“There has been a 16 per cent reduction in cancer as a result of the new investment since 1997”
While that particular example is from Gordon Brown at Prime Minister’s
Questions in December it is the kind of argument you will here
regularly from those trying to defend the performance of the NHS in
recent years. It is a much less meaningful statement than it might
seem. Over ten years new technologies will be developed and a richer
nation will usually spend somewhat more on healthcare – even if the
percentage of national income does not change.
To really understand Gordon Brown’s record on the NHS you need some
context. You need to compare the performance of British healthcare in
recent years with its performance in earlier periods and see how other
European countries – facing similar changes in the technological and
social environment – have fared.
Our new report, Wasting Lives: A statistical analysis of NHS
performance in a European context since 1981, has been released today
and aims to provide that context. It studies amenable mortality – the
number of deaths from certain conditions, at certain ages that a
healthcare system can reasonably be expected to prevent – and compares
Britain’s healthcare performance, over time, with European peers.
The results paint a stark picture of the failure of health policy in recent years. In the most recent year for which data is available, 2004, over 17,000 lives would have been saved if we had matched European levels of mortality amenable to healthcare. That is an enormous human cost to the failure of the NHS to deliver the quality of care expected and delivered on the continent.
Beyond that, the billions of pounds in extra funding since 1999 have failed to deliver results. NHS spending has generally been increasing, even relative to other European countries, since 1981 but there was a massive jump in the amount of funding available to the NHS from around 1999. Unfortunately, there is no discernable increase in the pace at which mortality amenable to healthcare falls despite that huge cash injection. The faster increase in spending relative to European peers since 1999 has meant £34.3 billion of extra spending and that money appears to have been wasted.
In order to get real improvement in the performance of the NHS we need to learn important lessons from how the most successful continental countries deliver healthcare.
The local institutions in the NHS are subject to massive control by central government. Many of their decisions – from how much to pay their staff, to which drugs they buy, to what computer systems to use and how much they will have to spend – are made centrally. What autonomy they have left is used to chase targets also set in Whitehall. Other countries decentralise healthcare, particularly Spain and Switzerland. This not only allows for decisions to be varied more in response to local conditions but makes for better decision making. It also becomes far easier to feed in local information and the views of individual professionals and patients.
The organisations in the NHS are monopolies protected by unique access to taxpayers’ money. Patients have little real choice or redress. Monopolies kill a vital imperative for an organisation to innovate, improve and reduce costs. Perhaps the most important priority for reform of British healthcare is to increase the amount of competition. In France, Germany and many other continental countries with insurance-based systems providers compete to offer quality service at low cost to insurers. Competition is being advanced in its most complete form, at least within the EU-15, in the Netherlands where consumers can choose between a number of nationwide insurance plans. Those plans compete on premiums, type of plan and service levels.
3. Ending political management
Running a monopolistic conglomerate with 1.4 million staff from Whitehall would be beyond even the most experienced and knowledgeable chief executive. However, the NHS doesn’t get experienced or knowledgeable chief executives. It gets politicians. Few of the Secretaries of State since the early eighties have had significant experience in management or medicine. Political management is a consequence of having an entire healthcare system administered by the state. Other European countries that have healthcare delivered by independent organisations, even if the politicians remain in charge of funding and regulating the system, rely far less on political management.
The poor quality of British healthcare should not be accepted as a given. If we can decentralise the NHS, encourage competition and end political management we can match the standards seen in other European countries. Doctors and nurses can get on with their jobs without the constant frustration of the absurdities of political management. Patients can live longer and healthier lives – thousands can be saved every year. All it requires is that we learn important lessons from how other countries organise the provision of healthcare.