The NHS under the coalition government

Part two: NHS performance
Comments: 9
This report, the second part of 'The NHS under the coalition government', looks at how well the NHS has performed under the coalition government. The report acknowledges that assessing the performance of any health service is an inexact science for many reasons, but using routinely available data, the report creates a conventional ‘production path’ – describing the financial inputs to the NHS before detailing its outputs, such as hospital admissions, or A&E attendances.

It draws on surveys of patient and staff experience; access to care as measured by waiting times; and data on outcomes, safety and quality of care. The report concludes with an analysis of NHS productivity and financial performance between 2010 and 2015, and an assessment of its prospects in the next parliament and beyond.   

Key findings

  • NHS performance held up well for the first three years of the 2010–2015 parliament but has since come under increasing strain.
  • Patient experience of the NHS generally remains positive, and public confidence is close to an all-time high and the very limited data on outcomes, safety and quality of care indicates some improvement. 
  • There are growing concerns about the quality of mental health services and challenges in achieving parity of esteem between mental and physical health.
  • A substantial NHS deficit in the final year of this parliament seems certain, despite extra funds during 2014/15 and with funding boosted more in real terms since 2010 than planned.
  • Most of the NHS is working close to its limits, and staff morale is a growing concern – making prospects for NHS performance in the next parliament extremely challenging.

Policy implications

  • The next government must commit to additional resources while avoiding grand reforming gestures. Without more funding, there is a real prospect of accelerating decline in NHS performance.
  • The NHS must renew its commitment to productivity improvements. This will involve finding time and ways to equip staff at all levels with skills in quality improvement.
  • A transformation fund is needed to pump-prime investment in new models of care on a scale commensurate with the challenges facing the health and social care system.
  • A greater priority must be given to reforming the NHS ‘from within’ – including developing leadership (especially clinical leadership) and nurturing cultures focused on safe and high-quality care.
The NHS under the coalition government front cover

Print copy: £10.00 | Buy

No. of pages: 70

ISBN: 978 1 909029 48 4

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#543409 Phil Taylor

On the whole a very balanced presentation.

The BBC online piece with the headline "NHS problems 'at their worst since 1990s'" looks like a hatchet job.

Surely you overplay the financial deficits issue? The net deficits across the system this year are likely to end up being some small number of £100 millions. This is pretty much a rounding error across the £113 billion overall NHS budget.

Yes, things are tight but where is the surprise in that?

#543412 Anthony Bowater

The BBC'S 'hatchet job' referred to by the last contributor is typical of the left wing bias shown by the organisation. There has been an increase in the negative reporting of Government actions and particulally those of Premier Cameron.

#543418 Dr Michael Crawford

This is lengthy but worth a read!

To interpret this report one needs to be aware of two things. Firstly, the way we fund health services in this country, by everything having to come out of a tightly-controlled budget, means that the defining characteristic of the NHS is that it is a competition between patients for resources. Contrast this with systems which involve invoicing for items of service at a realistic price; each patient generates new resources for the provider organisation.
Secondly, there is Goodhart’s Law, named after a Bank of England economist. “When a measure becomes a target it ceases to be a good measure.” The introduction of targets meant that patients using those parts of the service to which they apply become especially competitive; in this report we have surgical waiting, emergency department throughput times and cancer management. Of course, there is everything right about patients’ care meeting those targets but because we use attainment of the target as a measure, and Trusts need to be able to quote favourable results by these measures, patients who use other parts of the service find that resources are diverted. It was more important in Mid Staffs to employ nurses to get through a surgical list quickly than to give food and drink to patients on the wards for the elderly.
So, as financial pressures have developed over the past five years Trusts have protected elective surgery and cancer services; attainment of those targets failed to measure the true overall performance of the NHS. The finances have now deteriorated to the point where they cannot be protected any longer.
Patients requiring mental health services have never benefitted from targets in that way, so they are much less competitive. Those services have been plundered to support the others. Only now is this being recognised; I have long been aware that my cancer patients were not receiving anything like the amount of psychologist support that is appropriate. I suggest that over the last few decades access to mental health services would be a better measure of NHS performance than surgical waiting times.
The competitive nature of access to healthcare means that competitive people are at an advantage; Assertive, aware and affluent people will always out-compete the deprived in society. The one area where the playing field is most level is the emergency department. It is really no surprise that those who find their requests for GP attention are considered uncompetitive by the triage system end up in the ED. And patients who cannot be discharged from the ward because no appropriate out-of-hospital. Service is available out-compete those in the ED needing a bed. The effects are there for all to see. And as the Prime Minister will doubtless remind us in the next few weeks, as he did last night, when it comes to attention in the DE a very sick child with a prominent politician for a father will always trounce the competition.
Of course, when a Trust exceeds its income the deficit is required to be recouped in future years. This means that future patients are not merely competing with each other but also with past patients. They are also competing with the PFI provider.
There were no surprises for me in this report.

#543423 Nick Welch

This King's Fund report is a very fair assessment of the past five years, as is Dr Crawford's comments. It never fails to amaze me how well the healthcare workers do despite the ever-tighter budgets and bitching from the press - both of which must be morale-sapping!! Now we are in for weeks of false promises from those hoping to persuade us to vote for them. Our NHS should be removed from the political arena and meddlesome politicians!!

#543427 Christopher Clayton
Research Scientist

Our local hospital in Chester has been missing targets both for A and E, and for starting cancer treatment. It used to meet targets in both areas, and the failure to meet them has started in the last few quarters. I wonder whether the gentleman who accused the BBC of left-wing bias would be happy to have the start of his own treatment delayed, were he unfortunate enough to be diagnosed with this disease?

#543432 Chris Gunstone
East Staffs CCG / Queens Hospital Burton

There have been over 4 new consultants appointed to the NHS every day over the life of this government - a real achievement by any standards. However despite this, performance has deteriorated.
This suggests 3 possible reasons -
1) Appointment of consultants is inversely proportional to NHS performance (which seems counter-intuitive)
2) We would have been a lot worse if they hadn't been appointed - which is not supported by the initial improvement over the first 3 years of this parliament.
3) The most likely, yet most surprising conclusion, is that further consultant appointments are not related to NHS performance (as measured currently).
So are we measuring the correct things?
Or is the fact that the number of GPs has dropped in real terms of this parliament's lifetime significant? (Compared over 4 per day new consultants, we have barely managed 1 new GP every two days in the same time period!).

#543462 Nick Mann
Well St Surgery

Comments above regarding minimal deficits, increases in NHS doctors and left wing media bias seem extraordinary in pointing the finger yet again at lack of productivity in NHS.
Hospitals being forced into bankruptcy by PFI debts they have not incurred; falls in doctor:population and hospital bed:population ratios to virtually the lowest in OECD and Europe; five years of almost daily, factually inaccurate media denigration of the NHS and its medical staff; outsourcing and fragmentation of medical services and pathways to private companies despite repeated records of failure and fraudulent behaviour; failure to address A+E overflowing due to reduction in inpatient capacity; failure to match funding to the rhetoric of "transferring care into the community"....these are all a result of the active choices of a neoliberal government in denial, but seemingly determined to commercialise England's health service, whatever the consequences.
We are losing the infrastructure comprising the best health service in the world, but the argument continues to revolve around the design of the furniture.

#543464 JYG
District Nurse

Seemingly no one is is cognisant of the impact of cutting front line staff in the community. Despite noted increases in nursing staff there are 3000 fewer community nurses (all types excepl HVs) and nearly 2000 fewer qualified District Nurses (the nursing equivalent of a GP). You can discuss GPs vs consultants till the cows come home- if there's no improvement in community nurse numbers or adequate social services, A&E will continue to be overused and hospital wards overburdened. There's no need for great new schemes, but a desperate need to support these crucial out-of-hospital services that are being systematically destroyed as funding is diverted to those with the most power and the loudest voice

#543465 JYG

PS Agree with Nick's comments above and loved working as a DN being GP attached. Just a shame no one seems to realise what is being lost, and how difficult it will be to rebuild community services.

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