Our Future Health Secured?
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Our Future Health Secured?

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Email: publications@kingsfund.org.uk www.kingsfund.org.uk/publications. Edited by Isabel Walker, ...... school sports 37. Securing Good Care for Older ...

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01 Future Health Secured 4/9/07 11:42 Page i Our Future Health Secured? A REVIEW OF NHS FUNDING AND PERFORMANCE Derek Wanless John Appleby Anthony Harrison Darshan Patel 01 Future Health Secured 4/9/07 11:42 Page ii © King’s Fund 2007 First published 2007 by the King’s Fund Charity registration number: 207401 All rights reserved, including the right of reproduction in whole or in part in any form. ISBN 978 1 85717 562 2 A catalogue record for this publication is available from the British Library. Available from: King’s Fund 11–13 Cavendish Square London W1G 0AN Tel: 020 7307 2591 Fax: 07 2801 Email: publications@kingsfund.org.uk www.kingsfund.org.uk/publications Edited by Isabel Walker, Eminence Grise Text typeset by Andrew Haig & Associates, tables and figures by Grasshopper Design Company Printed in the UK by Hobbs the Printers Limited 01 Future Health Secured 4/9/07 11:42 Page iii Contents List of figures and tables v About the authors xiii Acknowledgements xv Summary xvii Foreword xxxiii Preface xxxv Part 1: REVIEW AND RECOMMENDATIONS 1 Chapter 1 Overview 3 Closing the gaps: the 2002 review 3 Public health and inequalities: the 2004 review 8 Where the money went: the current review 9 Chapter 2 Summary of NHS funding and performance since 2002 11 Introduction 11 Funding: how much was spent? 11 Input costs: the impact of the new staff contracts 13 Resources: staff, premises and equipment 15 Outputs: use of NHS services 21 Productivity: unit costs and quality 25 Health outcomes and determinants of health 31 Implications for long-term resource needs 38 Chapter 3 The policy framework 41 Policy development: moving away from central direction 41 Organisational change: a costly process 48 Service redesign to improve performance 52 Support programmes: from workforce to research 56 How effective is the policy process? 61 Chapter 4 Recommendations 69 01 Future Health Secured 4/9/07 11:42 Page iv Part 2: THE EVIDENCE 79 Introduction 80 Chapter 5 Funding: what was spent 81 Funding recommendations of the 2002 review 82 Actual health care spending since 2002 83 Health care spending beyond 2008/9 85 Chapter 6 Input costs: why they rose 89 Pay and the new contracts 92 Chapter 7 Resources: investment in staff, buildings and equipment 105 Changes in staffing levels 106 Taking a long-term view on workforce capacity building 110 New hospitals and premises 116 Information and communication technology 123 New scanners 129 Chapter 8 Outputs: the services delivered 133 Hospital services 133 Mental health 155 Primary care: general practice and prescribing 158 Other services: NHS Direct, walk-in centres and ambulance services 161 Chapter 9 Outcomes and determinants of health 165 Health determinants: smoking, obesity, exercise and diet 165 Process outcomes: safety, choice, access and satisfaction 182 Health outcomes: life expectancy, mortality and cancer survival 195 Chapter 10 Productivity: efficiency and quality 215 The 2002 review’s productivity assumptions 218 How has NHS productivity changed since 2002? 220 Unit costs of NHS services 227 Quality: changes in health outcomes 244 Appendix 1 Key drivers of overall spending paths in the 2002 review scenarios 251 Appendix 2 2002 review recommendations 257 Appendix 3 Achieving full engagement: securing good health for the whole population 261 References 263 Index 279 01 Future Health Secured 4/9/07 11:42 Page v List of figures and tables Figure 1 2002 Wanless review: UK health care funding scenarios, 1977/8 to 2022/3 5 Figure 2 2002 Wanless review : impact of cost drivers under fully engaged scenario for first five years, 2002/3 to 2007/8 6 Figure 3 2002 Wanless review : impact of cost drivers under fully engaged scenario for first ten years, 2002/3 to 2012/13 7 Figure 4 2002 Wanless review : impact of cost drivers under fully engaged scenario for first 20 years, 2002/3 to 2022/3 7 Figure 5 NHS production pathway 11 Figure 6 Projected demand for FTE doctors (based on 2002 Wanless review growth rates), 2000 to 2020,compared with actual supply 16 Figure 7 Impact of productivity assumptions on the 2002 Wanless review’s final spending recommendations under the fully engaged scenario, 2002/3 to 2022/3 25 Figure 8 Estimate of changes in NHS productivity using different measures, 1999 to 2004 26 Figure 9 GAD projections of male life expectancy in the United Kingdom, 1998 to 2022, compared with 2002 Wanless projections 33 Figure 10s of female life expectancy 1998 to 2022, compared with 2002 Wanless projections 33 Figure 11 Percentage of adults who smoke, 1980 to 2010, compared with 2005 White Paper and 2010 Public Service Agreement (PSA) targets 35 Figure 12 Historic UK spending on the NHS and projected UK spending under fully engaged scenario, 1950/1 to 2022/3 (2002/3 prices) 84 Figure 13 Projected UK spending on the NHS under different scenarios, 1990/1 to 2022/3 (2002/3 prices) 86 Figure 14 Historic and projected UK and EU spending on health care, 1960 to 2030 86 Figure 15 Rates of NHS-specific inflation and the GDP deflator, 1993/4 to 2007/8 90 Figure 16 NHS-specific inflation, 1997/8 to 2007/8, compared with inflation assumptions of the 2002 Wanless review 91 Figure 17 Pay inflation in hospital and community health services (HCHS), 1997/8 to 2007/8, compared with pay assumptions of the 2002 Wanless review 91 Figure 18 Vacancy rates for NHS staff groups, 2002–2006 95 Figure 19 Trends in emergency and elective admissions per nurse (FTE), 1999/2000 to 2005/6 96 Figure 20 Impact of the new contract on consultant pay scales, 1997 to 2006 97 Figure 21 Vacancy rates for consultants, 2000 to 2006 99 Figure 22 Trends in emergency and elective admissions per consultant (FTE), 1999/2000 to 2005/6 100 Figure 23 Average net income and expenses for GPs, 2003/4 to 2004/5 102 v 01 Future Health Secured 4/9/07 11:42 Page vi Figure 24 Cumulative increase in the headcount and FTE number of hospital consultants, 1999 to 2006, compared with the 2004 NHS Plan target 107 Figure 25 Cumulative increase in the headcount and FTE number of GPs, 1999 to 2006, compared with the 2004 NHS Plan target 108 Figure 26 Cumulative increase in the headcount and FTE number of nurses, 1999 to 2006, compared with the 2004 NHS Plan target 108 Figure 27 Cumulative increase in the headcount and FTE number of allied health professionals (AHPS), 1999 to 2006, compared with the 2004 NHS Plan 109 Figure 28 Numbers of medical staff compared with numbers of non-medical staff in the NHS, 1996 to 2006 110 Figure 29 Numbers of managers and senior managers in the NHS, 1996 to 2006 111 Figure 30 Projected demand for FTE doctors in England (based on Wanless review growth rates), 2000 to 2020, compared with actual supply 112 Figure 31 Numbers of NHS hospital beds, 1987/8 to 2005/6 118 Figure 32 Increase in number of intermediate care beds, 1999/2000 to 2005/6 120 Figure 33 Change in number of general and acute beds and average length of stay, 1999/2000 to 2005/6 121 Figure 34 Numbers of hospital beds, 1999/2000 to 2005/6 121 Figure 35 of delayed transfers of care, 2001/2 to 2006/7 124 Figure 36 Projected and actual ICT spending in the NHS, 2002/3 to 2006/7 127 Figure 37 Local and central government ICT spending in the NHS, 2002/3 to 2006/7 128 Figure 38 Local and central government ICT capital expenditure in the NHS, 2003/4 to 2006/7 128 Figure 39 Categorisation of NHS patients treated in hospital 135 Figure 40 Trends in total elective admissions for inpatients and day cases, 1998 to 2005 136 Figure 41 Absolute change in number of elective admissions by health care resource group (HRG), 1998 to 2005 136 Figure 42 Trends in elective and non-elective admissions, 1998 to 2005 140 Figure 43 Trends in total elective admissions, by source of admission, 1998 to 2005 142 Figure 44 Composition of the net increase in elective admissions of 605,000, by source and type of admission, 1998 to 2005 143 Figure 45 Sources of admission for elective patients, 1998/9 143 Figure 46 Sources of admission for elective patients, 2005/6 144 Figure 47 Trends in inpatient admissions by source of admission 144 Figure 48 Trends in day case admissions by source of admission, 1998 to 2005 145 Figure 49 Top 10 increases in planned elective admissions by health care resource group (HRG), compared with change in other sources of elective admissions, 1998 to 2005 148 Figure 50 Hospital admissions among patients aged 65–74 and 75+ per 1,000 population, 2000/1 to 2005/6 149 Figure 51 Numbers of first and subsequent outpatient attendances, 1994 to 2005 1512 Trends in referrals for first outpatient attendance, by source of referral, 1994 to 2005 151 Figure 53 Trends in first and subsequent outpatient attendances, 1994 to 2005 152 Figure 54 Trends in maternity-related admissions and hospital deliveries, 2002/3 to 2005/6 152 vi OUR FUTURE HEALTH SECURED? 01 Future Health Secured 4/9/07 11:42 Page vii Figure 55 Numbers of accident and emergency attendances 1987/8 to 2006/7 154 Figure 56 Trends in accidentencyes, 198 1547 Trends in finished consultant episodes and number of admissions where the primary diagnosis relates to mental health, 1998/9 to 2005/6 155 Figure 58 Numbers of outpatient attendances related to mental health, 2003/4 to 2005/6 157 Figure 59 Estimated total numbers of GP consultations, 1989 to 2005 158 Figure 60 Use of NHS Direct and NHS Direct Online, 1997/8 to 2005/6 161 Figure 61 Total numbers of emergency calls compared with calls resulting in an emergency response, 1995/6 to 2005/6 163 Figure 62 Numbers of ambulance journeys, by priority of journey, 1995/6 to 2005/6 164 Figure 63 Trends in numbers of consultants and registrars: public health compared with all other medical staff groups, 1997 to 2006 167 Figure 64 Numbers of NHS hospital admissions with a primary diagnosis that can be caused by smoking, 1995/6 to 2004/5 169 Figure 65 Proportion of deaths attributable to smoking, 2004 169 Figure 66 Percentage of men who smoke in selected countries, 2002 to 2005 170 Figure 67 Percentage of women who smoke in selected countries. 200 170 Figure 68 Percentage of adults who smoke, 1980 to 2010, compared with 2005 White Paper and 2010 Public Service Agreement (PSA) targets 171 Figure 69 Percentage of adults who smoke, by socio-economic group, 2001 to 2010, compared with the 2010 Public Service Agreement (PSA) targets 172 Figure 70 Percentage of obese adults, by gender, 1993 to 2005 176 Figure 71 Percentage of obese children (aged 2–15) by gender, 1995 to 2005 176 Figure 72 Percentage of obese people in 2003, by gender and age, compared with predictions for 2010 177 Figure 73 Percentage of adults who meet government guidelines for physical activity, 1997 to 2019, compared with government targets 178 Figure 74 Average consumption of fruit and vegetables per day among adults and children, 2001 to 2005 180 Figure 75 Percentage of population consuming five or more units of fruit and vegetables per day, 2001 to 2005 180 Figure 76 Number of MRSA reports compared with the MRSA target, 2001/2 to 2007/8 187 Figure 77 Percentage of patients offered choice, by primary care trust, in September and November 2006 189 Figure 78 Numbers of patients waiting, by length of wait, 2000 to 2006 190 Figure 79 of outpatients waiting longer than 13 weeks, 1996 to 2006 191 Figure 80 Percentage of accident and emergency patients seen within four hours, 2002 to 2006 191 Figure 81 Numbers of patients awaiting diagnostic tests, January to December 2006 192 Figure 82 Distribution of people waiting for diagnostic tests by number of weeks still waiting, January and December 2006 192 Figure 83 Self-reported health status: percentage of adults reporting that their general health was good, fairly good or not good, 1998 to 2005 196 Figure 84 Percentage of population reporting a longstanding or limiting longstanding illness in Great Britain, 1998 to 2005 196 LIST OF FIGURES AND TABLES vii 01 Future Health Secured 4/9/07 11:42 Page viii Figure 85 GAD projections of male life expectancy at birth in the United Kingdom, 1998 to 2022, compared with 2002 Wanless projections 199 Figure 86s of female life expectancy at bir 1998 to 2022, compared with 2002 Wanless projections 199 Figure 87 Comparative index of five-year relative survival rates for all cancers combined, among adults (aged 15–99) diagnosed in the period 1990 to 1994 and followed up to 1999, by sex, in selected European countries 203 Figure 88 Percentage change in the five-year survival rate for all cancers diagnosed between 1985–9 to 1990–4, by gender, in selected countries 204 Figure 89 Percentage change in male five-year survival rates for cancers diagnosed between 1985–9 to 1990–4 in selected countries 206 Figure 90 Percentage change in female five-year survival rates for cancers diagnosed between 1985–9 to 19ountries 206 Figure 91 Male and female five-year survival rates for selected cancers, 2001 to 2004 207 Figure 92 Percentage of population with a limiting longstanding illness in selected socio-economic groups, 2001 to 2005 210 Figure 93 Percentage of population with a longstanding illness in selected socio- economic groups, 2001 to 2005 210 Figure 94 Gini coefficient for equivalised disposable income in the United Kingdom, 1993/4 to 2004/5 211 Figure 95 Productivity and efficiency 216 Figure 96 Cumulative change in productivity associated with reductions in unit costs and improvements in quality under the slow uptake scenario, 2002/3 to 2022/3 217 Figure 97 Cumulative change in productivity associated with reductions in unit costs and improvements in quality under the solid progress and fully engaged scenarios. 2002/3 to 2022/3 217 Figure 98 Impact of productivity assumptions on the 2002 Wanless review’s final spending recommendations under the slow uptake scenario, 2002/3 to 2022/3 218 Figure 99 Impact of productivity assumptions on the 2002 Wanless review’s final spending recommendations under the solid progress scenario, 2002/3 to 2022/3 219 Figure 100 Impact of productivity assumptions on the 2002 Wanless review’s final spending recommendations under the fully engaged scenario, 2002/3 to 2022/3 219 Figure 101 Estimate of changes in NHS productivity using different measures, 1999 to 2004 220 Figure 102 Average length of stay in hospital, 1998/9 to 2005/6 2213 Percentage of elective patients treated as day cases 222 Figure 104 Percentage of patients readmitted as an emergency within 28 days of discharge, 2002/3 to 2005/6 222 Figure 105 Rates (net) of public satisfaction with NHS services, by type of service, 1996 to 2005 223 Figure 106 Summary of National Audit Office investigation into Gershon efficiency gains reported by the Department of Health to date, 2007 226 viii OUR FUTURE HEALTH SECURED? 01 Future Health Secured 4/9/07 11:42 Page ix Figure 107 Changes in elective inpatient activity, total costs and unit costs, 1998/9 to 2005/6 228 Figure 108 Changes in elective day case activity, total costs and unit costs, 19 228 Figure 109 Changes in emergency activity, total costs and unit costs, 1998/9 to 2005/6 229 Figure 110 Changes in elective plus emergency activity, total costs and unit costs, 19 229 Figure 111 Annual percentage changes in elective inpatient activity, total costs and unit costs, 1998/9 to 2005/6 230 Figure 112 Annual percentage changes in elective day case activity, total costs and unit costs, 19 230 Figure 113 Annual percentage changes in emergency activity, total costs and unit costs, 1998/9 to 2005/6 231 Figure 114 Annual percentage changes in elective plus emergency activity, total costs and unit costs, 1998/9 to 2005/6 231 Figure 115 The costs of not reducing unit costs in line with 2002 Wanless review, 2002/3 to 2005/6 233 Figure 116 Additional activity that could have been provided if unit costs had reduced in line with 2002 Wanless review assumptions, 2002/3 to 2005/6 233 Figure 117 Changes in outpatient activity, total costs and unit costs, 1999/2000 to 2005/6 234 Figure 118 Annual percentage changes in outpatient activity, total costs and unit costs, 1999/2000 to 2005/6 235 Figure 119 Changes in inpatient mental health activity, total costs and unit costs, 2001/2 to 2005/6 237 Figure 120 Changes in outpatient mental health first and follow-up attendance activity, total costs and unit costs, 2001/2 to 2005/6 237 Figure 121 Changes in mental health domiciliary visits activity, total costs and unit costs, 2001/2 to 2005/6 238 Figure 122 Changes in mental health secure unit activity, total costs and unit costs, 2001/2 to 2005/6 238 Figure 123 Changes in total costs, unit costs and number of prescriptions dispensed in the community, 2000 to 2006 240 Figure 124 2002 Wanless review projections of NHS expenditure on statins in the United Kingdom, compared with estimated actual expenditure, 2000 to 2010 241 Figure 125 Trends in numbers of prescriptions and statins dispensed in the community, 2000 to 2006 242 Figure 126 Changes in total costs, unit costs and numbers of statins dispensed in the community, 2000 to 2006 243 Figure 127 Changes in volume and unit costs of simvastatin dispensed compared with all statins dispensed, 2000 to 20006 243 Figure 128 2002 Wanless review: annual value of change in NHS productivity due to improvements in quality under fully engaged/solid progress scenarios, 2002 to 2022 245 Figure 129 Trends in Department of Health NHS aggregate output measures with and without adjustments for quality, 1998/9 to 2003/4 247 LIST OF FIGURES AND TABLES ix 01 Future Health Secured 4/9/07 11:42 Page x Table 1 Spending projections under different scenarios: overall summary 4 Table 2 Actual UK spending on the NHS compared with 2002 Wanless projections under different scenarios, 2002/3 to 2022/3 12 Table 3 Comparison of the NHS Plan growth targets with actual workforce growth 15 Table 4 Numbers of general, acute and intermediate care beds in England, 1990/2000 to 2005/6 18 Table 5 Number of NHS activity categories and estimated shares of total English NHS spending, 2005/6 19 Table 6 Trends in hospital admissions, 1998/9, 2002/3 and 2005/6 21 Table 7 Summary of percentage changes in real unit costs of services since 2002/3 27 Table 8 UK life expectancy projections in 2022 32 Table 9 Progress towards 1998 White Paper smoking reduction targets, by group 35 Table 10 Policy-making scorecard: government performance against Cabinet Office criteria 63 Table 11 Summary of health spending in the UK under different scenarios, 2002/3 to 2022/3 83 Table 12 Actual UK NHS spending compared with 2002 Wanless projections under different scenarios, 2002/3 to 2007/8 84 Table 13 UK NHS spending 2007/8 90 Table 14 NHS-specific inflation rates, 1997/8 to 2007/8 92 Table 15 Estimated costs of implementing Agenda for Change, 2005/6 to 2008/9 94 Table 16 Recruitment and retention of nurses and other health professionals in NHS trusts, 2006 94 Table 17 Breakdown of PCT spending on General Medical Services, 2005/6 102 Table 18 Number of doctors, nurses, allied health professionals and non-medical staff in the NHS (headcount), 1996 to 2006 106 Table 19 Projected demand and supply of FTE doctors under 2002 Wanless scenarios, 2005 to 2020, compared with actual supply 113 Table 20 Number of physicians per 1,000 of the population in selected OECD countries, 1999 to 2004 113 Table 21 Number of nurses per 1,000 of the populCD countries, 1999 to 2004 114 Table 22 Analysis of the increase in the total NHS wage bill, 2000 to 2004 115 Table 23 Number of NHS hospital beds in England by specialty, 1999/2000 to 2005/6 119 Table 24 Number of NHS intermediate care beds in England, 199 120 Table 25 Number of admissions in the United Kingdom, by country, in matched units, from 2005 and 2006 surveys 122 Table 26 Number of hospital beds in all sectors per 1,000 population in selected OECD countries, 1999 to 2004 123 Table 27 Spending on ICT in the NHS, 2002/3 to 2006/7 126 Table 28 Number of NHS activity categories and estimated shares of total NHS spend, 2005/6 134 Table 29 Trends in elective admissions for inpatients and day cases, 1998 to 2005 135 Table 30 Top 10 increases and decreases in total elective admissions by health resource group (HRG), 1998 to 2005 137 x OUR FUTURE HEALTH SECURED?