NHS bosses still dreaming



After 60 years, the NHS has signalled the end of cheap-and-cheerful, any-colour-so-long-as-it's-black healthcare. That's about 30 years after manufacturing, retailing, telecommunications and the rest of the service sector embraced the idea that the customer is king, and what he (or she) wants is quality service. But let's not quibble. Lord Darzi's review sets quality of care first, and everything else a distant second. Almost all the detailed changes he proposes are designed to raise standards. Doctors and hospitals will be measured by the quality of care they deliver, and rewarded accordingly. Patients will be asked their opinion, and other more specific outcome measures - such as how many patients die - will be used to determine just how good their care has really been.

In general practice, the Minimum Practice Income Guarantee (MPIG) will go. Income will instead depend more on the Quality and Outcomes Framework, which measures what GPs do, rather than what their historic income has been.

Hospitals that deliver a classy service will be paid more than the rest, under the tariff that determines the cost of every procedure. Everybody will publish annual Quality Accounts, equivalent to their yearly financial accounts.

Primary Care Trusts will be forced to pay for treatments passed cost-effective by the National Institute for health and Clinical Excellence, and Strategic Health Authorities given a legal duty to encourage innovation. Patients will get enhanced rights of choice over where they are treated, harnessing market power to raise standards. The theme is clear. "This whole report is about quality," Lord Darzi said. David Nicholson, chief executive of the NHS, said: "Quality is to become the organising principle of the NHS".

But can the service deliver? Historically, it has always valued shifting large numbers of patients through their episodes of care as a greater good than ensuring they were as well-treated as medical knowledge makes possible. Central targets enshrined this principle, to the fury of clinicians.

Lord Darzi now claims to have listened to the clinicians, and shaped his report from what he heard. "This is not a document pulled together by a small group of people in the Department of Health" insisted Mr Nicholson, as if we might possibly have suspected it.

At issue is whether the levers are strong enough to bring about change. The document assumes that quality improvement will have no victims. But better quality can only come about by chasing out bad: that means eliminating poor GPs, closing failing hospital services, or even entire hospitals. Otherwise there won't be the money to reward the good. These changes are painful. Lord Darzi envisages them being driven locally, but his chosen instrument, the primary care trusts, are weak reeds. Hitherto most of them have been easily managed by ingenious GPs and popular local hospitals. Most patients don't even know what PCTs are: and if PCTs try to do anything tough, they are easily characterised as "NHS bosses" cutting services.

There are also some spectacular gaps in the promises the documents make. The NHS Constitution - a "declaratory document" said Lord Darzi, for which read the usual well-meant pieties - makes only one new promise, that of universal patient choice. But when pressed, the Health Secretary, Alan Johnson, seemed unsure how that would apply to popular GPs whose lists are full, and Lord Darzi disabused anybody of the idea that it means you could choose a particular surgeon - for instance, him.

In his team of colorectal surgeons at St Mary's Paddington, all were equally good, he insisted. But if choice doesn't mean the right to choose a particular GP or a particular consultant, what does it mean? And if you can't really choose, how can bad practitioners be driven out to make way for better ones? Competition is a bloody business, as a million corner-shops run out of business by the supermarkets can attest.

Lord Darzi's report lacks any acknowledgement of this. It simply envisages an NHS aspiring ever upwards to unimagined levels of quality and care, leaving nobody behind: no victims, no bankruptcies, no tears. Life isn't like that.

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Australian public hospitals slower to see patients

Public hospital emergency departments are seeing a smaller proportion of patients within the recommended time than they did eight years ago - and the federal Government has admitted that "much work lies ahead" to fix the system. More than 6.7 million people sought treatment at Australia's emergency departments in 2006-07 - the equivalent of one-third of the population - and 30 per cent of these patients were not seen within the minimum recommended times laid down by the Australasian College of Emergency Medicine.

The figures, contained in the latest annual State of Our Public Hospitals report released by the federal Government, have prompted a chorus of protests from health organisations who say it shows the system has been starved of funds, even though overall spending on hospitals hasnearly doubled over the past decade.

Releasing the report yesterday, federal Health Minister Nicola Roxon said it illustrated "11 years of Liberal neglect". She said all states and territories except NSW were seeing a smaller proportion of emergency patients punctually in 2006-07 than they were eight years previously, in 1998-99. Over the same time frame, the number of people presenting to emergency departments rose by 34 per cent, up from five million in 1998-99.

The report showed there were 4.7 million admissions to public hospitals in 2006-07. Ms Roxon said the latest report showed admissions were growing by about 3 per cent a year - more than double the rate of population growth - and hospitals were "under severe strain". "While it will take time to turn around a decade of neglect, the Rudd Government is determined to deliver dramatic improvements in healthcare," she said.

The proportion of elective surgery patients seen within recommended times in 2006-07 ranged from 68.6 per cent in the Northern Territory, and 67.6 per cent in Tasmania, to 85.9 per cent in NSW. Longest waits are for knee replacement (162-day median wait), a type of nasal surgery called septoplasty (113 days) and hip replacement (106 days).

Between 1998-99 and 2005-06, the amount of commonwealth money provided for state hospitals rose from $6.1 billion to $9.2 billion. But over the same period, that money as a proportion of the total spending on state-run hospitals fell from 48.1 per cent to 42.7 per cent.

Yesterday's report also showed continuing increases in some states in the proportion of same-day procedures, and decreases in average lengths of stay. Both are techniques hospitals can use to cope with an ever-growing stream of patients needing treatment.

Australian Medical Association president Rosanna Capolingua said the report was "a wake-up call to the governments of Australia" and that doctors and regular patients "have known for a long time that our public hospitals are at breaking point".

Prue Power, executive director of the Australian Healthcare and Hospitals Association, called on the Government to increase its share of total hospital funding from its current level of 42 per cent. The annual indexation also needed to be raised from the "inadequate" current rate of 1.7per cent.

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