit on trusts’ financial deficits, was another sign of panic in Downing Street. He said the department was responding to deficits by centralising control and reducing choice.

http://politics.guardian.co.uk/publicservices/story/0,,1755844,00.html

Medical staff looked on in disbelief as they tried to retrieve lost records. “We had only been running the system for a couple of days when it went down,” said one manager. “You would try to get a patient’s records which you knew were there and it just locked you out.”

Although the system was functioning again the next day, some patient files seemed to have disappeared completely. The trust was so alarmed that it sent a report to the National Patient Safety Agency, warning that it had posed a potential risk to patients.

The collapse of the system and further failures led to cancelled operations and a backlog of outpatient appointments. Bob Cullen, 57, a postman who had been referred for treatment by his GP last year, found himself in limbo.

“I was in agony and was on painkillers, as well as taking liquid morphine,” he said. “I was phoning up the Nuffield in so much pain that I hadn’t slept for days and they said ‘We can’t find you on the system’. This was meant to be a hospital with the latest computer systems for patient care and I somehow got lost.”

All new computer systems suffer from “bugs” and the Nuffield’s trust says the problems were merely “glitches”. But to critics of the NHS’s expensive new computer project, Connecting for Health (CfH), the incident was a portent of further trouble.

So concerned are experts that last week 23 senior academics in computer-related science called for a independent review of the project. They fear that the entire scheme is misconceived, overpriced and a waste of billions of pounds.

Last week NHS trusts were facing an estimated deficit of £800m. Staff are being laid off across the country; wards are being closed; patients are being denied potentially life-saving drugs. Yet at the same time the NHS is spending a fortune on a computer system that, critics say, is needlessly expensive.

Even CfH admitted this weekend that the cost of the scheme, now not due to be completed until 2010, could reach £15 billion. Outside experts suggest that £30 billion is more realistic.

It is the largest civilian computer project in the world, designed to transform the NHS into a beacon of electronic wizardry. But could it instead become the mother of all IT disasters while the country’s hospitals remain desperate for cash?

FOR more than 20 years it has been clear that the NHS needed to modernise its information systems to improve patient care and cut delays. The question has always been: how? The initial suggestion under Labour was pragmatic. After a series of reports between 1998 and 2002, advisers recommended an “off-the-shelf” solution which would upgrade and link existing NHS computer systems and buy readily available software.

However, on February 18, 2002 Tony Bliar, a self- confessed computer illiterate, chaired a meeting at Downing Street on the NHS and information technology. Alan Milburn, then health secretary, and his officials outlined a bold new plan to link up GPs, hospitals and patients on a much grander scale.

It envisaged a new NHS computer system designed from the top down to hold the records of 50m patients on one huge database. The prime minister was impressed. One of the main advantages, he was told, was the instant access that the scheme offered to patients’ records. A complete medical history could be pulled up on a screen at the touch of a button — from anywhere in the country.

Patients would be able to book appointments with GPs on their home computer and once in the surgery would choose their preferred hospital for an operation.

Hospital staff would have instant access to electronic records of any accident victim and x-rays would be electronically transferred from one end of the country to the other.

The scheme’s ambition and potential cost were staggering. Yet Bliar gave it the go-ahead without public consultation. The government initially allocated £2.3 billion for the project and boldly proclaimed that electronic records for every patient in the country would be online by the end of last year. The costs and the delays have been mounting ever since.

It is an example, say critics, of how the management consultants contracted to deliver such systems are only too happy to think big since it makes more lucrative work for themselves.

The man tasked with running the CfH project is Richard Granger, a Bristol University graduate and management consultant. A driven, abrasive character, he bought a Porsche as soon as he started earning “serious money”, lives in a large country house in Cumbria and was appointed on a salary of £250,000, making him one of the country’s highest-paid civil servants.

Few dispute the need to make improvements — but critics say that a centralised system will require vast computing power, raises questions of security and will be a nightmare if it goes wrong.

“In the system they are building, errors can get spread and copied across the network and nobody can do anything about it,” said Ross Anderson, professor of security engineering at Cambridge University and one of the 23 academics calling for an independent review of the project. “What they are proposing is a recipe for chaos and disaster.”

Helen Wilkinson-Makey, a 40-year-old manager from High Wycombe, Buckinghamshire, says that her experiences highlight the pitfalls. She discovered that an inputting error had led to her being wrongly logged as having received treatment at an alcohol dependency unit in 1998. The computerised record had been distributed to her strategic health authority, primary care trust and a local “shared care agency”.

http://www.timesonline.co.uk/article/0,,2087-2136718.html

13 April- 800 NHS jobs axed
Sandwell and West Birmingham Hospitals NHS Trust is to shed up to 800 jobs at its three Birmingham and Black Country sites, it said at a budget meeting. Sandwell and West Birmingham Hospitals NHS Trust has an annual budget of £308m, more than 7,000 staff and serves a population of 500,000.

Its budget will fall to £303m in the next financial year and a £3m debt has to be repaid. It said expenditure on staff rose from £180m in 2003/4 to £217m last year.

11 April- 500 NHS jobs axed
The West Hertfordshire Hospitals NHS Trust said up to 500 jobs would have to go in the next 12 to 18 months to help tackle debts of £28.6m.

The trust said it would cut back on temporary staff – reducing the number of permanent staff affected.

7 April- 200 NHS jobs axed
York Hospital is to cut 200 jobs in a move to save £2.5m. The savings from jobs are part of a wider £7m cost-cutting package.

6 April- 720 NHS jobs axed
The Worcestershire Acute Hospitals NHS Trust announces 720 losses. It needs to save £30m.

5 April- 300 NHS jobs axed
The Royal United Hospital NHS Trust in Bath announces that 300 jobs are to go.

4 April- 400 NHS jobs axed
Surrey and Sussex Healthcare NHS Trust, which manages Crawley Hospital and East Surrey Hospital, announces 400 jobs cuts as it tries to reduce a £2m a month overspend and a total debt of £41.2m.

3 April- 160 NHS jobs axed
Up to 160 jobs to go at the Medway Maritime Hospital in Gillingham, Kent, the trust confirms. It needs to save £11m in 2006-07 and claw back a £1m overspend from last year.

29 March- 575 NHS jobs axed
Brighton and Sussex University Hospitals NHS Trust announces plans to cut 325 posts to save £10m.

The Queen Elizabeth Hospital NHS Trust in Woolwich says up to 100 jobs could go to save £10m.

Mid Staffordshire General Hospitals NHS Trust plans to cut more than 150 jobs, to save £10m next year.

28 March- 100 NHS jobs axed
Gloucestershire Health NHS Community confirms plans to close an 86-bed hospital and says jobs may also go.

27 March
The Norwich and Norfolk University Hospital says it will need to make cuts to address a £22m shortfall.

24 March- 74 NHS jobs axed
North Tees and Hartlepool NHS Trust says 74 jobs including 21 specialist specialist nursing jobs are “at risk”.

23 March- 700 NHS jobs axed
East Kent Hospitals Trust gives warning of possible cuts to claw back a £35m deficit.

County Durham and Darlington Acute Hospitals NHS Trust announces up to 700 job cuts over the next three years.

22 March- 670 NHS jobs axed
Queen Mary’s, Sidcup, south-east London says it will consult over the loss of 190 jobs.

The Royal Free Hospital, north-west London, announces 480 posts and 100 beds cut to save £25m and reduce a £13m deficit.

20 March- 800 NHS jobs axed

Plymouth Hospitals NHS Trust announces around 200 job cuts to make savings of £22m.

About 300 job losses are announced at Shropshire’s two main hospitals, the Princess Royal Hospital and Royal Shrewsbury Hospital.

Health chiefs announce 300 job cuts in Wolverhampton to claw back a £38m deficit.

16 March- 1000 NHS jobs axed
Up to 1,000 jobs to go at the University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, with up to 750 compulsory redundancies.

13 March- 185 NHS jobs axed
Peterborough and Stamford Hospitals NHS Trust will lose 185 jobs and plans to shut an operating theatre to save £2m.

10 March
The United Lincolnshire Hospitals NHS Trust, which has £17.5m debt, says there will be major job losses.

8 March- 300 NHS jobs axed
Royal Cornwall Hospitals Trust, which is facing an £8.1m shortfall, announces it is set to cut 300 staff.

Surrey and Sussex Strategic Health Authority says it is expecting an £83m deficit.

1 March
Selby and York Primary Care Trust announces jobs will have to go as part of a plan to tackle debts of £23.7m.

The number of strategic health authorities in England is to be cut from 28 to 10, which the government argues will lead to improved services for patients, while savings on back office functions would mean better value for money for the taxpayer, it said.

The Downing Street meeting with chief executives of NHS trusts comes as the health service prepares to declare a record overspend and shed thousands of jobs.

Ms Hewitt, the health secretary, told the BBC on Wednesday: “What we are doing this morning is bringing together a number of hospitals which have had financial problems. Some of them have already put in place very successful recovery programmes and have come through, making the care they are giving patients better.

“The great majority of hospitals and other parts of the NHS are not only paying their staff far more, not only hitting all their targets and treating more patients than ever before, (but) they’re doing it within these very substantially increased budgets we’ve given them. That’s what we expect every part of the NHS to do.”

Separately on Wednesday, a report from the Reform think tank blamed the current difficulties on the expansion of services and argued the government should concentrate on building a smaller and more efficient health service.

Andrew Haldenby, the director of Reform, said: “A bigger NHS workforce is one of the major reasons for the service’s financial difficulties. A smaller number of more effective staff will help the service return to financial reality as well as improving care for patients.”

The number of jobs and posts lost in the NHS in England has already cleared 6,000 this year, with more to come. West Hertfordshire Hospitals NHS Trust said on Wednesday it would cut 500 jobs in the next 18 months while last week York Hospital said 200 vacancies would not be filled as it tries to save £7m in the coming financial year.

The move follows warnings from several key health service figures.

The former head of the Department of Health’s strategy unit warned last week that the NHS was entering a period of “creative destruction” with hospitals needing to close and services to be reconfigured while Professor Aidan Halligan, former deputy chief medical officer, said any suggestion of real reform in the NHS has been “a deceit”.

The government on Wednesday also announced the biggest hospital PFI project outside London with a £1bn redevelopment of NHS hospitals in Birmingham and St Helens.

http://news.ft.com/cms/s/2936095a-ca00-11da-852f-0000779e2340.html

Swindon PCT had argued that it would only fund the drug for patients in “exceptional circumstances”, and that the drug was not licensed for the treatment of early-stage breast cancer, which is the kind Ms Rogers has.

But the Court of Appeal judges ruled that the PCT’s policy was “irrational and unlawful”.

They ruled that the focus should be what a doctor felt was right for their patient.

They ruled that: “In the case of personal characteristics, there is no rational basis for preferring one patient to another”.

Ms Rogers, said she was “extremely delighted and relieved” at the Appeal Court’s “humanitarian” judgement.

From now on treatment should depend on clinical need and not on where you live

“I couldn’t have asked for a better verdict. I did this for all women battling this dreadful disease. I believe everyone prescribed this treatment by their doctor should be given the same health care wherever they live. I can now look forward to the future and have more confidence that I will win this battle against breast cancer.”

Yogi Amin, of solicitors, Irwin Mitchell, who represented Ms Rogers, said “This truly landmark judgement makes clear to PCTs that they cannot overlook the clinical needs of the patient.

“People need to be confident that they will receive the drugs their doctor prescribes for them and it is therefore good news for doctors and patients alike.”

He said ministers now needed to set out clear guidance on how drugs should be funded by PCTs.

In a statement, Swindon PCT said: “Although the judgement said generally our policy on funding is lawful, we accept that when considering this case and exceptional circumstances we should have taken costs into account to make our decision more rational.”

It said it would consider its policy, taking into consideration the points made by the court.

Herceptin targets the HER-2 protein, which can fuel the growth of breast tumours. Around a fifth of breast cancers are HER-2 positive. A year’s treatment with the drug costs an estimated £20,000.

The treatment is currently licensed for the treatment of advanced breast cancer but not for early-stage breast cancer, which research has suggested it could also help.

Makers Roche submitted their licence application for early-stage breast cancer to European drug authorities in February.

Once that is granted, NHS drugs watchdog the National Institute for Health and Clinical Excellence (NICE) promised to fast-track its appraisal if Herceptin is cost-effective

That process is set to be completed later this year.

Jeremy Hughes, Chief Executive of Breakthrough Breast Cancer said: “From now on treatment should depend on clinical need and not on where you live, how much money you have, or how “exceptional” you are.

“Today’s decision is a real victory for the 1,000 women whose lives could be saved by this drug each year.”

A Department of Health spokeswoman said the judgement provided clarification to PCTs.

“As is the case with other unlicensed drugs, clinicians can take the decision to prescribe Herceptin to patients with HER2 positive early breast cancer.

She said PCTs should not rule out treatments on principle, but consider individual circumstances when reaching decisions and should not refuse to fund Herceptin solely on the grounds of cost of the drug. This position remains unchanged.

http://news.bbc.co.uk/1/hi/health/4902150.stm

The letter is unprecedented. Suppliers say they have been warned off speaking about the NPfIT, and IT directors in the NHS fear being victimised if they openly express critical views. Academics, who are independent of the NHS, can express their concerns without fear of repercussions.

The letter said, “Concrete, objective information about NPfIT’s progress is not available to external observers. Reliable sources within NPfIT have raised concerns about the technology itself.

“The National Audit Office report about NPfIT is delayed until this summer, at the earliest; the report is not expected to address major technical issues. As computer scientists, engineers and informaticians, we question the wisdom of continuing NPfIT without an independent assessment of its basic technical viability.”

The open letter was sent to the Health Committee by Martyn Thomas, visiting professor of software engineering at Oxford University and expert witness in legal cases involving complex software engineering issues. He has served on the advisory group for the government’s Foresight programme on intelligent infrastructure systems.

The letter is endorsed by senior figures in the IT community. Alan Stevens, chairman of the medicine and health panel for the Worshipful Company of Information Technologists, supports the proposed review.

He said, “It seems to me that the government should welcome a thorough independent technical review of the NPfIT to help allay the tide of concern being expressed by doctors and other front-line healthcare professionals that their work lives and, indeed, patient care may not be enhanced by the new systems.”

Tom Brooks, a long-standing member of the Parliamentary IT Committee, who for several years helped members of parliament with their scrutiny of NHS IT development, said a thorough fundamental independent review of the NPfIT was now overdue.

He said, “A number of informed parliamentarians and many senior managers in NHS trusts have lost confidence in the implementation plans and programme and in its management.”

Brooks said that he would write to members of the Health Select Committee to express support for the open letter and an independent assessment of the NPfIT’s basic technical viability.

He will also urge the Select Committee to “obtain and examine a complete financial plan for implementing NPfIT to 2013, including full trust costs” and explore whether the costly “top- down approach is the right priority at this point in time”.

There is widespread support for the objectives of the NPfIT, especially its aim to allow the sharing of electronic medical records on 50 million patients in England. But four years after it was launched, the programme has a record of delays in the delivery of fully integrated systems that are central to the programme’s original objectives.

Ministers had announced that a “full national health record service” would be “implemented, and accessible nationally for out of hours reference” by the end of 2005. But the widespread exchange of patient files is not expected to happen in the near future.

Connecting for Health, which is managing the NPfIT, says there have been thousands of deployments. But the agency’s critics say the national plan has largely turned into interim systems and local initiatives that are reminiscent of some schemes underway before the NPfIT was conceived. Meanwhile, suppliers working to deliver fully integrated systems are facing problems.

Two weeks ago Accenture, the main supplier to two of the five NHS “clusters” in England, announced a predicted write-off of £260m on the contract. The share price of its main subcontractor iSoft, which supplies three of the clusters, has more than halved since it warned at the end of January that its profits on the NPfIT would be lower than forecast.

Another major supplier, BT, has been fined more than once for poor performance. A fourth, CSC, has announced significant job losses and put itself up for sale.

In their letter the academics urge the commissioning of the review “with all possible speed”.

Connecting for Health declined to comment.

http://www.computerweekly.com/Articles/2006/04/07/215309/TopUKITexpertscallforauditofNHSprogramme.htm

Research by the Liberal Democrats suggests that just over 6,000 job cuts have been announced by hospitals that together have a combined deficit of £130 million.

However, this represents only a quarter of the £550 million budget deficit that ministers have predicted in the NHS this year.

If similar levels of job losses are announced by the hospitals that account for the rest of this deficit, the total number of posts to go could climb as high as 24,000. While the Government insists that this year’s budget deficit will be between £550 million and £600 million, critics have warned that the figure could be much higher.

The Conservatives have predicted a figure of £800 million, while the union-funded Health Emergency campaign group has said it could top £1 billion.

Steve Webb, the Liberal Democrat health spokesman, said ministers could not carry on ignoring the crisis.

“The Government is refusing to come clean about the crisis that is afflicting the NHS,” he said. “Every day brings further news of more job cuts which will undoubtedly affect front-line patient care.

“Staff morale and public confidence in the NHS will continue to crumble until ministers take action to reverse this trend.”

But the Department of Health moved swiftly last night to reject the Lib Dem analysis.

A spokesman said: “We would completely dispute these figures, which sound very much like a back-of-the-envelope calculation.” But ministers cannot disguise the growing unease on their own back benches over the damage the job losses are causing Labour on the doorstep.

Many in the party fear that the almost daily announcements of cuts will bring a backlash from voters in next month’s local elections.

Charlotte Atkins, the Labour MP for Staffordshire Moorlands and a member of the Commons health select committee, urged ministers to find extra money to help hospitals ease the pain of job losses.

Her local hospital is the University Hospital of North Staffordshire in Stoke-on-Trent, which recently announced it would be shedding 1,000 jobs.

Miss Hewitt visited the hospital last week, making it one of only a dozen or so hospitals that the Health Secretary has managed to visit over the last year.

Miss Atkins said managers at the hospital were trying to soften the blow of job losses by helping staff affected to move into new jobs in local community health clinics.

But she said the trust needed extra funding from Whitehall to make such a plan work.

“We do not want to lose the expertise of clinical staff and that is why the plan is being put together to ask for some money to keep them in jobs in the community,” she said.

“Hopefully there will be transitional funding to help them make that move. Patricia Hewitt certainly sounded positive when she was here on Tuesday.”

However, there were few signs in Whitehall yesterday that Miss Hewitt was ready to give any ground.

Senior officials insisted that the round of job losses was an inevitable part of the drive to deal with long-standing funding problems within the NHS.

“There’s certainly no prospect of extra money. Spending on the Health Service is already set to rise to £92 billion by 2008, which is nearly three times more than Labour inherited in 1997,” said one source.

“Even if the Liberal figures are right, it is still 20,000 jobs out of a workforce of nearly 1.3 million.”

The latest predictions on job losses came as it emerged that the Health Service was spending millions of pounds leasing luxury cars for senior managers. About 35,000 senior NHS executives and consultants are getting subsidies of up to £6,600 a year to lease cars that they can later buy at a discount. The total bill for NHS staff is approaching £90 million.

A Department of Health spokesman said last night: “Out of the million or so staff in the NHS, a minority of posts are given a fixed entitlement for leasing cars.

“If they want to hire a more expensive car, they repay the additional costs back to their trust.”

http://www.telegraph.co.uk/news/main.jhtml;jsessionid=5502KTZ4FNVFBQFIQMGSFGGAVCBQWIV0?xml=/news/2006/04/10/nhs10.xml&sSheet;=/portal/2006/04/10/ixportaltop.html

There is an abundance of research in Britain, Canada and the US showing the importance of folic acid in preventing babies being born with spina bifida and brain defects and the medical profession has known for some time that women who take the vitamin at the start of their pregnancy can avoid the defect which affects between 700 and 900 pregnancies in Britain every year.

It seems however that large numbers of women are not following the advice to take folic acid in order to reduce the chance of their babies being born with neural tube defects including spina bifida.

Now experts believe that folic acid may also prevent strokes, bone disorders and heart disease in the whole population.

The recommendation was first suggested ten years ago but was rejected in 2003 by the food watchdog by one vote, due to concern that the fortification of food would mask cases of vitamin B12 deficiency among the elderly.

Since such concerns have proved largely unfounded the Food Standards Agency now recommends in principle the fortification of all brown and white flour with folic acid.

The move will be the first time since the Second World War that manufacturers have been ordered to add nutrients to food on the ground of public health.

The decision will cause controversy because regardless of scientific evidence, there is no guarantee that the addition of folic acid is without any negative side-effects and many will contest the Government’s right to impose mass medication on the population.

Objectors are already saying free choice should be allowed, and if the evidence is so convincing on the value of folic acid, an information and education campaign to persuade women to take it is more appropriate.

Proponents argue that no information campaign reaches everyone and as much as 20 per cent of the population will disregard such campaigns as they do their own health and that of their unborn children.

They say the issue is a classic public health one and cite facts such as the eradication of many killer infections because of public health policies.

Countries that have started compulsorily adding folic acid to flour have seen a 30-50 per cent drop in numbers.

http://www.news-medical.net/?id=17125

The documents reveal that health trusts across London have drawn up plans to establish panels that will “monitor” how many patients are referred to hospital by GPs. Local health trusts have been told that they must cut GP referral rates to those of the lowest 10 per cent nationally. This, the document claims, would save £25 million a year in the capital.

Consultant-to-consultant referrals are also being limited, in many cases denying patients a second opinion.

Patients who use hospital accident and emergency units to obtain care that could be provided by GPs are also targeted. Emergency care practitioners in A&E; departments will “redirect” 40-70 per cent of patients back to GPs or walk-in centres. Hospitals that treat people who ought to have been sent to their GPs will not be paid.

It is not known how many similar schemes are in existence, but the British Medical Association has confirmed it has found examples in Kent, Oxfordshire, Dorset, Wiltshire, Surrey, Sussex, Cornwall, Shropshire, Suffolk, Lancashire and Yorkshire, as well as London.

The draft paper, headed Pan London Demand Management Arrangements 06-07, says that Hammersmith and Fulham has found that a fifth of consultant-to-consultant referrals are “clinically not necessary”.

Matching that across London would save another £7 million, the paper says. But the bureacracy needed to screen all the referrals will itself cost £1.6 million. The London paper says that primary care trusts (PCTs) which cannot demonstrate that their referrals match the lowest 10 per cent nationally will be required to help to set up “review panels” in dermatology, ear, nose and throat, gynaecology, ophthalmology, rheumatology, trauma and orthopaedics.

These panels will review referrals by GPs, and cut them back. What this means is that patients will be denied appointments that their GPs believe they need. The language of the document makes no pretence that this will improve care, and emphasises cost savings throughout. “It is imperative that London balances its books overall,” the first paragraph says.

It also indicates that the measures proposed are “the bare minimum that we expect all PCTs to be doing”.

Urgent consultant-to-consultant referrals will be audited. “All urgent clinical referrals found to be clinically inappropriate will not be paid for by the PCT,” the document says.

The BMA yesterday condemned such schemes. Hamish Meldrum, the chairman of the association’s GP committee, said that they left patients in limbo, with no one clear where the responsibility lay if the condition worsened or the patient died.

Jonathan Fielden, deputy chairman of the BMA consultants committee, said: “It’s clear that clinicians don’t know how these referral management systems aid improvements in clinical care. To them they are purely cost-saving.

“The way they work is not transparent or clear. If clinicians don’t know, patients cannot know either. That certainly flies in the face of the Government’s Patient Choice agenda.”

Hospitals will also be penalised for the common practice of admitting people who have waited almost four hours in accident and emergency departments without being dealt with — thus avoiding the four-hour A&E; target being breached.

http://www.timesonline.co.uk/article/0,,2-2122800,00.html

The council was taken over by “save our hospital” candidates and a Labour minister lost his seat after the local hospital closed its accident and emergency department but kept diagnostic and treatment services.

The change in the hospital’s services was described by Prof Ham as “relatively small”. However, he said, if the health service was to improve and get back into financial balance ministers needed to take “some brave but very unpopular decisions” over where and how care is provided.

“If they don’t, where do they think they will find the money to keep services going as presently constructed?” he said.

In north-west London alone perhaps two large hospitals needed to close for services to be provided effectively, he said.

His warning came at a British Medical Association conference on NHS reform where James Johnson, the BMA’s chairman of council, said the government, managers and clinicians had “probably [only] two years to get the NHS right” and ensure that it remained a tax-funded, free at point of use service. After that the big spending increases would cease, he said.

Doctors, he acknowledged, were sharply divided over the merits of the government’s reforms. Some would fight them. But he, alongside Dr Hamish Meldrum, chairman of the BMA’s GPs committee and Dr Jonathan Fielden, deputy chairmanof the consultants’ committee, all acknowledged that the way hospital services were provided needed to change.

Prof Ham said the government’s introduction of a supplier market, driven by new private providers, money following the patient, patient choice and more competition, was leading to “creative destruction” which would help enforce some of the changes.

But he and the senior BMA figures all judged that commissioning of services – primary care trusts and GPs deciding which services are bought where – remained the “Achilles heel” of the reforms.

http://news.ft.com/cms/s/c77e796a-c43f-11da-bc52-0000779e2340.html

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

Last week, a patient who was refused the drug Herceptin for her breast cancer launched a High Court challenge to the decision. But The Independent on Sunday has established that an “exciting” new range of drugs which work in a similar way is also being denied to patients.

Doctors are furious that drugs such as Avastin, which is used to treat colon cancer, and Cetuximab, a treatment for head and neck cancers, are being blocked by the National Institute for Clinical Excellence (Nice), a government-appointed quango set up to decide which drugs should be routinely prescribed on the NHS.

But backlogs mean that Nice is taking up to two years to make its decisions. That means drugs such as Avastin, which have been officially licensed and approved for use, are currently denied to NHS patients although well-off people can obtain them privately. In some cases, patients are being told they face a three-year wait if they want to obtain these life-saving treatments free.

Cancer charities, MPs and leading specialists are warning that this is creating a two-tier system where only those with money, and the well-informed, can afford the drugs, which cost many thousands of pounds. They also condemn the postcode lottery over prescribing of cancer drugs, which means that some people are turned down for treatment but others are successful in proving that their case is “exceptional”, depending on what part of the country they live in.

Senior Labour and Liberal Democrat MPs last night called jointly for a radical overhaul of how trusts provide treatment, with the public having a say in the decision on how cash is to be allocated.

A prominent committee of MPs is also demanding that the Government ring-fence money for cancer treatment and that specialist networks, not NHS trusts, should be set up to decide where the cash is spent.

The All Party Group on Cancer, which last week published a damning report revealing the huge inequalities in provision of cancer drugs, wants decisions to be fast-tracked by Nice.

“It’s now becoming a case of life or death for cancer patients,” said Ian Gibson, the group’s chair. “People are not getting the drugs they need and it’s not acceptable to have one region where people survive and others who do not.”

Nice acknowledged there was a backlog but said there was no reason for trusts to withhold treatment using drugs that had not yet been approved. A spokes-woman also said that Nice had speeded up the system so that cancer drugs would by approved by the panel “within weeks” of being licensed.

“It’s not acceptable for trusts to use Nice as an excuse not to prescribe,” she added. “It’s true that there is a backlog, but we believe our process is thorough. Our new process will ensure that newly licensed drugs are approved within a matter of weeks.”

Professor Steve Webb, the Liberal Democrat spokesman on health, said that the prescribing lottery was “unacceptable” and called for patients to be consulted over how NHS trusts spend their surplus cash. “These arbitrary variations based on postcodes are unacceptable,” said the MP for Northavon.

“Each year the PCTs (Primary Care Trusts) should consult the public about how they want the money to be used. Local people should have more say.”

Leading cancer specialists also point out that Britain is lagging behind much of Europe in the availability of the newest generations of cancer drugs. They are calling for the gap between the licensing of drugs and Nice approval to be closed as a matter of urgency.

One of Britain’s leading oncologists, Professor Jonathan Waxman of Hammersmith Hospital in London, said that trusts were also guilty of “outrageous arrogance” in how they decided who received life-saving treatment and who was turned down, especially as they are dealing with people for whom even a day’s delay is a blow to their chances of survival.

“Why should cancer in Tottenham be different from cancer in Totnes? There should be a fair, central process,” said Professor Waxman, who has written to Patricia Hewitt, the Secretary of State for Health, outlining his concerns over how NHS trusts operate.

“It’s outrageous arrogance that trusts say it’s not appropriate to provide drugs to certain people.”

The charity Cancerbacup, which provides advice for patients, backed demands for specialist cancer networks to replace the current system where hundreds of funders try to manage small pots of money.

“Access to new cancer treatments depends on where you live or failing that how much money you have,” said Joanne Rule, the charity’s chief executive.

“Consultants tell us that they are treating their private patients with drugs they can’t use in the NHS. The process for making new treatments available on the NHS needs to be speeded up.”

THE DRUGS
AVASTIN (BEVACIZUMAB)
Effective treatment for colon cancer that can shrink tumours by 40 per cent. Yet to be approved for general NHS use. Cost for 24 treatments: £20,000

HERCEPTIN (TRASTUZUMAB)
Breast cancer drug that uses natural immune system to kill cancer cells. Costs £20,000 a year. Currently denied by NHS to women in early stages.

CETUXIMAB (ERBITUX)
Stops cancer cells growing and increases effectiveness of chemotherapy. Available on NHS only in exceptional circumstances. Twelve doses: £7,000

http://news.independent.co.uk/uk/health_medical/article355173.ece

Senior doctors yesterday rounded on Mr Brown, condemning as “petty and vindictive” his decision to award them a one per cent pay rise in order to demonstrate that the Government was keeping down public sector pay settlements.

Alone among other doctors, dentists and nurses, the consultants’ pay rise is being staged with one per cent paid from April and another 1.2 per cent in November.

According to the YouGov poll, 64 per cent of those questioned believe that there is a financial crisis throughout the NHS, with hospitals having to cut back on patient care. The NHS in England is expected to be in the red by £1 billion this year.

Voters also think Mr Brown has got his priorities wrong. Asked which should receive any extra money, education or the NHS, a large majority favoured the health service over schools.

In his Budget last week, Mr Brown – apparently embarrassed by the cuts being ordered by hospital trusts – made no mention of the NHS, even though it has received record increases in spending since Labour came to power.

Instead, he outlined his long-term ambition to raise spending on education so that state school pupils had the same level of spending as those in private schools.

Dr Paul Miller, the chairman of the British Medical Association’s consultants’ committee said he could not believe that the Government had been “so mean-minded”.

James Johnson, the association’s chairman, said that by singling out consultants, the Government had lost far more in goodwill than it has gained in salary costs.

Even Patricia Hewitt, the Health Secretary, acknowledged yesterday that the saving would be “modest”. She announced at the same time a 2.2 per cent increase for junior doctors, 2.5 per cent for nurses, 2.4 per cent for salaried dentists and three per cent for high street dentists.

Dentists, who received the largest pay rise but who are fighting the Government over a new NHS contract, were also critical. The award was derisory and would fail to restore the confidence of dentists in working for the NHS, the British Dental Association said.

The awards will give a hospital consultant £69,991 from April and £70,823 from November; a newly qualified nurse £19,166 and a junior doctor, £30,433.

As the awards were announced, a hospital in Woolwich, south-east London, with debts of £100 million became the latest to reveal job cuts yesterday. The Queen Elizabeth Hospital, which was built using money from the Government’s Private Finance Initiative, said it would lose 100 posts in a plan to “deliver serves more efficiently”.

Senior managers at the hospital said before Christmas that it was technically insolvent and that the PFI debt added about £9 million a year to its running costs.

Commenting on the crisis in the health service, which has seen almost 5,000 jobs cut this month, Fiona Godlee, the editor of the British Medical Journal, said the NHS was too important to be left in the hands of politicians.

In today’s issue she said that for the first time in anyone’s memory, sizeable numbers of NHS staff were losing their jobs.

“If the NHS is to stop being a political football kicked from one party’s version of an internal market to another’s, it needs to be protected from party politics,” she said.

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/03/31/nhs31.xml

It said PCT chief executives forecast that 6% of dentists will stop providing free NHS treatment for adults over the next 12 months and 5% will withdraw NHS treatment for children.

Nearly 20,000 dentists were paid for NHS work last year, according to official figures from the Dental Practice Board. But the board’s total included many dentists who also did private work and there was no reliable estimate of the number of patients who could be affected.

The confederation, representing NHS managers and trusts, said the position could change if dentists realised the benefits of the new contract, which is intended to provide better rewards for preventive work and less for “drill and fill”.

The survey of 124 chief executives found there is already a shortage of NHS dentists in many parts of England.

NHS dentistry lists in 15% of PCT areas were closed for adults, making it impossible for newcomers to the area to register. For children, lists were closed in 10% of trusts.

Dame Gill Morgan, the confederation’s chief executive, said media reports of the end of NHS dentistry were wrong. PCT chiefs were engaging alternative providers to maintain services in areas where not enough dentists were signing the new contract.

“However, the introduction of the new contract has caused uncertainty and the confederation is calling for better communication about the benefits for dentists and patients.”

The government may have to review the contract next year.

Peter Ward, chief executive of the British Dental Association, said many dentists were signing the new contract while continuing to dispute the terms.

“The profession recognised the need for change from the old system which, in the words of the Audit Commission, put dentists on the treadmill. But the new contract is target-driven and untested, and the fear is that it won’t give time for more preventive care.”

The health minister, Rosie Winterton, said: “All the current indications are that most of the dentists leaving do relatively little NHS dentistry, and account for only a small fraction of NHS services.”

http://politics.guardian.co.uk/publicservices/story/0,,1744594,00.html