The NHS: changing with the times

Patricia Hewitt MP, Rt Hon Secretary of State for Health, covers how the NHS is working for greater cost efficiency

The values of the NHS will never change - it will always be free at the point of need. However the world is changing and the NHS has to change with it. So the future destination of the NHS cannot, and will not, be defined by the number of beds, hospitals or operations it does - there is no ‘one size fits all’ vision of how the NHS should look.

Take Ron in Dudley - in his 70s and with a serious heart disease. In the past, when things got really bad, his wife would call 999, the ambulance would come and he’d be admitted to hospital as an emergency case.

Today Ron has a community nurse, an assertive outreach worker. Now, if he feels his condition is worsening, he calls her. And now, Ron says, she can do the necessary tests and stabilise his treatment in a few hours, something it would often take their hospital several days to do for him.

The year before the community nursing service started, Ron was admitted to hospital five or six times. In the first twelve months of the new service he wasn’t admitted at all. And it’s been a similar experience for all the patients targeted by the new service.

The result: transformation for the patient and the local healthcare community. In the last two years the programme has slashed the number of emergency admissions, saved over 40,000 hospital bed-days and taken 1 day off the average length of stay. Dudley’s new acute hospital has successfully reduced in size from 900 beds to just 600. And the local NHS is under-spending on its hospital budget, freeing up further savings for investment in other services.

This approach isn’t unique, but neither is it universal. But through GPs being given more freedom and more responsibility through practice based commissioning, an opportunity now exists to extend these benefits to patients everywhere.

Change is the only option
Change is not an option it is a necessity - the NHS isn’t changing the sake of it, but because if not, it will be overwhelmed: Overwhelmed by an ageing population - by 2025 the number of people over 85 in the UK will go up by two thirds, every one costing five times as much to care for than a 16 or 44 year old.

Overwhelmed by a chronically sick population - if the health challenge of the last century was infectious disease, the challenge of the 21st century is chronic disease. Patients like Ron - patients with long-term conditions - use 80 per cent of GPs’ time and 80 per cent of in-patient bed days. Overwhelmed by the challenges medical advances present. We can now keep alive babies with profound disabilities who would have died only five or ten years ago - and prolong that life, not just into childhood but into a long adulthood too.

Overwhelmed by the health risks of modern lifestyles - almost 13 million adults in Britain will be clinically obese by 2012 - and already the NHS is dealing with the impact, with a rise in strokes, heart attacks and Type II diabetes. That means we need a health service that increasingly focuses on prevention - a national wellness service, as well as a national illness service.

If there isn’t change, it is likely to prove too big a challenge to meet the financial burden placed on us by advances in technology and medical science. As pharmaceutical companies translate the human genome into new drugs and therapies, bio-engineered to the unique requirements of a particular individual with a particular disease, money to deploy the most effective new treatments must found. If we don’t change, how will the NHS keep pace with people’s expectations? Patients now rightly want the NHS to provide the same level of control, choice, safety and convenience they expect from other services.

Not many years ago, people in Britain could wait 12, 15, 18 months for a hip operation. Now it is less than six months and soon it will be less than 18 weeks from GP referral to hospital operation. But even before we’ve got there, people are already saying even that sounds like a long time. Demographics, medical science and technology and people’s expectations are global pressures, which mean we potentially face costs rising without limit.

Unless we act, the result will be growing deficits in our health services. And we are not alone. In England the deficit was £500 million last year, but in France it is £8 billion, in Spain it is £3 billion and Germany has just returned to surplus after accumulating a £2 billion deficit. There are three potential responses to this:

One may be to increase funding, as has been done in the UK, but in any system there will always be limits to how much people can pay for healthcare. Secondly services can be cut, though this means reducing quality, population coverage and the services available, which is neither necessary nor desirable. Or thirdly, to improve quality and value for money. The latter is the best option and the right option for the NHS.

Innovation and technology
In 2000, we launched our National NHS Plan - a ten-year programme of investment and reform.

As a result, the NHS has taken on over 300,000 more staff. Waiting times have dropped dramatically, cancer care has been transformed, over 200,000 more lives have been saved. But much of what has been achieved so far has been driven top-down, with nationally set targets and tough performance management. There will always be a place for national standards, including those set by the independent National Institute for Healthcare and Clinical Excellence which evaluates treatments for clinical and costeffectiveness. But too much top-down performance management demotivates staff and discourages innovation. And it has not enabled the big, consistent improvements in value for money that we need to see.

So this stage of our reforms is shifting the whole emphasis from top-down to bottom-up. Moving away from the old monolithic, monopoly NHS, to a selfimproving system where every provider organisation and member of staff has the right incentives to continue doing even better for patients and the public.

Those reforms have four key elements. Firstly on the demand side, more choice for people about the services they use, and more freedom and more responsibility for GPs. As practice based commissioners, GPs working with Primary Care Trusts focus on prevention and getting the best services for people with long-term conditions, and the best treatment for those needing acute care. Secondly on the supply side, more diverse providers with more freedom to innovate and improve in response to what patients and commissioners want.

That includes Foundation Trusts with acute hospital Foundation Trusts now able to offer community services as well, helping to break down the barrier between primary and secondary care.

Thirdly, money following the patient with a tariff system that will increasingly encourage best practice and support the provision of more services in the community. And ultimately a national system of regulation to ensure a level playing-field with the same high quality standards and the same provision of information everywhere.

Value for money
When hearing the words ‘value for money’, some interpret this as the health service being handed over to accountants. As difficult decisions are made to deal with over-spending, accusations are made of putting money above patients.

The opposite is the case. For example, if a patient with chronic heart disease, who can be better looked after at home, ends up as an emergency admission to hospital where they would not be receiving the best care, they will have been let down by their health service. If an elderly lady who stays up to 45 days in hospital after a hip fracture, when best practice would have had her home safely in 11 days, she will have been let down by her health service; the young woman who is brought in to hospital unnecessarily the day before her gynaecological procedure, instead of coming in on the same morning, will have been let down by her health service.

These patients aren’t getting the best care, with the NHS wasting precious staff time and precious money - time that should have been used to improve the care for other patients, money that is needed to pay for all the new Herceptins that science is developing.

The Department of Health recently published new information on quality and value across the NHS. It was found that there existed unacceptably large variations on all these latter, and other issues. Indeed it is estimated that if all hospitals simply achieved the same results as the top 25 per cent of hospitals - not those who are world-class, not even the top ten per cent, but the top 25 per cent - the NHS would save over £2 billion that could then be re-invested in better care and new treatments. So better quality for patients and better value for patients’ money go hand in hand. And our reforms are designed to achieve both.