If I ever have a heart attack, I want the full County General treatment, just like on ER. I want to come bursting through those double-doors on a gurney with paramedics chanting a litany of vital signs. Most of all, I want clot-busting drugs coursing through my arteries in seconds flat. Fat chance of that on the NHS, it seems. According to an upbeat summary from the Department of Health: “Nearly 80 per cent of heart attack victims now receive thrombolysis within 30 minutes of arriving at a hospital, compared to only 38 per cent in March 2000.” Thirty minutes? Excuse me, but isn’t this an emergency? While I am gratified things are only half as bad as they were three years ago, from the perspective of an overweight, chain-smoking potential consumer of this service, I find the NHS’s target disconcertingly unambitious.
But then, what do I know? I’m not a doctor. It could be that, in terms of survival rates, it doesn’t matter two hoots whether I get the drugs in five, ten or 20 minutes. All I know is that my expectations are higher than the health service can match. True, my expectations have been artificially raised by an American TV soap, but – along with those of millions of others – raised they assuredly are. For ministers, that’s a political fact.
My expectations might equally have been raised by seeing how things are done in the private sector. More and more of us, even those without insurance, are dipping into private medicine, often for diagnostic work – X-rays, blood tests, ultrasound and so forth – before returning to the NHS for our operations. Many of us have also been impressed by how well healthcare systems work in other European countries. Such experiences are bound to colour our perceptions of the NHS.
I have been in and out of hospitals for weeks, filming the first in a series of Newsnight reports on whether the government is delivering across a range of public services. The first question we asked ourselves was what we meant by “delivering”. At the most fundamental level, delivery is about whether the NHS is now better, worse or pretty much the same as it was when this government took office in 1997. But it has to be about more than that. We need to know whether the right policies and mechanisms have been established to sustain any improvements there may have been; and we need to take account of reasonable expectations. If the NHS were twice as efficient as it was six years ago, yet were offering a markedly poorer service than is available in France and Germany, would people judge that the government had “delivered”?
Labour has kept its promise to commit more money to health. Under the Tories, NHS spending used to rise (yes, it did) at an average of 3.1 per cent a year. Now, with the extra spending announced in last year’s Budget, it’s going up every year from now until 2008 by 7.4 per cent – the largest sustained increase ever known. In January 2000, when Tony Blair promised to increase the share of GDP allotted to health to meet the European average, his “pledge” was scaled back by the spinners to a mere “aspiration”. At that time, the UK was languishing in 11th place in the EU spending league. Now, aspiration or pledge, it doesn’t matter. By the time Gordon Brown’s new money is spent, we will be devoting more of our GDP to health than any other member state except Germany. The Chancellor has bet the farm. He believes in a health service of solidarity and service, funded out of general taxation. The danger is that if the NHS cannot be turned around with such levels of investment, we may despair that it ever can be. There is no shortage of other options. Almost every think-tank in town is offering a social insurance- or competition-based alternative.
In exchange for the extra resources, ministers have demanded reform. Under the Tories, some health service managers felt that their chief role was to keep costs down. Now they are forced to think about improving the quality of care they provide, meeting national standards, bringing down waiting times, and even about outcomes – improving the overall health of the nation. This new, “patient-centred” focus is policed by scores of targets and performance ratings, such as the star system.
The Royal United Hospital in Bath is a zero-star hospital, despite being in the top ten for clinical excellence. It failed its last appraisal mainly because of its long waiting times. Indeed, a year ago, two-thirds of the patients in the whole country who were waiting more than six months to see a specialist were on the books of the RUH. Jan Filochowski, one of a new breed of NHS troubleshooters, went in to sort it out. Hundreds of operations were subcontracted to private hospitals. Coachloads of patients were shipped to Lille for treatment. “When I was negotiating with my French colleagues,” says Filochowski, “I had to spell out what waiting lists were. They simply had never heard of such a thing.” While the French system has excess capacity, our own has far too little. Filochowski has redesigned the system for booking appointments and operations. Now the RUH is treating more patients than ever before. Yet on the day Newsnight visited Bath, nine long-planned operations had to be cancelled because emergency cases had taken up the last available beds. It is the same everywhere you look. A chronic shortage of doctors, nurses and beds stymies the sensible reforms managers try to implement.
In Hackney – the kind of deprived area where you’d think the government’s commitments to ending health inequalities would be most vigorously pursued – the primary care trust says it is 30 GPs short. Yet it is still under pressure to meet the national target requiring all patients to get an appointment within 48 hours.
A few weeks ago at Homerton Hospital in Hackney, a team of NHS bureaucrats, clipboards and stopwatches in hand, spent a week monitoring the government’s target for a maximum four-hour wait in accident and emergency for either admission or discharge. The Homerton passed magnificently, but only because it had drafted in staff from other departments, though it did not go as far as some hospitals and cancel all elective surgery. The medical director admits this success was completely unsustainable – a one-week wonder. He is unapologetic. He says he now knows exactly how many more staff to ask for. But under the new NHS structure, it is Hackney’s primary care trust – which has its own staffing crisis – that decides where most NHS money is spent.
Even the most rational-seeming target can have unforeseen consequences. Cancer patients should now get to see a specialist within two weeks of referral. But some specialists complain they are being inundated with unnecessary appointments: one recent study at a London hospital found that most patients referred turned out not to have cancer at all. Meanwhile, genuinely urgent cases were crowded out.
Yet there is evidence that overall, the target regime is forcing up standards. The NHS Modernisation Board can point to hundreds, even thousands, of small but significant ways the service is getting better. But as the Commission for Health Improvement admitted in a report published this month, the government’s reforms are “not yet affecting front-line delivery of services on a large enough scale to impact on most members of the public”.
Until the underlying capacity problem is solved, the NHS will always be running just to catch up with itself. The government tells us that since 1997 it has recruited nearly 50,000 more nurses, 5,500 more consultants and 1,200 more GPs. But we remain way behind our neighbours. During the 1990s Germany had more than twice as many doctors per 1,000 population than the UK; and the French were only just behind. According to the NHS’s projections, it will be at least 2024 before we reach the European average for 1997. Sir Derek Wanless, who advises Gordon Brown on long-term NHS funding needs, says that with smart working practices we might manage with fewer doctors and nurses than the French or the Germans. But no one has yet determined how many fewer. No wonder that when you ask NHS staff when they think they will be able to offer a service comparable to that of our European neighbours, even the most recklessly optimistic of them say we should allow 12 or 15 years for “delivery”.
Newsnight‘s report on NHS delivery is broadcast on Thursday 15 May, 10.30pm, BBC2