REFORMING THE NHS

HUGH BAYLEY

The achievements of the Labour government in improving the quality and quantity of care provided by the NHS have been considerable. For example:

* no patient waits more than 18 weeks for elective surgery;

* most patients are dealt with within 4 hours of arriving at an NHS A&E facility;

* hospital-acquired infection rates are being continually reduced;

* investments in national service frameworks in cancer, heart disease, renal diseases , diabetes and other areas of care have produced quicker and more effective evidence-based care.

However, these significant improvements in the quality and quantity of healthcare provided to patients have been costly, with a 50 per cent increase in real NHS funding  They also raise questions of how much health gain has been provided for citizens and whether these investments have been the most cost-effective possible.

Furthermore, as demonstrated by a recent report of the Health Select Committe, the government’s record in reducing inequalities in health is disappointing. Despite targeting investments in programmes such as Health Action Zones, the failure to implement these policies consistently and evaluate them systematically means that despite good intentions, inequalities in health remain considerable and resistant to change, particularly from NHS investments.

Tackling avoidable illness  

The main determinants of health are not the NHS and other forms of healthcare, but the behaviour of citizens. Over-use of alcohol, tobacco, fat, and salt and peoples’ failure to take adequate exercise produce organ failure, cancer and heart disease. The 2007 Foresight report, ‘Tackling Obesity’, forecast that by 2010,

28 per cent of women and 33 per cent of men in the UK would be obese. This epidemic is creating avoidable illness and premature death.

There are obvious lessons to be learned from policy elsewhere and research about how to tackle such problems. As part of the planning for the Obama healthcare reforms, the taxation of sugar-sweetened beverages is being considered. Already over two dozen US states tax these drinks and research indicates that this may be an effective way of reducing the consumption of high users such as young people, the poor and those who are already overweight.

As in the public health campaigns to reduce tobacco consumption, taxes on bad foods should be complemented with controls on advertising. A ban on TV advertising of sweets and crisps. particularly when children are viewing, would contribute significantly to improving public health (even if it reduces Gary Lineker’s income!)

Sweets and crisps have already been banned from school canteens. The NHS could and should contribute to this consumption reduction by refusing to sell such products on its premises.

Price interventions 

The Chief Medical Officer, Sir Liam Donaldson, supports Scottish proposals to set a minimum price for alcohol. The Scottish government plans to legislate this autumn to set a minimum price per unit of 40 pence, but to date our government has not announced similar legislation for England. In his annual report, Donaldson advocated a minimum price of 50 pence per unit. Price levels such as these would double the unit price and increase the revenue of producers. Furthermore, there is evidence that heavy drinkers are particularly dependent on alcohol products with low unit costs. Raising the unit price would reduce their use and the damage heavy drinkers inflict on themselves, their families and the community.

Using the price mechanism to alter individuals’ behaviour in this way would offer society health gains. However, these interventions are regressive and will be criticised in ways we are familiar with from the decades-long campaign to reduce tobacco use. Industry would be concerned about its revenues, employment and exports. However, in a time of chronic fiscal problems such policies could be used to garner increased tax revenue while at the same time improving the health of the community.

Improving NHS efficiency 

In 1976, Barbara Castle, then Secretary of State for Health and Social Services, published a consultation document which highlighted the need for a systematic development of day case surgery and reductions in variations in clinical practice (DHSS, Priorities in Health and Personal Social Services, HMSO, 1976).

In 2008, the Health Minister, Ara Darzi, published a report advocating improvement in quality and productivity in the NHS. The themes in this document are very similar to those in Castle’s paper in 1976. Successive governments have been less than vigorous in their pursuit of increased efficiency in the delivery of healthcare.

The government has created some building blocks to pursue efficiency more effectively. Hospital activity data has been collected for 20 years, but only recently has it been analysed and fed back to consultants and managers. Using methods pioneered at the University of York, the Department of Health now publishes comparative activity rates for all English consultants by specialty.

However, activity data alone is insufficient to inform management and make clinical performance more transparent. Two other reforms are gathering pace and are of primary importance for the management of productivity in the difficult years ahead: cost and outcome data.

Patient-level costing systems 

Hospitals are now creating ‘patient-level’ costing systems, which will identify variations in the costs of treating patients. However, the most fundamental reform is measuring patient outcomes, i.e. providing evidence that patients get better.

The 1845 Lunacy Act required all psychiatric units to measure patient outcomes in terms of whether they were dead, recovered, relieved or unrelieved. Furthermore, physicians who failed to collect this essential performance data were fined £2, a considerable sum in those days.

Since April 2009, all NHS hospitals treating patients for hip and knee replacements, hernia repairs and varicose veins use well-validated quality of life measures (such as www.euroqol.org ) before and after surgery to identify improvements – or not –  in the patients’ physical and psychological wellbeing. These patient-reported outcome measurements (PROMs) will be risk-adjusted and published starting in 2010.

These essential elements of a regulation system – patient level costing, activity data and PROMs – have the potential to make the performance of individual clinicians and hospitals much more transparent, and decision makers more accountable for their performance.

Incentives for change 

Data such as this should be used to incentivise change and protect patients. For example, there are certain things that should never occur in hospital: wrong site surgery (e.g. cutting off the wrong limb), wrong drug or wrong dose administered to patients, pressure sores, infections such as MRSA and C.diff, catheter-induced urinary tract infections, items left in patients after surgery and lack of prophylaxis for deep vein thrombosis.

These ‘never’ events should not be paid for. Since the inception of the Commissioning for Quality and Innovation framework (CQUIN) in April 2009, such policies are slowly being implemented at long last.

The privately owned and managed NHS independent treatment centres were created to provide independent comparators of quality and cost of treatment within the NHS. Without activity, cost and outcome data being in the public domain, however, comparison is impossible.  The Department of Health should amend its contracts with these private care providers to require them to collect and publish exactly the same information as NHS hospitals. They are spending public money to treat NHS patients and they, and their clinicians, should be publicly accountable like the rest of the NHS.  When they were created, the independent treatment centres were reimbursed on a more generous tariff than NHS trusts.  In the new climate of tighter NHS budgets, the price advantage which the independents enjoyed to cover their start up costs will be withdrawn as new contracts are issued for this activity in 2010.

The last Conservative government introduced the purchaser/provider split, and it is still there.  PCTs, supported by GP practice-based commissioning, decide what services are needed and pay NHS acute trusts to provide them.  This was supposed to make hospitals more accountable for the quality and cost of their care.  When NHS trusts and clinicians start to publish comprehensive and intelligible activity, cost and outcome data, this will provide simpler ways of holding them to account and incentivising improved performance.  At this stage radical reform of PCTs will be possible and this could go as far as their abolition, as has already taken place in Scotland and Wales. The ‘value added’ of the current purchaser/provider structure is limited, with PCTs generally acting as passive ‘bank clerks’ rather than innovators – the drivers of improvement in efficiency and productivity. In an era of tighter budgets, their abolition would reduce administrative overheads and release additional resources for frontline services.

The way ahead 

‘After seven years of plenty, the NHS now faces seven years of famine’ (Maynard and Street, BMJ, 2006). To deal with increased parsimony in funding, health policy needs to innovate with interventions that prevent illness, such as taxing sugar products, controlling the advertisements which encourage obesity and setting minimum prices for alcohol. These health policy interventions need to be complemented with healthcare policies which exploit the slow but consistent progress in creating a data system that facilitates regulation of clinical practice.

Obviously, identifying variations in cost, activity and outcome is a necessary but not a sufficient way of improving NHS productivity. Decision makers also have to be incentivised to change. Currently PCTs have little leverage on the hospitals and GPs that they fund. The NHS has to be empowered with data and willingness to penalise poor performance in hospitals and primary care, such as ‘never’ events.  It also needs to measure performance in and to manage and reimburse NHS independent treatment centres on the same terms as other NHS providers, and should look at whether sufficient progress has now been made in improving accountability of NHS trusts and clinicians to make administrative savings by abolishing PCTs.

As in the 1970s, times of financial stress offer the opportunity for reform to improve patient care and value for money for taxpayers. Such opportunities have to be pursued with vigour, enthusiasm and rigour if that precious national asset, the NHS, is to survive and continue to be successful through a period of real extreme economic stress.

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