Myth 3: The NHS doesn’t need any change

The Government's Claim:

Someone in this country is twice as likely to die from a heart attack as someone in France. Survival rates for some cancers are amongst the worst in the OECD. Premature mortality rates from respiratory disease are worse than the European average. The number of managers in the NHS doubled under Labour, and productivity went down year-on-year.

The Rebuttal

Health Outcomes

"Someone in this country is twice as likely to die from a heart attack as someone in France. Survival rates for some cancers are amongst the worst in the OECD. Premature mortality rates from respiratory disease are worse than the European average."

This statement has been rebutted by Prof John Appleby in the British Medical Journal. In his article Prof Appleby says:

Although statistics from the Organisation for Economic Cooperation and Development (OECD) confirm that in 2006 the age standardised death rate for acute myocardial infarction was around 19/100,000 in France and 41/100,000 in the United Kingdom, comparing just one year—and with a country with the lowest death rate for myocardial infarction in Europe—reveals only part of the story. Not only has the UK had the largest fall in death rates from myocardial infarction between 1980 and 2006 of any European country, if trends over the past 30 years continue, it will have a lower death rate than France as soon as 2012.

These trends have been achieved with a slower rate of growth in healthcare spending in the UK compared with France and at lower levels of spending every year for the past half century. The most recent OECD spending comparisons show that in 2008, the UK spent 8.7% of its gross domestic product on health compared with 11.2% for France—28% more.

Prof Appleby illustrates the standardised mortality with the following graph.


It is clear from this graph the huge improvement over the last two decades. A considerable amount of effort has gone into this and not only has Cameron not acknowledged this effort but he suggests that the situation is worse than it is.

As to cancer rates, Prof Appleby indicates that the situation is not as bad as the government suggests:

Our apparently poor comparison with other countries on cancer deaths has also been a key argument for reforming the NHS. However, comparisons are not straightforward and depend where you look. Death rates for lung cancer in men, for instance, rose steadily to a peak in the UK in 1979. But since then they have steadily fallen, mirroring long term changes in smoking patterns, and are now lower than for French men, where the peak death rate occurred over a decade later in the 1990s. Similar long term trends are evident for breast cancer mortality. Since 1989, age standardised death rates per 100,000 in the UK have fallen by 40% (from 37.8 to 24.4) to virtually close the gap with France, where they have fallen by just 10% (from 25.5 to 22.0). Again, if trends continue, it is likely that the UK will have lower death rates than France in just a few years.

Yet again, Prof Appleby indicates that the government is not being honest by suggesting that the cancer rate is as high as they are suggesting.

Productivity

"The number of managers in the NHS doubled under Labour, and productivity went down year-on-year"

The figures quoted in the "myth" come from the NHS Information Centre (employees) and from the Office for National Statistics (productivity). Let's have a look at these figures.

The NHS Information Centre gives these figures for the number of employees:

 

1997

2008

2009

1997 to 2009 change (%)

NHS Employees

1,058,686

1,368,693

1,431,996

35

All doctors

89,619

133,662

140,897

57

Qualified Nurses

318,856

408,159

417,164

30

Managers

22,173

39,913

44,661

101


These show that the number of managers increased by 101% over the period 1997 to 2009 (the source of the "managers in the NHS doubled") but at the same time the number of doctors has increased by 57% and the total number of employees has increased by 35%.

The productivity figures come from the ONS:

  % change 1997 to 2008 Mean
Volume of Output 62.6 4.4
Volume of Input 66.6 4.6
Productivity -4.0 -0.2


These figures show that productivity decreased on average -0.2% each year over the period 1997 to 2007. This is the source of the statement "productivity went down year-on-year".

Productivity depends on the inputs (funding) and the outputs (the work carried out). ONS says that over the period 1997 to 2008 the outputs increased by 62.6%, yet over this period the number of doctors increased by 49%, nurses by 28% and the total NHS staff increased by 29%. The NHS outputs increase much more than the increase in the number of employees, showing that the productivity in terms of manpower has increased.

Any increase in the number of employees requires an increase in the number of managers. Over the period 1997 to 2008 when the outputs increased by 62.6% the number of managers increased by 80%. While the number of managers increased more than the increase in NHS outputs, the increase was not double.

Productivity is difficult to measure in healthcare, and the ONS figures are not the only measure of NHS productivity. The Centre of Health Economics at the University of York produced a study in 2010 of the regional variation of productivity in the NHS. CHE Research Paper 57 says that the productivity figures from the ONS are flawed:

Our estimates differ from those of the Office for National Statistics, which estimates that productivity fell by 0.3% in 2007 and by 0.7% 2008. The main reasons for the differences are that:
  • The ONS measure of output is not comprehensive, capturing around 80% of activity. In particular much community care activity is omitted, where growth has been above average. This biases the ONS productivity measure downwards.
  • The ONS measure of labour inputs does not account for the contribution of non-NHS (eg agency) staff. There have been recent reductions in the use of non-NHS staff. Omitting their reducing contribution biases the ONS productivity measure downwards.
  • The ONS estimates of productivity for 2008 are based on projections based on the first quarter’s data. The accuracy of these projections will not be established until the actual data are available.
This is significant because it shows that the figures being used to say that the NHS has had falling productivity are not accurate. The CHE study says that productivity did fall from 1997 until 2003, and from that point on "not only are more patients being treated, but the quality of the care they receive has been improving". The study says:

Between 1998/9 and 2003/4 there was strong input growth, particularly after 2000/1, averaging 5.5% a year. Recruitment increased ... there was greater investment in equipment and buildings. Over the same period output growth lagged behind input growth. Even so, year-on-year increases in the number of patients treated meant that output growth averaged more than 3.8% per year up to 2003/4. The net effect, though, was slightly negative productivity growth between 1998/9 and 2003/4.

This has since changed. NHS output has continued to rise, but at the faster rate of 5.7% a year. Not only are more patients being treated, but the quality of the care they receive has been improving. The index of input growth suggests a slowdown in input growth since 2004/5, which has been increasing at a rate of 4.8% a year, compared to 5.5% previously. This slowdown is due to a levelling off in staff recruitment and reduced reliance on agency staff. Since 2004/5 growth in inputs has been matched or slightly exceeded by growth in outputs, so recent NHS productivity growth has been slightly positive.

Therefore, the statement that "under Labour productivity went down year-on-year" is clearly wrong because productivity since 2004/05 has been "slightly positive" according to the CHE study. Indeed, the negative productivity between 1997 and 2003 has been explained by the CHE study to be due to growth in inputs ("greater investment in equipment and buildings") which will not be repeated during this Parliament. A further reason for the negative productivity between 1997 and 2003 is due to the European Working Time Directive which "placed limits on working hours, entailing reductions in the number of patients per doctor". This reduction in the number of patients per doctor (ie each patient gets more doctor-time) is a good thing and represents an increase in quality of care.
 

Management

Managers are not a Labour phenomenon, the rise in management in the NHS started in 1985, due to the Thatcher government implementing the Griffiths Report. The following graph shows the change in the number of managers since 1985 (using data from the NHS Information Centre, the Office for National Statistics, the Kings Fund and written answers in Hansard) and indexed output of the NHS (using Office for National Statistics figures):

This graph shows that the rise in managers in the NHS over the period 1997-2010 follows a similar trend that started under previous administrations. The blue line shows the indexed outputs of the NHS where 100 is the level of output in 1995. It is clear from this graph that outputs (the amount of work the NHS does) has increased considerably and as the NHS does more work it needs more managers.

It is hypocritical of a Conservative government to blame Labour for management in the NHS when it was a Conservative government who introduced management grades in the first place. Note that the number of manages decreased in 2006 and 2007 (when have you heard Lansley point that out?)

Public Satisfaction

Of course, no organisation can avoid change, nor should it. The NHS makes use of high technology and new discoveries far more than any other public service, indeed, far more than any service, and therefore it has to change constantly to use the new technology. The question is whether the NHS needs a re-organisation or more importantly, does the public think that the NHS needs yet another re-organisation. The answer to this question is an emphatic No! The evidence for this comes from several places.

The Commonwealth Fund is a US organisation that conducts surveys annually about the healthcare systems of the major Western countries. The results for 2010 shows that the UK public are very satisfied with the NHS. Paul Corrigan (a former Health advisor to Tony Blair) provides an interesting analysis of the survey results.

The public were asked, “If they were seriously ill would they be confident/very confident that they would get the most effective treatment?” This for me is the Nye Bevan question. He wanted to create a health care system where the individuals were not just secure but were “serene” in their expectations of their health care system. ... In 2010 92% of people in the UK were either confident or very confident that they would get the most effective treatment. This was the highest in the world and for me says that the NHS in this year generally passes the Nye Bevan test. (76% in Canada and 70% in the US).

Further, Corrigan says:

the public were asked that if they looked at the health system as a whole, do they think it needs minor changes in the system; fundamental changes; or do you think it should be rebuilt completely. ...3% in the UK think the system needs to be rebuilt completely (the lowest in the world). 34% think there needs to be fundamental changes, and 62% think that only minor changes are needed. The UK public think their health care system needs changing less than any of the other countries surveyed.

The results from the Commonwealth Fund indicate that there is little support for a complete, top-down re-organisation like the one being suggested by Lansley.

In June 2010 the Kings Fund hosted a presentation by Ipsos MORI which included the result of a survey of patient satisfaction with the NHS. The pertinent graph is reproduced here:


As you can see, 67% of respondents report satisfaction with the NHS, Ipsos MORI says that this is the "highest ever level of satisfaction" for the service.

The longest running survey of public satisfaction with the NHS is the British Attitudes Survey published by the National Centre for Social Research. At the end of 2010 the survey had good news for the NHS. The report (pdf) says:

When the Labour Party came to power in 1997, only a third of people (34%) were satisfied with the NHS, and this was the lowest level since the National Centre for Social Research (NatCen) began its annual British Social Attitudes survey in 1983. But by 2009, satisfaction stood at 64%, the highest since the survey began, says NatCen.

NatCen say that the percentage of very or quite satisfied declined from 1983 (the first survey) until its lowest point at 1997: clearly Conservative governments result in decreasing satisfaction with the NHS. The NatCen results show increasing satisfaction with the NHS from 1997 to the final survey in 2009: clearly Labour governments result in increasing satisfaction with the NHS.

Interestingly, NatCen analyse the survey results and concluded:

Increased satisfaction partly reflects the fact that people recognise and value the improvements that have taken place within the NHS, particularly in relation to waiting times, but the promotion of patient choice (within England at least) has not led to higher levels of satisfaction with NHS services.

This should be particularly concerning for the Government who have scrapped waiting time targets (which has now led to waiting lists for the waiting lists in some areas of the country) and are trying to sell their Any Qualified Provider policy to the public as "patient choice".  The NatCen results show that there will be dissatisfaction from longer waiting times without a satisfaction boost from increased choice. Lose-lose for Lansley.

A good summary about British satisfaction with the NHS can be found in the BMJ article in March 2010 by Prof John Appleby of the Kings Fund. Prof Appleby makes two important points. The first is about the public satisfaction with the NHS:

The latest BSA survey reports that 64% of the British public are either very or quite satisfied with the NHS—the highest level of satisfaction since the survey began, and part of a continuous upward trend since 2002. ... Leaving aside the unlikely explanation that expectations have been taking a dive over the past decade, the NHS must have been doing something right to earn this extra satisfaction—something even Conservative supporters have noticed—and something probably not unadjacent to the large rise in funding since 2000.

Yet again, he points out that public satisfaction with the NHS is the highest ever measured. The second point is where he comments on the importance of the NHS "as an issue" with the public

Improvements in satisfaction are inversely mirrored by Ipsos-Mori’s monthly polling of the "most important issues facing Britain today." From the turn of the century, when around seven out of 10 people said it was an "issue", the number of people concerned about the NHS fell to a low of just over one in 10 in 2009 and, most recently, one in five this year. Worries about the economy, on the other hand, dramatically reflect the global banking crisis and ensuing recession.

Here, Prof Appleby points out that because the public are satisfied with the NHS they do not regard it as "an issue". This is why the NHS was barely discussed during the 2010 election, the public assumed that the NHS was doing well, did not need changes and so did not ask the candidates what they intended to do about the NHS.

Department of Health Surveys

The Public Perceptions of the NHS survey has been conducted two or three times a year since Spring 2000. It is commissioned by DH and conducted by Ipsos Mori. The survey for March 2010 (the most recent survey) says:

Satisfaction with the running of the NHS remains high at 72%. This level of satisfaction has now been recorded for over a year (since December 2008) suggesting that there has been a decisive positive shift in the public’s perceptions of the NHS. Pride in the NHS also continues to climb and is at its highest recorded level; 71% agree Britain’s National Health Service is one of the best in the world.

The report shows a graph of the level of satisfaction over time, which appears to be an updated version of the data presented to the Kings Fund shown above:


This is such a ringing endorsement of the service you would have thought that the Department of Health would have made a fuss about these figures. The Department, however, did not publish these figures when they were delivered in June 2010. In March 2011 The Observer reported:

The Observer has learned that the polling organisation Ipsos MORI submitted the results last autumn to the Department of Health for inclusion in a government survey of public perceptions of the NHS. The data, commissioned by the department, shows that more members of the public than ever believe the NHS is doing a good job – a finding contrary to health secretary Andrew Lansley's insistence that it is falling short and needs urgent change.

The department has had the findings for six months, but has yet to make them public – the most recent information on its website relates to 2007. The decision to "sit on" the positive information has fuelled a row over the way in which the government is rooting out negative statistics about the NHS to justify reforms.

In response to this article, and to a challenge to the Secretary of State by Valerie Vaz MP during the Health Select Committee, the Department finally decided to publish the results.

This "myth" is in two parts.

The first half is totally untrue since the UK has improved remarkably over the  last decade. The fact that cancer rates are not as good as other OECD countries is because the rates were so bad in 1997 and it there was a huge amount of catching up to do. The evidence is that the cancer rates are falling so quickly the UK will have a rate equivalent to France in 2012. It is disgraceful that the government continues to use cancer rates as a "justification" for the re-organisation.

The second half quotes the rise in numbers of managers and productivity. The numbers of managers in the NHS has increased over the period 1997-2010 but the rate of increase was the same as under the previous Conservative administration. Moreover, the NHS has consistently done more every year and so the rise in managers has reflected this.

Finally, and an issue that the "myth" did not cover, there are record numbers of the public satisfaction with the NHS, the public clearly do not think that the NHS needs wholesale changes.

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