Stark Wanless warning ahead of CSR

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Just ahead of the political conference season – and October's eagerly anticipated comprehensive spending review announcement – our chief executive Niall Dickson reflects on the likely consequences of Sir Derek Wanless's new review of NHS funding and performance for The King's Fund.

The government has just received one of the most comprehensive assessments of its record spending on the NHS from the individual who was responsible for making the case for that investment in the first place.

There will be those who will claim Sir Derek Wanless's review for The King's Fund is a damming indictment – evidence of government failure and wasted millions. It is certainly possible to cherry-pick the findings and to tell a gloomy tale. But that would be to oversimplify a brave attempt at reform and to reach a premature judgement on a process that in many ways has only just got under way.

Sir Derek's 2002 review for the then Chancellor marked a turning point in attitudes towards the funding of the NHS. It created a new consensus that health care in this country had been significantly under-resourced for many years. It provided both the justification and the route map for future investment. Now, five years on, it is inevitable that questions are being asked about where the money has gone and whether the Wanless vision is starting to be realised. So have we moved closer to the sustainable and world-class health care system, and ultimately healthier nation, that he envisaged?

The picture that emerges is mixed. The achievements should certainly be acknowledged. The health service today is better – considerably better – than it was in 2002; there has been real progress in tackling the very long waits for treatment that were once routine; there have been significant improvements in cancer care, the management of coronary heart disease, stroke and mental health illness; and most patients arriving in accident and emergency have a much better experience.

The review also makes the important point that it is too early to say whether the key reforms are effective or not. A week may be a long time in politics, but a few years is not enough to complete a transformation of a national health system. Sir Derek supports the broad direction of government health policy – concluding that the reform agenda is the right one.

But the review raises several concerns. First, it is clear that the additional funding has not produced the improvements in productivity that were hoped for. The way in which we measure productivity and how meaningful it is as a concept remain controversial, but the evidence does point to rising costs of providing hospital and other services. Hospital activity has certainly gone up, but the biggest increase has been in emergency admissions, which raises questions about how well people are being managed in the community. Continued delays with the national IT programme also have the potential to undermine future productivity gains.

Alongside all this is the perennial nightmare that is public health. The original Wanless report warned that unless we became better at keeping people as healthy as possible the NHS would be put under ever-increasing pressure. The depressing truth is that instead of improvements, we have seen dramatic rises in adult and child obesity with the result that the UK now faces much higher levels than even the least ambitious predictions of the 2002 review.

This need not be a counsel of despair. Four things need to happen. First, we must continue the drive to make the health system more productive, with significantly better clinical outcomes. That means greater attention must be paid to financial incentives, using the imperfect contracts with staff to change working practices and encouraging new providers to deliver new models of care. It will also mean driving clinical quality through the commissioning process like never before.

Second, we need to develop the current architecture of system reform so that it meets the needs of patients with long-term conditions and not just those requiring episodic treatment.

Third, there is much more to do to enable people to take more responsibility for their own health and health care and, in particular, to help tackle unhealthy lifestyles. The health service has a key part to play in this, although it is by no means the only player - individuals have a key role to play too.

And finally, there is still a long way to travel to create a service that is genuinely responsive to those who have to use it – patient satisfaction rates are high, but too often the experience is not as it should be and patients are denied the choice and control they should be given. For that a cultural revolution is needed.

Creating such a responsive, world-class service is not beyond the realms of possibility, but it will take time to achieve and it will not happen unless significant progress is made in these crucial areas. Without these changes, as Sir Derek indicates, there will inevitably be a new set of questions – this time about the long-term viability of our health service.

Published in The King's Fund bi-monthly update, September 2007