Where is the NHS now?

Anna Dixon, Director of Policy

A high-performing NHS? A review of progress 1997 –2010

Editors: Ruth Thorlby and Jo Maybin

http://www.kingsfund.org.uk/publications/a_highperforming_nh.html

Features of a high performing health system

- Available and accessible

- Safe

- Promoting health

- Clinically effective

- Delivering a positive patient experience

- Equitable

- Efficient (offering value for money)

- Accountable

Key questions

What was the situation in 1997?

What policies did the Labour government introduce?

What progress has been made?

Where should the new government focus its efforts?

Availability & Access

Successes:

– Waiting times for hospital care

18 months to 18 weeks

- Establishment of NSFs and NICE

Weaknesses:

- Access problems persist in some areas –community mental health, physiotherapy & out of hours

- Shifting care out of hospital

A high-performing health system makes a comprehensive range of services available,

and ensures that people can access them in a timely and convenient manner.

Median waiting times (weeks), inpatients and outpatients, England, 1994–2009

Percentage increase in GP practices offering extended opening hours, 2008/9

SafetyA high-performing health system protects patients from injury or death arising from the

delivery of care – particularly medical error, or from the conditions in which it is provided,

such as hospital-acquired infections.

Reductions in those HCAIs that have been targeted:

– MRSA 54% (2006/7 – 2008/9)

– C. Diff 35% (2007/8 – 2008/9)

Increased incidence of patient safety events but likely to reflect increase in reporting

Under-reporting, especially in primary care (0.5% of all reports)

‘Blame culture’ still persists

Number of MRSA bloodstream infection reports, England, by quarter, June 2006 to September 2009

Care setting of incident reports, England, 2008/9

Health PromotingA high-performing health system supports individuals to make positive decisions about

their own health and how to manage the impact of long-term conditions.

Smoking:

– rates are declining, but in line with trend

– Socio-economic inequalities persist

Obesity:

– Increasing for adults; some levelling off for children

Alcohol:

– no significant change in alcohol abuse

– liver cirrhosis on increase against trends in other countries

Long term conditions:

– support for management of LTCs not yet sufficient

Prevalence of cigarette smoking among men and women (weighted), 1998–2007

Prevalence of obese (including morbidly obese) adults in England, 1993–2007

Clinically EffectiveA high-performing health system delivers services to improve health outcomes in terms of

successful treatment, the relief of pain and suffering, restoration of functions and, where

these are not feasible, adequate care and support.

Improved outcomes in line with international trends

Under-75s mortality for major killers has declined…

Cancer mortality 19% since 1995-7

CHD mortality 44% since 1995-7

Greater compliance with NICE guidance and clinical standards, though often from low base

But: geographic variations persist and challenge of increases in co-morbidities

PROMS data provides opportunity

Deaths per 100,000 population from diseases of the circulatory system 1990–2007, selected OECD countries

Performance against quality indicators from the Myocardial Ischaemia National Audit Project, England

Patient ExperienceA high-performing health system delivers a positive patient experience. This includes

giving patients choices and involvement in decisions about their care, providing the

information they need, and treating them with dignity and respect.

Proportion of patients saying they had a good NHS experience high but stable - c.75%

Poor experience for inpatient mental health patients and systematic differences by age, health status, ethnicity and region

Public satisfaction highest ever

Choice of location introduced – but patients want to be more involved in decisions about treatment and for family and carers to be involved

Public satisfaction with the way the NHS is run, 1993–2007

Proportion of patients reporting their doctor always involves them in treatment options and decisions

EquityA high-performing health system is equitably funded, allocates resources fairly, ensures

that services meet the population’s needs for health care, and contributes to reducing

health inequalities.

Ambitious outcome targets set on reducing gaps between deprived & average on infant mortality and life expectancy = gap is widening

Lack of knowledge about whether those in need are accessing services & getting treatment –‘inverse care law’ in GP services

Equality Bill going through Parliament – will require equitable access (deprivation, age, gender, disability, religion, sexual orientation)

= major data collection & analysis task

Distribution of GPs per 100,000 population, by deprived area, England 2005

Value for MoneyA high-performing health system uses the available resources to maximum effect. This

requires productivity in the delivery of care, economy in the purchase of the goods and

services a health service requires to deliver that care, and effectiveness in the design and

selection of its services.

Activity has increased more slowly than the increase in resources = slight decline in productivity

Higher pay costs have absorbed more than half of extra money

Pay EU average for drugs, and made savings on procurement

Still room for further savings on reducing length of stay, increasing day surgery & using lower cost drugs

AccountabilityA high-performing health system can demonstrate that it is achieving high standards of

care, taking into account the views of those who it serves and that it has in place effective

systems to remedy poor performance.

‘Targets and terror’ : have they worked? What has been the cost?

Decentralisation to commissioners but performance still judged to be ‘weak’

Public involvement and accountability to local communities

– Repeated changes to local structures PPI, LINks

– Variable levels of engagement by FT members

Introduced quasi-independent regulators of organisations

– Burden of multiple agencies & data requests

Looking forward . . .

Still unwarranted variations in access to & quality of care

Need to ensure patients’ experiences have an impact on quality of care locally

Need to deliver improvements & investment in prevention and management of chronic disease

Trade-offs inevitable, especially in light of tighter budgets