Waiting Lists

Writing in the Health Service Journal in 1998 the then Health Secretary Alan Milburn said: "Long waiting lists undermine public confidence in the NHS. They embody the sense of bureaucracy, slowness and inconvenience at the heart of declining satisfaction with the health service." He concluded: "By comparison with other countries' healthcare systems, they are our Achilles heel. Like it or not, lengthening waiting lists are a powerful metaphor for the state of the health service." By 2000, this rhetoric has been transformed into the NHS Plan, and at its core was a war on waiting.

Fast forward to December 2004 - the deadline for many of the Plan's targets, and NHS chief executive Sir Nigel Crisp's annual report claimed success.

Sir Nigel said: "In the summer, I said that if the NHS was a business, our share price would be rising. At the end of 2004 I have not changed my mind because we are hitting our key targets and our surveys show that patient satisfaction levels are very high."

The bad news is that the government hasn't quite met its targets. The NHS Plan aimed to eliminate all inpatient waits over six months by 2005, but just under 70,000 were still waiting longer than this in October 2004. It also pledged to end all outpatient waits in the same period, but despite strenuous efforts, 77,000 people were still waiting longer in September.

Meanwhile, the total number waiting for admission to hospital remains huge - 857,000 at the last count, a fall of just 5% in four years. Despite these less than triumphant figures, the government genuinely has something to celebrate, with 99% of people now able to see a GP within two days, and a similar proportion of A&E visitors staying no more than four hours.

Sir George Alberti, the government's emergency care czar, said: "The A&E target was groundbreaking and more ambitious than any international equivalent. The NHS has transformed its emergency care performances so that it is now the envy of the world."

While this claim suggests the government thinks it has cracked the waiting list problem, increasing the system capacity remains at the top of the agenda.

Two of the fundamental principles developed further by the government in 2004 - the diversification of providers (from nurse and pharmacist supplementary prescribers to day surgery treatment centres) and greater patient choice (beginning with choice of where to have surgery), both stem from the need to develop more capacity and to cut down waits.

Giving patients a choice may give them a feeling of consumer-style control over their care, but it also provides a fast increase in capacity which will deliver to short political timelines.

1 April 2005 will see the latest major reform to secondary care, the Payments by Results system. The system will make the cost of hospital treatment more transparent and thus allow greater competition between providers of care. As with previous reforms, many groups have serious reservations about the new scheme.

Responding to Sir Nigel's end of year report, King's Fund chief executive Niall Dickson warned: "We are embarking on a major experiment using market forces which may extend choice for patients but could create instability and we remain concerned that not enough is being done to improve the health of the most disadvantaged groups."

BMA Chairman James Johnson, speaking at a conference on the NHS Improvement Plan, said there was little benefit of granting patients a choice of extra hospitals for an operation and that it jeopardised the financial future of some acute trusts.

He said: "Under Payment by Results, if a hospital attracts patients, it attracts the money.  But if it doesn't attract them in sufficient numbers then it goes bust."

Despite protestations from primary care leaders, secondary care  will remain the political priority, and in turn, the greatest ideological battleground.

But there is some cause for optimism. Payments by Results is far from being the only major reform due in 2005, and many of the others tackle other problems in the service.

Most fundamentally, proposals contained in the Public Health White Paper will undoubtedly do much to transform the NHS from a sickness service into a health service, but the government knows that this could take decades.

PCTs are now consolidating their role as commissioners of care, and the introduction of GP commissioning in 2005 should be a further catalyst in the shift away from a hospital-focused NHS to a primary care-led service.

Shaky foundations

After a protracted and bitter political battle with its own backbench MPs and other critics, the government succeeded in creating the first 20 foundation trusts on 1 April but the flagship hospitals have been plagued by financial concerns almost from the very outset.

Fears that the top-performing hospitals would create a two-tier NHS had been the primary objection among backbenchers and unions, but worries about the financial independence of the trusts were uppermost in the thoughts of Chancellor Gordon Brown.

It took just months for the vision to fall apart, with three foundation trusts losing their three-star rating in the annual performance review in June.

Addenbrookes Hospital, Moorfield Eye Hospital, Papworth Hospital and Peterborough Foundation Trusts each lost one of their three stars but were allowed to retain their foundation status.

Monitor, the independent watchdog set up specifically to monitor foundation trusts revealed that failure to meet financial management targets set by the Healthcare Commission was implicated in three out of the four hospitals.

However, Monitor effectively dismissed the assessment of the other watchdog, saying it was satisfied all had 'sustainable and viableb' usiness plans against its own separate criteria.

Then, in October, Monitor conceded that another one of the pioneers really was facing serious financial problems.

Bradford Teaching Hospitals NHS Foundation Trust is expected to end the financial year in March 2005 with a loss of £11.3 million, a worsening financial situation only uncovered by Monitor in August in a routine review.

A spokesman for the trust said implementing the new NHS pay scheme Agenda for Change, the new consultant contract and other inflationary pressures were affecting not just Bradford, but all trusts.

"Additionally, as an NHS Foundation Trust, we are piloting the new funding systems for NHS hospitals and we no longer have access to financial support from the wider system," he said.

A firm of consultants, Alvarez and Marsal,  specialising in 'turning around' failing institutions, has been drafted in to help the trust improve its standing, or risk being the first to lose the special status.

Foundation trusts are expected to deliver against the same key national targets as other trusts reducing waiting times and improving clinical outcomes, but have greater freedom to raise capital and pursue plans for service development independently.

Balanced against these freedoms, the trusts are accountable to a locally elected board and can have their 'licence' withdrawn if they are found to be mismanaging their finances.

BMA criticism of foundation trusts remains centred on fears they could divide the NHS and create large variations in the quality of patient care. Chairman James Johnson said: "Until all hospitals have the same freedom from Whitehall control as foundation trusts, the quality of treatment you get could depend on where you live."

Tony Blair has claimed all NHS acute trusts in England will be in a position to apply for foundation status by 2008, but the current difficulties faced by some of those in the vanguard casts serious doubt on this bold vision.

A YEAR IN THE LIFE OF THE NHS

In January, 574 Patient and Public Involvement Forums covering every NHS trust and PCT were created, replacing existing independent Community Health Councils (CHCs) after much dispute about the new body's ability to challenge authority and represent patient interests.

The national co-ordinating body, the Commission for Patient and Public Involvement in Health (CPPIH) admitted at the outset that between 10,000 to 15,000 people were needed to make the system fully operational across the country, and in July, the figure stood at just 5,000.

Established in 2003, the CPPIH only got into its stride once the new PCT-based forums were established  but by July found itself one of the victims of the government's war against bureaucracy.

Along with a number of other 'arm's length bodies' the CPPIH is to be abolished in order to streamline bureaucracy and redirect funds to the frontline. No other body is to take on its functions, but local forums will have administrative help from the Department of Health.

Sharon Grant, chair of the body concluded: "I believe that these proposals will be seen as betraying the government's promises to provide an independent voice for patients and the public in health."

In February, the government signalled that the profusion of targets measuring NHS performance had done their job, and declared the emphasis would shift to quality of care.

Health Secretary John Reid told NHS chief executives and senior clinicians: "NHS targets are working," adding that in four years time, near the end of the NHS Plan's ten year period, most will have been reached.

'Core standards' will outline the quality of care every patient can expect, while a second set of 'developmental' standards will set out what NHS organisations should aspire to - educating patients to manage their own long-term conditions, for example.

NHS professional organisations have welcomed the Standards for Better Health document and the accompanying consultation. James Johnson, chairman of the BMA said he was pleased the government had responded to its repeated calls for fewer targets and more useful information for patients.

"Doctors dislike and distrust the star ratings system. It serves only to measure the hospital's ability to meet political targets and fails to recognise the quality of patient care."

Johnson added that the process interfered with patient care by skewing clinical priorities and neglecting patient needs.

In March, Pfizer and Haringey Teaching Primary Care Trust (TPCT) launched a joint project to help patients with coronary heart disease, congestive heart failure and diabetes manage their condition better.

The 12-month pilot is intended to produce measurable health improvement in around 600 enrolled patients, helping them take greater control of their conditions and make best use of NHS services.

The programme did not cover any agreement on the prescribing of its drugs, which will remain in the hands of NHS professionals.

Company spokesman Roy Sutherwood stressed: "There is no quid pro quo in this agreement," but added: "If you are confident in your products then yes, of course, there should be commercial benefits."

The £250,000 project is jointly funded by Pfizer and NatPaCT, the primary care modernisation unit, and is part of its wider Transformational Change Programme for PCTs, aimed at redesigning services around patients with chronic conditions.

Four care managers, hired and trained specifically to run the programme will educate patients enroled in the scheme and will use care management technology tools developed by Pfizer Health Solutions, a subsidiary of the pharmaceutical company.

April means a new NHS financial year and a major new set of reforms too.

In 2002, the government chose 1 April to make the new Primary Care Trusts the most powerful NHS bodies, with the aim of devolving power to local frontline staff and reversing decades of NHS management which emphasised a secondary care led system run directly from Whitehall.

Two years on, the theme of devolution and reform continued with the first ten foundation hospitals, the new GP and consultant contracts and a single NHS standards watchdog, the Healthcare Commission, all coming into being on the same day.

In May, the NHS Alliance spoke out on the struggle of frontline clinicians to overcome the older, hierarchical systems based around health authority control.

PEC chairs, the PCT chair and chief executive are intended to be the core decision-makers or Three at the Centre in every local health economy in England, but the NHS Alliance says this vision has not been fully realised in many PCTs.

NHS Alliance chairman Dr Michael Dixon said: "The balance of power that has been in place for half a century has shifted. Perhaps not yet fully or perfectly, but it has shifted in a way that is irreversible.

"The Three at the Centre leadership structure is absolutely fundamental to creating a modern, patient-centred, quality health service. But much of the NHS is wedded to a binary system chair and chief executive, lay board and management. The PEC is a conundrum in action."

In June, the government promised to eliminate postcode prescribing in cancer once and for all, unveiling a number of measures to monitor prescribing patterns more closely.

A report by government cancer tsar Professor Mike Richards found regional variations could not be attributed to differences in case mix or numbers of consultant oncologists and haematologists, but that wider capacity issues - lack of space to prepare and administer the drugs or shortages in pharmacists, nurses or junior doctors - had contributed to the problem.

The introduction of electronic hospital prescribing will be brought forward to 2006 in order to more easily identify which trusts are lagging behind in prescribing, and the NHS has struck a deal with data suppliers IMS to provide a better picture on prescribing patterns.

Michael Dixon, chairman of the NHS Alliance said: "Some people refer to NICE as the organisation that can't say no," he recently told the BBC. "NICE tends to approve a lot of procedures and medications that simply aren't a priority on the frontline. The fact that some NICE guidelines are ignored is not necessarily a bad thing."

This view is not shared by many charities, who continue to push for greater access and who have welcomed the new measures.

In July, the latest star ratings for 569 trusts in England were produced by the new watchdog, the Healthcare Commission. It said the ratings showed the NHS was improving overall, with more trusts awarded two or three stars, and 93% of acute trusts having no one waiting more than nine months for inpatient treatment, even though the ratings system was tougher than last year.

But the overall improvement in PCT ratings masked a huge change around in the rankings, with 31 of the 44 PCTs awarded three stars last year dropping out of the top ranking - most dropping to two star status - but Hertsmere PCT losing all of its stars in just one year. Their places have largely been taken by former two star trusts, but the factors which separate a three star trust and a two star neighbour are often very small.

In August, the government unveiled a plan for the second half of the 10-year period covered by the NHS Plan, claiming that the war on waiting times will soon be won, and that patient choice is now central to improving the service.

Despite plans for expanded use of private contractors in fast-track surgery centres and increasing the number of foundation trusts, Health Secretary John Reid told the Commons the government was committed to the founding principles of the NHS.

From the end of 2005, the government says patients will have the right to choose from at least four to five different healthcare providers and by 2008, will have the right to choose from any provider, as long as they meet clear NHS standards and are able to do so within the national maximum price agreed by the NHS.

Bolstering this central agenda of patient choice and patient-centred care will be the launch of HealthSpace a secure online medical record for each NHS patient, allowing them to note their individual preferences about their care.

The NHS Confederation was just one representative body to pour a little cold water on the plans, warning the government not to focus exclusively on solutions for headline-grabbing secondary care.

Chief executive Gill Morgan said: "It is important to give people who need surgery a say in when and where it takes place. But with 17.5 million people living day in, day out, with long-term conditions, it is vital the choice debate does not become exclusively preoccupied with hospital care."

A poll of Confederation members found that 77% of NHS leaders feel the current health debate ducks many of the difficult decisions facing local NHS organisations, with the majority claiming postcode variation in services was legitimate when based on local choices, and that "not all hospitals will be able to provide all services in the future".

In September, a groundbreaking new pharmacy contract was agreed, promising to transform the profession into a new convenient route for patient access to NHS services.

Fundamentally, the contract will reward pharmacists for the range and quality of services they provide rather than, as at present, the volume of medicines they dispense the same philosophy used in the new GMS contract introduced in April this year.

Health minister Rosie Winterton said: "This new contract represents the beginning of a new era for pharmacy in the community, in which everyone will benefit. Until now, pharmacists have been an untapped resource. I want to see them more integrated with the NHS family."

Accredited community pharmacists with the relevant training and facilities will be able to offer patients a Medicines Use Review service, allowing patients to discuss their medication with the pharmacist and designed to develop patients' understanding of their condition and how to get the most from their medicines.

The government hopes the contract, part of its plans to offer more health services through a wider range of providers, will encourage pharmacists to broaden the range of preventative services they offer into areas like checking blood pressure and offering smoking cessation services. The government will provide funding of £1.8 billion for the contract, which comes into effect on 1 April 2005.

In October, the government unveiled plans to reintroduce general practices commissioning care for the first time since the fundholding era.

The move is intended to motivate primary care clinicians and accelerate progress towards patient-centred care, beginning in 2005.

The system has similarities with GP fundholding, a system considered to have many positive aspects but widely criticised for having serious flaws, but differs significantly in that PCTs will hold the purse strings and any savings made from managing referrals more efficiently will be shared between practices and PCTs, with all savings reinvested into patient care.

North Bradford PCT is already involved in Practice-led Commissioning and Dr Ian Rutter, a GP in Bradford, said: "Our experience of offering Practice-led Commissioning has been immensely positive. It has achieved greater involvement of clinicians and practices with their patients in decisions about care.

"We have been able to deliver improved quality and better use of resources by empowering primary care to manage secondary care budgets."

Any overspends will be met by the PCT, but practices will nevertheless be expected to balance their books over a three-year cycle. Those that are unable to do this will be barred from the scheme except in exceptional circumstances.

In November, the government published its long-awaited Public Health White Paper, including plans to turn the NHS from a sickness service into a health service.

Nigel Edwards, director of policy for the NHS Confederation, said: "This White Paper really pushes public health towards the top of priorities across the whole spectrum of government for the first time. For too long, there has been a focus on waiting lists and hospitals to the detriment of the real health benefits that could be gained by tackling public health issues. Now we have the foundations in place to make a real difference, but the hard work is still to come in putting this into practice."

In December, the government announced that its Agenda for Change programme for simplifying and reforming NHS staff pay scales had been agreed with unions.

Health minister John Hutton said it was the biggest job evaluation ever, with some 650 different types of jobs covering over 70 professions assessed over the last five years.

Healthcare union Unison leaked proposals that could see nurses performing surgical procedures such as hernia repair, vasectomies and arthroscopies. Up to 5,000 'surgical care practitioners' will be appointed over the next decade in a move considered necessary to make up for the shortage of junior doctors now working fewer hours under the EU working time directive.