THE NHS: Are the Reforms Working? …

                    THE NHS: Are the Reforms Working?
                             David Green and Nick Seddon


The Prime Minister, Tony Blair, has repeatedly challenged the British public to judge his
Government on the performance of the NHS. In January 2002, for instance, he accepted
that his government may stand or fall on the reform of the NHS: `things are starting to get
better, and they will be dramatically improved. I am so confident of that, let me say this: if
the NHS is not basically fixed by the next election, then I am quite happy to suffer the
consequences. I am quite willing to be held to account by the voters if we fail'.1
     Even Polly Toynbee and David Walker, in a panegyric to the Blair administration that
sets out to show how the government has `immunised itself from the charge' that there is
`nothing to show for the big increases in spending',2 are forced to concede that an improved
service is not the inevitable outcome of greater expenditure. `The government itself said
that by 2004 the NHS had become bloated,' the authors cede, `at least to the extent that
£6.5bn worth of efficiency gains could be squeezed out'. They acknowledge that John Reid
nearly had `an attack of apoplexy' when, in October 2004, the Office for National Statistics
found productivity in the NHS had been falling, despite the huge increases in spending.3
Toynbee and Walker point to improved personal care, expensive new medicines, and
higher wages; but, although they are prepared to accept the diseconomies of restructuring
and the disruption of IT schemes,4 they dismiss outright the accusation that money is
being misspent on management.
     However, according to the NHS Boardroom Pay Report 2005, the pay of NHS chief
executives rose 70 per cent in ten years, while nurses' pay only went up by 50 per cent. The
NHS accounts in the year to March 2004 show that the average salary of chief executives in
England was £107,500, with the fattest cat of them all being the chief executive of
Hammersmith Hospitals who was awarded £212,500 last year. The King's Fund states that
`In comparison to [other] staff groups... pay levels for NHS trust chief executives and other
boardroom staff are significantly higher.' In contrast, the King's Fund draws on research by
the Royal College of Nursing to show that, while pay levels for directors of NHS primary
health care trusts have been escalating, and within just one year (2003/04) their average
salary went up 28 per cent, almost 45 per cent of nurses in London have a second job in
order to increase their income.5 `NHS management has increased significantly since
Labour came to power. Between 1993 and 2003, the number of managers rose by 12,376
(from 21,434 to 33,810), representing an increase of 58%... Managers as a percentage of
total NHS staff rose by 32% (from 2.5% of total NHS staff in 1997 to 3.3% of total NHS
                                                                                               2
staff in   2003).'6   Even if that percentage seems relatively small, it remains significant
enough to fuel concerns about the excessive allocation of funds to bureaucrats.


                                            Productivity
Inasmuch as this corrects the notion that greater spending on healthcare would
automatically improve outcomes, this is important; but there is nevertheless strong
evidence for a direct relationship between inputs and outputs in certain areas, and the
overall impression gained from the OECD's latest publication of health data is that the
quality of the UK's underfunded healthcare compares unfavourably with the other
countries in the study.7
      UK healthcare spending as a proportion of Gross Domestic Product (GDP) has
increased rapidly in recent years. The English NHS spending doubled between 1997 and
2005. The 2004 Spending Review shows spending in 1996/97 in England was £33bn. In
2004/05 it was £69.4bn and in 2005/06 £76.4bn. This year, total spending on the UK
public health sector will be more than £81.1 billion.8 While the 2000 figure was 7.3 per
cent, which was `lower in the United Kingdom than in other comparator countries except
Japan',9 data for 2002 show that spending is now 7.7% of GDP; and with levels increasing
7.5 per cent a year, UK health spending is expected to rise to 9.4 per cent of GDP in
2007/08.10 However, between 1980 and 2001 spending on health as a percentage of GDP
rose less quickly in the UK than elsewhere. In 2002, according to the Wanless report ­ `a
devastating analysis and justification for huge extra spending'11 ­ the UK's accumulated
under-investment was £267 billion.12 Even now, after all the publicity surrounding
government investment in the NHS, the UK remains well short of France (9.7%) and
Germany (10.9%) in particular, and following rapid growth in the late 1980's the United
States is way out ahead.13 As the King's Fund has recently reported, `the UK still lags
behind many other countries in terms of the proportion of the GDP spent on health.'14
      Health expenditure per capita is another measure of the resources devoted to
healthcare. Although certain caveats should be taken into account, including a range of
demographic factors and variations in exchange rate, expenditure per head can be
correlated with health status15, for increased expenditure is associated with improved
health outcomes.16 On this calculation the UK is again significantly below par, with some
86 per cent of the average for the five European countries covered. Only Italy ranks behind
the UK; Germany, Sweden and France all perform better. At the top end of the scale, health
spending in the US reached 14.6 per cent in 2002 ($5267 per capita), almost 140 per cent
above the OECD average ($2144).17
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  The most cogent evidence correlating expenditure and productivity concerns medical
resources, to the extent that increased availability has a beneficial impact on medical
outputs. Zeynep Or has demonstrated that `a 10 per cent increase in doctors, holding all
other factors constant, would result in a reduction in premature mortality of almost four
per cent for women and about three per cent for men.'18 Jeremy Hurst of the OECD and
Gaetan Lafortune accept that `empirical evidence... suggests that higher doctor numbers
are significantly associated with lower mortality, after controlling for other determinants of
health.'19 And in its 2003 report, International Health Comparisons, the NAO cites Or's work
in declaring that the number of doctors per 1,000 of population is the second most
important variable after occupation in terms of explaining variations in premature
mortality.20
     While the statistics need careful interpretation, the UK ranks at the bottom with 1.8
per 1,000 ­ considerably below the mean of 2.521 ­ and even though the number rose
steadily in the period between 1980 and 2000, and total NHS employment in England was
22 percent higher in 2003 compared with 1995,22 the reported provision in other countries
has generally increased at a faster rate.23 It is not merely a question of doctors in general,
but also of specialists, that matters. It has long been accepted, for example, that cancer
care is under-resourced. Professor Karol Sikora, former head of the World Health
Organisation's Cancer Programme, has shown that `Britain has fewer radiotherapists per
head than Poland and fewer medical oncologists than any country in Western Europe.'24
Similarly, `Hungary and the United Kingdom have the lowest number of neurologists, 0.4
per 100,000 population, likely reflecting the lower spending on health care of these two
countries, while Japan and Korea are the countries with the largest numbers of
neurosurgeons per 100,000 population, 4.6 and 2.9 respectively.'25
     As well as having the lowest reported number of doctors per head, the UK has the
second lowest reported number of practising nurses in relation to the population. While
Germany and Sweden have 9.3 and 8.4 nurses per 1,000 of population, the UK has 5.3, and
in Europe only Italy is lower with 4.5. Consequently, although the UK in fact fares
reasonably well on acute admission rates and is above all the other European countries in
terms of its provision of nurses per acute day, it scores poorly overall.26 It would not be
difficult to blame a combination of absolute underfunding and resource misallocation.
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                                   Composite measures
The Office for National Statistics recently reviewed the method of measuring overall NHS
productivity and came up with a more refined measure covering the period from 1995 to
2003. It compares NHS outputs on one measure with NHS inputs on two different
measures. Health outcomes are measured in terms of a variety of indicators and can be
defined as `those changes in health status strictly attributable to the activities of the health
system'.27 Having found that output had increased by 28 per cent and inputs had grown by
32 per cent on one measure and 39 per cent on the other, the ONS concluded that the
average annual change in NHS productivity between 1995 and 2003 was between -1 and
zero per cent.28 When the data were fed through a series of permutations and subjected to
thorough examination, a decrease of anything between 3 per cent and 8 per cent was
observed in NHS productivity from 1997 to 2003.29 These figures raise questions about the
value for money that taxpayers are getting for their investment.
     Academics at the LSE have tried to develop a better measure of overall health system
achievement, their hypothesis being that a measure of health attainment more closely
linked to the healthcare system would produce a systematically different ranking. The
World Health Report of 2000 ranked countries according to `disability adjusted life
expectancy', which deducts a proportion of the expected years of life to allow for the
reduced quality of life resulting from disability.30 Ellen Nolte and Martin McKee compared
the results of the WHO report with a new ranking of health attainment: `mortality
amenable to health care'. The two measures produced substantially different results and
the UK's performance was poor. On the measure that assumed half of the deaths due to
ischaemic heart disease to be the result of poor health care, the UK came 19th out of 19
countries. It had been tenth out of 19 on the WHO measure. When ischaemic heart disease
was excluded, the UK was 18th out of 19.31
     The available data can rarely disentangle the health system effects from other effects,
such as socio-economic or environmental factors and, since healthcare systems are
complex, making judgements about their performance overall is complicated. It is largely
due to the difficulty of making such distinctions that it is necessary to consider single
indicators separately. All the same, as the following analysis of waiting lists, productivity
and hospital acquired infection shows, the individual measures of performance reflect the
assessments and confirm the rigour of the aggregate measures.
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                                        Waiting lists
Due to the fall in overall NHS waiting lists ­ people waiting for admission to hospital ­
from 1,158,000 in 1997 to 857,000 by September 2004, the Department of Health has
deployed waiting lists as key evidence of an improvement in performance. Waiting `had
been the single most complained-about feature of the NHS since the days of Nye Bevan,'
according to the authors of Better or Worse?, `and now it was ending.'32 Elsewhere, they
claim that `[e]xtra money had taken the waiting out of wanting to be treated.'33 But if the
NAO's July 2001 document Inpatient and Outpatient Waiting in the NHS endorses the
opinion that waiting lists are `a key measure of performance', it also introduces a note of
scepticism. For `there has been a considerable debate about the adequacy of waiting lists
and times as a measure, the impact of initiatives to reduce waiting lists and what waiting
list statistics actually indicate.'34
      The NAO was at the time prepared to give the NHS the benefit of the doubt. While
trusts were `not completely consistent in what they include on waiting lists', and while the
NAO could not be assured `of the complete accuracy' of the figures, it did accept the
defence that `attempts to cut waiting lists have to contend with a dynamic situation'.35 The
report then went on to say that the `extra resources that have become available to the NHS
since its foundation have made it possible for more people to enjoy a wider range of
operations', the consequence being that `that very success has led to more people coming
forward for treatment.'36 Later that year, however, the NAO changed its tune dramatically.
In December 2001, it published a report entitled Inappropriate Adjustments to NHS
Waiting Lists which concluded that: `Nine NHS trusts inappropriately adjusted their
waiting lists for some three years or more, affecting nearly 6,000 patient records. For the
patients concerned this constituted a major breach of public trust and was inconsistent
with the proper conduct of public business.'37
      By March 2003, when the Audit Commission produced a report entitled Waiting List
Accuracy, things had hardly improved. The Commission found that while waiting lists for
patients with possible breast cancer were generally well managed, `there was evidence of
deliberate misreporting of waiting list information' at three trusts and in a further 19 trusts
auditors found evidence of reporting errors ­ deriving from inadequate policies,
procedures or operational systems for collecting or recording data; and ineffective, wrongly
set up or poorly integrated IT systems ­ in at least one of six performance indicators.38 The
report concluded that the fraudulent actions were `disturbing'; that `data quality varies
widely'; that `a number of trusts were found to be operating in ways that seem weighted
away from the interests of patients'39; and that where mistakes were not made
                                                                                                 6
intentionally `trusts could and should be doing [more] to reduce the likelihood of
reporting errors'.40
     As recently as March 2004, the King's Fund was announcing that `the true scale of
such inappropriate adjustments across the NHS is unknown',41 which at the very least
implies that any evaluations of the `considerable achievement' of having generally made
waiting times `shorter than at any time in the history of the NHS' should be treated with
caution. Success, the report said, has been `patchy, with Wales and Northern Ireland, for
example, experiencing growing problems with their waiting times.'42 In February 2005, the
King's Fund produced another report, entitled Cutting NHS Waiting Times, which found
that confidence in the current figures might be misplaced. It states that `there has been
some success in reducing very long waiting times but average waiting times have changed
very little.'43 In addition, it argues that NHS waiting time reduction policies have relied on
`the incorrect view that waiting lists represented a backlog that could be removed by
temporary initiatives' when in fact `sustainable reductions must rely on long-term policies
designed to respond to a range of factors.'44 The publication closes with the point that
`important issues concerning the goals of policies on waiting times, demand management
and the development of more appropriate targets focusing on access to care still need to be
addressed.'45
     Nevertheless, in the context of emergency care, Toynbee and Walker are determined
to present waiting time management as almost uniformly triumphant. `Despite a large
increase in numbers seen during the winter (of 2003-04),' they affirm, `waits in accident
and emergency had been cut, 96 per cent of patients seen within four hours. Waiting on
trolleys for admissions was rare ­ always more likely to be the result of some local
concatenation of circumstances than system failure.'46 Such figures, not incorrect, deceive
by the incompleteness of the picture they present. In the week ending March 31 2003, the
Department of Health conducted a pre-announced audit of A&E waiting times in A&E
departments in England, and, in response to concerns voiced by the Health Services
Journal that trusts would marshal `unsustainable resources' in order `to meet the A&E
target',47 the BMA conducted a survey of A&E waiting times.
     The results showed that `in the majority of A&E departments efforts were directed at
meeting the government's target at the expense of clinical quality, staff wellbeing, and
broader objectives such as developing long-term improvements in capacity.'48 Among a
range of specific criticisms, it stated that `low priority patients were being seen at the
expense of the seriously ill and traumatised', with the result that `waiting room patients
[were] very angry that lower priority [were] being seen first'.49 Furthermore, the BMA
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found, `patients were being "rushed through"' so that some `had been moved before being
adequately assessed or stabilised, or sent to the wrong specialty'. There were, too, reports
that `computer records have been altered, so that A&E waiting times have been falsified to
avoid patients going over the 12 hour trolley wait'. Not only were `existing staff, especially
senior doctors and emergency nurse practitioners... exhausted and disillusioned that
funding and resources have not been continued,' but there was also `increased stress and
bullying of senior medical staff.' Clearly, more than a passing connection can be made
between this demoralisation and the observation that `staff can get so preoccupied with
meeting the targets they miss the bigger picture regarding what's best for the patient'.50 In
March 2004, it was still the case that reducing waiting times `raised concerns amongst
some consultants that they have been pressured by NHS managers to treat less urgent
patients in front of more urgent cases in attempts to meet targets.'51 `As NHS managers
joke, reducing waiting times is the "P45 target" ­ fail to achieve them and you can start to
look for another job.'52 Even Professor Sir George Alberti, the emergency services `tsar', has
indicated that emergency care staff should concentrate more on improving care in their
departments rather than just on meeting targets, and admitted that there is still some way
to go to reach his vision for the service.53
     Since information about performance is vital for service improvement, and many
groups, including patients, hospital doctors, GPs, health service managers, politicians and
regulators, and the wider public, depend on the information, it is important that they can
be confident in its accuracy. As the Audit Commission stated in its report Waiting List
Accuracy, `reliable information about performance is the bedrock of service
improvement'54. Yet there is cause for concern if `the true scale of... inappropriate
adjustments across the NHS is unknown',55 not only because of incompetence but also
fiddling of the figures. On 4 December 2004, the BMJ reported that James Johnson,
chairman of the BMA Council, told the House of Commons Public Administration Select
Committee `that the government's claims to be giving patients more choice was in practice
limited to a small area of policy: the reduction of waiting times for inpatients.'56 A
comparative analysis carried out by the OECD supplements the evidence, for it not only
found that the UK's supply of technologies and facilities was unimpressive, with among the
longest waits for both CT scans and MRI, but also that situations of inequitable access were
arising where patients were able to skip public sector queues.57 Mr Johnson said that the
government is using patient choice as a means to drive down costs: it `is clearly being
employed as an economic concept...'58 It would clearly be unwise to rely on politicised
waiting lists for an assessment of the NHS.
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                                        Cancellations
As Chris Grayling, the Conservative health spokesman, has pointed out, there is strong
evidence of a link between Labour's target of a maximum four-hour wait in accident and
emergency departments, and a subsequent increase in cancellations of non-emergency
operations.59 In order to ensure that patients do not wait more than four hours between
arriving and being treated, more are being admitted straight to hospital, which in turn
leads to an increase in cancellations for planned operations because of a shortage of bed
space. In February 2000, the NAO found that bed unavailability was the most common
cause of cancelled operations, with beds occupied by new emergency cases or patients
whose discharge has been delayed.60 `Some 70 per cent of NHS acute trusts' told the NAO
`that the intended bed being occupied by a new emergency admission was the most
common cause of a cancelled elective operation.'61 Although at the time the UK had fewer
beds per 1,000 of population (3.3) than Germany (6.4), Italy (4.5), France (4.2) and
Australia (3.8),62 it is most likely, not that there was an absolute shortage of beds, but that,
as the chairman of the House of Commons public accounts committee said, the findings
were `symptomatic of poor bed management.'63
     As with waiting lists, the sheer unreliability of the data makes it difficult to determine
with any exactitude the degree of the problem. The Audit Commission has found that:
`Many trusts had incorrect or confused policies for how to record DNAs [Did Not Attends]
and cancellations. A typical example would be where, when recording outpatient
appointments cancelled by the trust, the waiting time was reset incorrectly to the
cancellation date rather than being left as the date the referral was received originally'.64
The Department of Health figures indicate that cancellations have been rising steadily
from 50,505 in 1997-98 when the present government started its tenure to 66,303 in
2003-04. In those years there have been 15,798 more cancellations ­ or an increase of 31.2
per cent. Figures to Q3 in 2003-04 (46,238) and 2004-05 (47,010) suggest that the
numbers are still rising, although some fluctuation should be permitted. The Patient's
Charter states that a patient's elective operation should not be cancelled by the hospital on
or after admission, for non-medical reasons, and that where it does occur, the hospital is
required to treat the patient within one month from the date of cancellation. Although the
number not admitted within twenty-eight days of cancellation rose dramatically from 7250
in 1997-98 to 19,087 in 2001-02, there has been a decrease again, down to 6270 in the year
2003-04.65
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     However, beating the 24-hour cut off point means that the hospital is not obliged to
treat the patient within one month of cancellation. The Sunday Times has calculated that
the NHS may be cancelling more than twice as many operations at short notice than the
government has acknowledged. The paper said that the figures disclosed in reports
prepared by individual hospital trusts contradict ministers' claims that 66,000 operations
are cancelled a year, with the figure instead estimated to be at least 132,000.66
Frustratingly, `[t]here are no national data on the number of operations cancelled before
the date of admission', and the proportion of operations cancelled varies across NHS acute
trusts.67 That said, there are some hospitals which do collect this information. For
example, the Royal Shrewsbury Hospitals NHS Trust cancels around five operations before
the day of admission for every one operation it cancels on the day.68 Early cancellations
were widespread in other trusts. According to a study published last year by the health
scrutiny panel of Worcestershire county council, only 856 of the 1,791 operation cancelled
in 2003 were called off within 24 hours of the appointment. Jonathan Fielden, vice-
chairman of the BMA's consultants' committee, said: `This is not uncommon. When
managers are faced with losing their jobs if they miss a target they will find any way to get
round that target.'69 Clearly, the claim that Labour has abolished `hidden' figures does not
stand up to close examination70.


                                       Productivity
The World Health Organisation stated in 2000 that `Better health is of course the raison
d'etre of a health system.'71 Life expectancy partly reflects the performance of the health
care system, although the figures are not generally considered persuasive because
mortality is affected so many non-medical factors beyond the scope of the health system.72
A recent study by the National Audit Office, based largely on 2002 OECD data, looks at
how the UK compared with nine other advanced countries. The UK performs poorly: for
life expectancy at birth the UK comes ninth out of the ten countries. The World Health
Organisation uses another measure, the `potential years of life lost', which assumes that all
deaths before age 70 are premature. It calculates the number of people who died before the
age of 70 per 100,000 population. Because the UK comes seventh out of the ten countries
compared, the NAO cautions, `[t]his illustrates the dangers of relying on single indicators
to draw conclusions'; yet the UK is still notable in performing towards the bottom of the
range.73
     Infant mortality ­ deaths of babies aged under one year per 1,000 live births in the
same year ­ is considered to be an important measure of an effective system. This is largely
                                                                                                10
because declining levels can be explained by better ante and post-natal care and
widespread immunisation against diseases ­ `influences', as the NAO says, `within the
control of health policy makers.'74 The results of recent research indicate, for example, all
else being equal, that a 10 per cent increase in the number of doctors would result in
almost a 6 per cent decrease in perinatal mortality and a 6.5 per cent decrease in infant
mortality.75 Despite formulating a hypothesis that suggests a compliment to the UK ­ that
publicly funded systems provide more equitable health service provision76 ­ it was tenth
out of the ten countries compared.
     Since, as the NHS Cancer Plan recognises,77 the quality of medical intervention is a
key determinant, cancer mortality statistics provide another important indicator. Despite
falling rates of cancer deaths, the UK again performs badly. An examination of the trend
over the last two decades reveals that, in the last year of complete comparisons, the UK and
New Zealand jointly had the highest cancer death rates and the UK has the highest rate for
breast cancer. An alternative calculation, that of death rates for all cancers against a
standardised age profile designed to take account of the different demographics in the
comparator countries, also reveals that the UK has relatively high death rates. The rate is
2.5 per cent higher than France, 5 per cent higher than Germany, and 18 per cent higher
than Sweden, the country with the lowest cancer death rate among those compared by the
NAO.78
     The most comprehensive international data about the value added to healthcare
systems relate to cancer survival rates. The standard measure is the percentage of cancer
patients alive five years after treatment. Yet again, `[t]he performance of England is
consistently at or near the bottom of the league, alternating bottom position with
Scotland.'79 The latest evidence of cancer survival rates comes from the EUROCARE-3
study, which compares results in 22 European countries up to 1999. Survival rates are
given for 19 countries, based on survival for 5 years after diagnosis. Separate figures are
given for England, Scotland and Wales. All are below the European average for all cancers.
England was below the European average for survival rates from liver cancer80, below
average for breast cancer survival,81 had the lowest survival rates for lung cancer (along
with the lowest proportion of small cell lung cancer patients receiving chemotherapy82) and
among the lowest survival rates for prostate cancer.83 Overall, England comes 11th out of 19
and Scotland 12th for survival rates among men, and England is 12th and Scotland 13th for
women.84
     The situation regarding deaths from circulatory diseases ­ cardio-vascular diseases
including ischaemic heart disease, myocardial infarction and cerebro-vascular disease ­ is
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equally as worrying. UK death rates are highest, second highest and third highest
respectively across the group of countries for these three circulatory conditions.85 Despite
recent improvements, internationally the death rate from Coronary Heart Disease (CHD)
in the UK is relatively high. Among developed countries only Ireland and Finland have a
higher rate than the UK. While the death rate from CHD has been falling in the UK it has
not been falling as fast as in some other countries.86 The statistics show that victims of
heart disease, stroke or breast cancer in Britain die early, and perhaps unnecessarily,
compared to other western countries. Worse still, it seems that access to care is being
limited according to age. Roger Dobson, a regular contributor to the BMJ, reports on an
international study that found the proportion of health spending on those aged 65+ in
England and Wales is not keeping track with that in other countries.87
     Where stroke is concerned, the UK is literally in a league of its own. When the OECD
Age-Related Diseases (ARD) team reported in 2002 on in-hospital mortality and one-year
case mortality for stroke patients, it found that there were few differences between the
countries, with the exception of the UK. Fatalities in the UK over the first seven days were
approximately twice the average for all age groups, making it the only country in the study
classed as having high death rates. These data do not, though, reflect the total continuum
of care which includes care outside the hospital setting: to do that, it is necessary to also
account for non-hospital deaths by using case fatality rates. These rates were lowest in
Denmark and highest by far in the UK, and the OECD observed that the UK stood out for
its poor performance.88 A year later, the OECD found that relatively speaking things had
scarcely improved. For age-standardised mortality rates, the UK was high ­ behind only
Hungary and Japan ­ and while the rates were decreasing they were not doing so as fast as
elsewhere. 7-day hospital mortality was substantially higher than in any other country in
the survey for all age categories, both male and female, with the gap widening for 30-day
hospital mortality,89 and of the 11 countries included in the study, only the UK was labelled
as exhibiting high fatality rates.90


                                Hospital acquired infection
Hospital acquired infections are infections that are neither present nor incubating when a
patient enters hospital. According to the NAO in February 2000, Britain has the worst
record in Europe. At any one time, 9 per cent of patients ­ equivalent to at least 100,ooo
infections a year ­ had an infection that had been acquired during their hospital stay. The
effects varied from an extended length of stay and discomfort to prolonged or permanent
disability and, in at least 5,000 patients a year, death. These infections were costing the
                                                                                                12
NHS as much as £1 billion a year and around 15 per cent could be prevented by better
application of good practice, releasing resources of £150 million for alternative NHS use.91
In the same year, the Committee of Public Accounts concluded that the lack of grip on the
extent and costs of hospital acquired infections impeded NHS trusts in targeting activity
and resources to best effect. In addition, it claimed that a root and branch shift towards
prevention would be needed at all levels of the NHS if hospital acquired infection were to
be kept under control. But in his December 2003 report, Winning Ways92, the Chief
Medical Officer stated that such data as are available show that the degree of improvement
has been small.
     A major obstacle to tackling the spread of antibiotic resistant bugs is that while
patients and staff prefer hospitals which are visually clean, this will only have a minimal
impact on the spread of MRSA. Even the Department of Health's Patient Environment
Action Teams (PEATs) only assess cleanliness on visual criteria. Many more hospitals are
now rated `good' by the PEATs, but over the same period (2001-02 to 2002-03) rates of
MRSA (0.17 per 1000 bed days) have not changed, according to the MRSA surveillance
scheme, and between 1993-2002 the number of deaths increased fifteen-fold.93
  Many of the conclusions of previous NAO reports were repeated in July 2004. Improving
patient care by reducing the risk of hospital acquired infection: A progress report found that good
practice with respect to the prevention, control and management of hospital acquired
infection needed to be more widely known and that there was a lack of basic comparative
information on infection rates. It expressed concern that there appeared to be a growing
mismatch between what was expected of infection control teams and the staffing and other
resources allocated to them, and identified considerable scope for improving performance.
`Implementation of our and the Committee's recommendations has been patchy... wider
factors continue to impede good infection control practice and there has been limited
progress in improving information on the extent and costs of hospital acquired infections.
Progress in preventing and reducing the number of infections acquired while in hospital
continues to be constrained by the lack of data, limited progress in implementing a
national mandatory surveillance programme that meets the needs of the NHS, and a lack
of evidence of the impact of different intervention strategies.'94 The upshot is, as Michael
Howard said on 16 February 2005, that `you are more likely to die of an infection you pick
up in hospital than to be killed on Britain's roads'.
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                                             Conclusion
Whether judged according to expenditure, waiting lists or the various gauges of
productivity, things in the NHS do not look good. Even the sympathetic King's Fund, in its
recent audit of the NHS under Labour, has concluded that `the NHS as a whole has not yet
been transformed. There are still important problems to be solved and there is as yet no
firm evidence to show that Labour's reforms have produced a marked difference in health
outcomes.'95
                                                 Notes


  1 The Guardian, 28 January: 2002. http://society.guardian.co.uk/print/0,3858,4344349-
  106632,00.html

  2 Polly Toynbee and David Walker, Better or Worse? Has Labour Delivered? London: Bloomsbury,
  2005, p. 11. Hereafter: `Better or Worse?'

  3 Better or Worse? p. 37.

  4 Better or Worse? pp. 37-39.

  5 King's Fund, Has the Government Met the Public's Priorities for the NHS? A King's Fund briefing for
  the BBC `Your NHS' Day 2004, London: King's Fund, March 2004, pp. 12-13. Hereafter: `BBC "Your
  NHS" Day 2004 briefing'.

  6 King's Fund, An Independent Audit of the NHS Under Labour (1997-2005), London: King's Fund,
  2005, p. 62. Hereafter: `Audit of the NHS Under Labour'.

  7 The United States, Germany, France, Canada, Australia, Italy, New Zealand, Sweden and Japan. See:
  OECD Health Data 2004, Paris: OECD, 2004. Hereafter: `Health Data, 2004'.

  8 HM Treasury 2004 Spending Review, London: HM Treasury, 2004, pp. 93, 100. http://www.hm-
  treasury.gov.uk/media/801/75/sr2004_ch8.pdf

  9 National Audit Office, International Health Comparisons, London: NAO, 2003, pp. 3-4. Hereafter:
  `Health Comparisons, 2003'.

  10 Health Comparisons, 2003, p. 4.

  11 Better or Worse? p. 14.

  12 Wanless, D., Securing our Future Health: Taking a Long-Term View, Final Report, HM Treasury,
  2002.

  13 Health Data, 2004.

  14 Audit of the NHS Under Labour, p. 15.

  15 Domenighetti, G., Quaglia, J., `Comparisons internationales', in Kocker, G., and Oggier, W., Système
  de santé Suisse 2001/2002, Concordat des assureurs-maladie, 2001.

  16 Or, Z., `Determinants of health outcomes in industrialised countries: a pooled cross-country, time-
  series analysis', OECD Economic Studies, Vol. 2000/1, No. 30, 2000A. Hereafter: `Or, 2000A'.

  17 Health Data, 2004.
                                                                                                         14


18 Or, Z., Exploring the Effects of Health Care on Mortality Across OECD Countries. Labour market and
social policy ­ Occasional Papers, No. 46, Paris: OECD, 2000.

19 Hurst, J. and Lafortune, G., Health At a Glance, OECD Health Policy Unit, Paris: OECD, 2001.

20 Health Comparisons, 2003, p. 9.

21 See also: Derek Wanless, Securing Our Future Health: Taking a Long-Term View, Interim Report,
HM Treasury, 2001.

22 Public Service Productivity: Health, London, ONS: October 2004, p. 15. Hereafter: `ONS, 2004'.

23 Health Comparisons, 2003, p. 10.

24 Sikora, K., `Cancer survival in Britain', British Medical Journal, 1999, pp. 461-462.

25 Moon et al, 2003, p. 21.

26 Health Comparisons, 2003, pp. 9-16.

27 Hurst, J., `Performance measurement and improvement in OECD health systems: overview of issues
and challenges', in Measuring up: improving health system performance in OECD countries, OECD:
Paris.

28 ONS, Public Service Productivity: Health, London: ONS, October 2004, pp. 1-2.

29 ONS, 2004, pp. 21-25.

30 World Health Organisation, The world health report 2000. Health systems: improving performance,
WHO: Geneva, 2000. Cited in Nolte, E. and McKee, M., `Measuring the health of nations: analysis of
mortality amenable to health care', British Medical Journal, 327: 1129 (15 November: 2003).

31 Nolte, E. and McKee, M., `Measuring the health of nations: analysis of mortality amenable to health
care', British Medical Journal, 327:1129-32 (15 November: 2003).

32 Better or Worse? p. 13.

33 Better or Worse? p. 15.

34 National Audit Office, Inpatient and Outpatient Waiting in the NHS, London: NAO, July 2001, p. 1.

35 Inpatient and Outpatient Waiting, p. 31.

36 Inpatient and Outpatient Waiting, p. 2.

37 National Audit Office, Inappropriate Adjustments to NHS Waiting Lists, London: NAO, December
2001, p. 1.

38 Audit Commission, Waiting List Accuracy, London: AC, 2003, p. 3.

39 Waiting List Accuracy, p. 20.

40 Waiting List Accuracy, p. 21.

41 BBC `Your NHS' Day 2004 briefing, p. 19.

42 BBC `Your NHS' Day 2004 briefing, p. 14.

43 King's Fund, Cutting NHS Waiting Times: Identifying strategies for sustainable solutions, London:
                                                                                                      15

King's Fund, February 2005, p. 2.

44 King's Fund, Cutting NHS Waiting Times, p. 3.

45 King's Fund, Cutting NHS Waiting Times, p. 8.

46 Better or Worse? p. 16.

47 Health Services Journal 03/04/2003, Vol. 113, No. 5849, pp. 5-6. Cited in British Medical Association,
BMA Survey of A&E Waiting Times, London: BMA, 2003 HOQB
http://www.bma.org.uk/ap.nsf/Content/AEsurvey/$file/AEsurvey.pdf

48 British Medical Association, BMA Survey of A&E Waiting Times, London: BMA, 2003 HOQB
http://www.bma.org.uk/ap.nsf/Content/AEsurvey/$file/AEsurvey.pdf

49 BMA Survey of A&E Waiting Times. This conclusion was anticipated by the NAO's 2001 report,
Inpatient and Outpatient Waiting in the NHS.

50 BMA Survey of A&E Waiting Times

51 BBC `Your NHS' Day 2004 briefing, p. 14.

52 BBC `Your NHS' Day 2004 briefing, p. 20.
53 BBC `Your NHS' Day 2004 briefing, p.24.

54 Waiting List Accuracy, p. 5.

55 BBC `Your NHS' Day 2004 briefing, p. 19.

56 Rebecca Coombes, `Choice in the NHS is limited to waiting times', British Medical Journal, 329: 1305
(4 December: 2004). http://bmj.bmjjournals.com/cgi/content/full/329/7478/1305-a

57 Moon, L., Moise, P., Jacobzone, S., and the ARD-Stroke Experts Group, Stroke Care in OECD
Countries: A Comparison of Treatment, Costs and Outcomes in 17 Countries, OCED Health Working
Papers, No. 5, DELSA/ ELSA/ WD/ HEA (2003)5, p. 22.

58 Rebecca Coombes, `Choice in the NHS is limited to waiting times', British Medical Journal, 329: 1305
(4 December: 2004).

59 George Jones, `Operations "are being cancelled to meet targets"', Daily Telegraph, 18/02/2005.
http://www.arts.telegraph.co.uk/core/Content/displayPrintable.jhtml?xml=/news/2005/02/18/ntory21
8.xml&site=5

60 National Audit Office, NHS Executive: Inpatient Admissions and Bed Management in NHS acute
hospitals, London: NAO, 24 February 2000, p. 22. Hereafter: `NHS Executive'.

61 NHS Executive, p. 22.

62 Health Comparisons, p. 13.

63 Linda Beecham, `NHS cancels record number of operations in England,' British Medical Journal, 320:
599 (4 March: 2000). http://bmj.bmjjournals.com/cgi/content/full/320/7235/599

64 Waiting List Accuracy, p. 18.

65 http://www.performance.doh.gov.uk/hospitalactivity/data_requests/cancelled_operations.htm
(downloaded: 22/03/2005)
                                                                                                        16


66 Sarah-Kate Templeton and Jonathon Carr-Brown, Sunday Times, 06/03/2005.
http://www.timesonline.co.uk/printFriendly/0,,1-523-1513588,00.html

67 NHS Executive, p. 2o.

68 NHS Executive, pp. 20-22.

69 The Times, 06/03/2005. http://www.timesonline.co.uk/printFriendly/0,,1-523-1513588,00.html

70 Better or Worse? p. 12.
71 ONS, 2004, p. 6.

72 Or, 2000A.

73 Health Comparisons, 2003, p. 17.

74 Health Comparisons, 2003, p. 17.

75 `Exploring the effects of health care on mortality across OECD countries, OECD Labour market and
social policy', Occasional Papers, No. 46 (January 2001), paragraph 55. Cited in Health Comparisons,
2003, p. 17.

76 Health Data, 2004.

77 The NHS Cancer Plan, Department of Health, September 2000.

78 Health Comparisons, 2003, pp. 19-20.

79 Health Comparisons, 2003, p. 21, pp. 21-27.

80 Faivre, J., Forman, D., Obradovic, M., Sant, M., and the EUROCARE Working Group, `Survival of
patients with primary liver cancer, pancreatic cancer and biliary tract cancer in Europe', European
Journal of Cancer, Vol. 14, No. 14, 1998, pp. 2184-2190.

21 Quinn, M.J., Martinez-Garcia, C., Berrino, F., and the EUROCARE Working Group, `Variation in
survival from breast cancer in Europe by age and country, 1978-1989', European Journal of Cancer, Vol.
14, No. 14, pp. 2204-2211, 1998.

82 Janssen-Heijnen, M.L.G., Gatta, G., Forman, D., Capocaccia, R., Coebergh, J.W.W., and the
EUROCARE Working Group, `Variation in survival of patients with lung cancer in Europe', European
Journal of Cancer, Vol. 14, No. 14, pp. 2191-2196, 1998.

83 Post, P.N., Damhuis, R.A.M., Van der Meyden, A.P.M., and the EUROCARE Working Group,
`Variation in survival of patients with prostate cancer in Europe since 1978', European Journal of Cancer,
Vol 14, No 14, 1998, pp. 2227-31.

84 Coleman, M. P. et al, `EUROCARE-3 summary: cancer survival in Europe at the end of the 20th
century, Annals of Oncology 14 (Supplement 5): v128-v149, 2003.

85 Health Comparisons, 2003, p. 21.

86 http://www.heartstats.org/temp/Mortalityspchapter.pdf, p. 2. For example the death rate for men
aged 35-74 fell by 39% between 1989 and 1999 in the UK, but it fell 47% in both Norway and Australia.
For women the death rate fell by 41% in the UK, but in Australia, Finland and Ireland the rate fell by 52%,
46% and 44% respectively.

87 Dobson, R., `Proportion of spending on care for older people falls', British Medical Journal, 325:355
(17 August: 2002).
                                                                                                    17


88 OECD, ARD Team, `Summary of Stroke Disease Study' (Draft), What is Best and at What Cost? OECD
Study on Cross-National Differences of Ageing related Diseases, DEELSA/ ELSWP1/ ARD (2002)4.
OECD Working Party on Social Policy, Ageing-Related Diseases, Concluding Workshop, Paris, 20-21 June
2002.

89 Moon, L., Moise, P., Jacobzone, S., and the ARD-Stroke Experts Group, Stroke Care in OECD
Countries: A Comparison of Treatment, Costs and Outcomes in 17 Countries, OCED Health Working
Papers, No. 5, DELSA/ ELSA/ WD/ HEA (2003)5, pp. 64-70.

90 Moon et al, 2003, p. 86.

91 The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England,
London: NAO, February 2000, p. 10.

92 Winning Ways: working together to reduce Healthcare Associated Infection in England: Report by
the Chief Medical Officer, Department of Health, December 2003.

93 BBC `Your NHS' Day 2004 briefing, p. 25, p. 27.

94 Improving patient care by reducing the risk of hospital acquired infection: A progress report,
London: NAO, 14 July 2004, p. 2.

95 Audit of the NHS Under Labour, p. 6.