Chapter 7

2008 - 2017

Chronology:

Introduction

The decade opened with a world wide overhang of financial problems.  The sub-prime mortgage crisis in the USA escalated into global economic difficulties and a general credit-crunch.  The United Nations eight millennium development goals, combating hunger, child mortality and AIDS, were unlikely to be met as rising food prices and the cost of oil pushed millions more into poverty.

Compared with the muted celebration of the 50th anniversary of the NHS, the 60th was more widely commemorated.  Health Service Journal listed the 60 people considered most influential - Bevan being the undoubted winner. 

Few among the many publications celebrating the anniversary dealt with clinical developments or the service to patients.  Most dealt with macro issues of politics and funding. The Chief Executive of the NHS, David Nicholson, produced his illustrated annual report on the state of the NHS that was far from humble. The King's Fund produced data briefings.  The House Magazine (of the Houses of Parliament) produced an anniversary supplement with articles commenting on the qualities of the Secretaries of State of the last 30 years together with articles by those ex Ministers.  Frank Dobson attacked the current health policies of his party as not only unpopular but wrong in its accent on the market place.  Alan Milburn believed that devolution had not proceeded far enough and suggested that the better local authorities might undertake health service purchasing.  The King's Fund produced an analysis of changing workload, finance and waiting times over 60 years.  The braver souls predicted the future of the service, some urging major changes in finance and organisation that were unlikely to occur. The Nuffield Trust published Rejuvenate or Retire, views of the NHS at 60 in which senior figures mused on the past performance and future possibilities of the NHS. There was basic agreement that it should remain taxpayer-funded, free at the point of use. Even those who believed in the insurance model did not think it would happen.  When the question of radical alterations had been raised 20 years previously with Mrs. Thatcher, Sir Kenneth Stowe then Permanent Secretary, recalled her saying "There is no constituency for change."  Most agreed that the purchaser-provider split was vital, that the private sector must provide important competitor services within the NHS and that more decisions should be taken locally.

Labour had been in power throughout the sixth decade of the NHS.  Now the popularity of the party and the prime minister was on the wane.  Economic problems as a result of rapidly rising fuel prices risked sending the economy into recession.  Public sector workers considered or took strike action.  The housing market showed falling prices, month after month.

The four UK Health Ministers restated the principles of the NHS.

1. A comprehensive service available to all

2. Access to services based on clinical needs and not on the ability to pay

Aspiration to high standards of excellence and professionalism

NHS services must reflect the needs and preferences of patients, their families and their carers

Working across organisational boundaries with other organisations in the interests of patients, communities and the wider population

Commitment to the best value for taxpayers' money, making the most effective and fair use of finite resources

Accountability to the public, communities and patients that it serves.

Within a few months these principles were challenged when patients, who found effective forms of treatment were not being provided by the NHS, and paid for them privately, sometimes had their NHS care withdrawn.  Some new drugs were costly and extended the life of those with an incurable disease, but did not affect the outcome.  NICE, applying the criteria of cost effectiveness, might not approve these drugs.  Patients faced with death which might be delayed by therapy not available within the NHS sometimes bought them  personally, perhaps at the cost of thousands of pounds.  This might debar them from receiving normal NHS care at the same time.  Protests in the Sunday Times led the Secretary of State to commission an enquiry. In November 2008 Professor Mike Richards recommended that the Government,  NICE  and  the  pharmaceutical industry should act to ensure that more drugs were available for NHS patients on the NHS, but that those few that still wished to buy additional private care should  not  lose  their entitlement  to  NHS  care  as  long  as  the private element could be delivered separately from NHS care. The speed with which such drugs were referred for assessment by NICE should also be increased. Government accepted these recommendations.

Information systems

Internet was now a major source of information for professionals and the public alike.  Even 19th Century archive material, such as the British Medical Journal, was available online at PubMed.  Patients had reliable sources of information from the NHS website  (NHS Choices), but also from a patient's perspective on  Health talk online.

Medical Progress

The Drug treatment of disease

Public Health

The goal of the WHO declaration in 1978 on Healthcare for All, with its accent on primary health care, was not achieved.  In 2008 a new report appeared from the same city, Alma Ata now known as Almaty, Now more than ever.  The evidence was robust that better outcomes for the population at lower cost were achieved in systems that distributed resources according to health care needs, eliminated co-payments, assumed responsibility for funding and provided a broad range of services within primary care.   The goals of 1978 had not been achieved, but now at least more was known about how to handle the challenges.

The geographical pattern of mortality in Great Britain over the past 25 years was mapped to show how likely was death depending on location. The Grim Reaper’s Road Map: An Atlas of Mortality in Britain showed how people’s deaths are affected by where they live, how much money they have, the type of work they do and their lifestyle. They showed a person’s chances of dying from a particular cause in a particular place, compared to the national average chance for that cause of death, having standardised the distributions of population by age and sex in each area. The maps showed deaths from a range of causes, including heart attack, cancer, murder, electrocution and death during surgery.  The average age of death since 1981 is 74.4 years; 71.2 for men and 77.4 for women, while in the best neighbourhoods, including Eastbourne (on the south coast of England), 42 percent of those who died were over 80 years old, in others, including Glasgow Easterhouse, 25 percent were under 60 years of age. Across much of the south of England outside London, and in a few isolated enclaves of prosperity in the north, Wales and Scotland, people’s chances of dying each year have been up to 30 percent lower than the average since 1981.  What causes most of the variations were not genetic factors, said the authors, but environmental issues and whether we smoke, drink and exercise.  Death rates are higher where people were poorer. Internal migration was another key factor, making different parts of Britain increasingly home to either the poor or the rich.  The maps were based upon 14 million death records which showed the standardised mortality ratios of every town and city in Britain from 1981 to 2004. Policy Press) 

In its drive for quality, the Department of Health had set targets for the reduction of deaths in the major groups such as cancer, circulatory diseases, suicide and undetermined injury, and accidents.  Throughout the developed world death rates were falling, and in most cases they were doing so in England.

Immunisation

As a result of lower levels of immunisation against measles, the numbers of cases continued to rise exceeding 1000 in 2008.  Targeted immunisation programmes were introduced.

Cardiology and cardiac surgery

For some 20 years coronary angioplasty had been available and increasingly centres had been using it in the acute phase of a heart attack.  In 2008 the Department of Health said that this treatment should be made universally available and hundreds of lives would be saved by following this policy.  Already routine in conurbations, expansion to country areas was clearly going to be difficult.

Organ Transplantation

The scope of tissue transplantation was widened by a pioneering biomedical engineering operation. A joint team from Bristol, Spain and Italy collaborated in the procedure which enabled the removal of  trachea damaged by tuberculosis, and its replacement with a new piece, without the need to use drugs to suppress tissue rejection.  They began with a 7 cm segment of trachea from a 51 year old woman who had died of a brain haemorrhage. After stripping the trachea of all its potentially antigenic cells, the scientists reseeded the cartilage scaffold with cells from the recipient—a culture of epithelial cells from her own right bronchus for the inside of the graft and chondrocytes transformed from her own stem cells for the outside. They grew both types of cell in specially adapted cultures before being transferred to the graft over four days in a newly developed bioreactor.

Radiology and diagnostic imaging

The technology available to radiologists had changed dramatically with internet, affordable high performance computers, digital imaging and picture archiving and communication systems (PACTS)._{(BMJ 2008: 337: a785)}  As a result, imaging and interpretation were no longer confined to one site.  Remote assessment, already frequent in the USA, became more prevalent in the UK. Complex imaging procedures were frequently required in accident departments around the clock.  Out-sourcing of interpretation was one way of dealing with increased demand coupled with a shortage of radiologists.  Some English hospitals outsourced part of their work into Europe, as far away as Barcelona.  Teleradiology and outsourcing had, however, their problems.  Access to other test results or previous images was seldom possible, nor the easy communication with other specialties.

Neurology

Hopes of better treatment for multiple sclerosis, a serious and disabling disease of the brain, were raised in 2008 by a trial of a monoclonal antibody Alemtuzumab, that targets CD52 on lymphocytes and monocytes.  It reduced the risk of sustained accumulation of disability compared with a previous drug, but had dangerous side effects.  Thrombocytopenic purpura developed in three patients, one of whom died.

Ophthalmology

Technological improvements led to the development of better diagnostic equipment, for example simpler equipment to test for glaucoma, or to image the retina.  Multifocal lenses were tried in the treatment of cataract, but did not prove wholly satisfactory.  Drugs for the treatment of glaucoma, Avastin and Lucentis, were approved for general use by NICE and success was reported in the use of stem cells in the treatment of a rare form of inherited blindness, Leber's congenital amaurosis.

Mental illness

How many beds?  Between 1955 and 1995 the number of beds for mental illness and learning disability fell from 150,000 to fewer than 55,000.  Over the next ten years there was a further reduction of 30%, care increasingly being delivered by community based teams.  While the number of admissions (perhaps for depression or dementia) fell, the number of those admitted 'involuntarily' increased by 20%, particularly for drug and alcohol problems.  Admissions for psychosis remained roughly constant.  The case-mix of inpatient facilities was changing as the number of beds continued to fall, and increased use was made of private facilities contracted to the NHS. BMJ 2008;337:a1837

Primary Care

Progressively the way primary care was provided changed.  Primary care trusts (PCTs) had an increasing influence on practices.  There ability to go beyond a single national contractual framework helped innovation.  A practice might find the PCT willing to fund new staff members in the practice team, for example a physiotherapist providing open access to patients or a psychotherapist.  They could bring pressure on practices to extend their hours of opening as well as use the quality and outcomes framework as an incentive.

The quality and outcomes framework, essentially a contractual system of financial incentives for the delivery of quality care and improve outcomes,  was improving the process of care.  Significantly, practices in deprived areas achieved similar levels of cover to practices in more affluent areas.

Most GPs did not take their own phone calls out of surgery hours and there was a reliance on various systems of triage.  Studies suggested that the decisions taken by "triagists" varied and that a substantial proportion of decisions were wrong.  Outcome studies did not reveal many problems as a result, possibly because most calls were only about trivial matters.  Advice was given after asking too few questions, and without properly interpreting the answers.  There were significant dangers to patients and the protocols used were hard to assess because they were not publicised, nor available on-line allowing them to be studied._{(BMJ 2008:337: a1167)}  The Healthcare Commission, reporting on emergency and urgent service in September 2008, found gaps and variation in performance.  In 65% of areas, out-of-hours GP services met the requirement that they started telephone assessments within 20 minutes of a patient’s initial contact if a patient’s needs were urgent, and within 60 minutes otherwise. In some areas, less than 80% of assessments are started within these timescales. NHS Direct exceeded the target for starting telephone-based assessments within 20 minutes for urgent calls (priority 1) and 60 minutes for other urgent calls (priority 2) in 95% of cases. It achieved this for 98% of priority one, and 99% of priority 2 calls.  The Commission suggested the piloting of a single telephone number for urgent care services which had the potential to ensure fewer people attend the wrong services.  The delay patients experienced, in general greater than in earlier times when the GP or his deputy immediately picked up the phone, was one possible cause of increased strain on A & E Departments. 

Substitution of nurses for doctors in primary care, increasingly common, might be cost effective and outcome studies suggested no great differences between the two types of practitioners in fields such as the follow up of patients with long term illnesses.  Nevertheless the characteristics of GPs and nurses differed,.  Doctors, said a BMJ editorial, needed to deal with uncertainties and take risks, while nurses were more attuned to following protocols and providing hands on care.

Hospital Services

As a result of the devolution of health service management to the four nations of the UK, marked differences were emerging.  It was not just differences in the money available to spend.  Policies led to different incentives.  In England targets to improve performance, payment by results and the increasing emphasis on the provider/commissioner split and patient focus gad driven change.  Scotland had abolished the internal market and had integrated boards purchasing and providing primary and secondary care, Wales was looking at the Scottish model and Northern Ireland continued with its integration of health and social services.  Compared with the others, England had shorter waits in A and E in part because the reduction of waiting times seemed associated with a greater rise in attendances than elsewhere.  Proportionately more patients were discharged rapidly, within a day of admission, in England.

Hospital reconfiguration.

Some reconfiguration of services took place quietly and steadily.  Moorfield's Foundation Trust continued to open off-site units of which there were 11 by 2008.  Hospitals would approach Moorfield's for assistance in maintaining a viable ophthalmic services, both sides benefiting. Clinical networks developed at a professional level with little management involvement.  Planning for reconfiguration of services such as stroke and heart attack, under the Regions' "Darzi" proposals, was a delicate balancing. Ambulance services would have to triage patients effectively. While perhaps only 0.1% of A & E patients needed the facilities of major trauma units, would specialists gravitate to those centres, and would the Royal Colleges be happy with training posts where young doctors never saw or carried out major emergency surgery?  How far would the essential care of the majority of patients be undermined by centralisation.

Independent sector treatment centres were failing to deliver full value.  Though paid above tariff levels, few seemed likely to deliver more than 90% of the services for which they were paid during the first 5 years of their contracts. Transferring waiting list work from NHS units was sometimes used, but it seemed unlikely that all ISTCs would justify renewal of contracts or succeed when payments moved to tariff. levels.  The Department agreed to meet the buy-back costs of residual assets were a centre to close.

Hospital building

The NHS Plan (2000) had announced a major building programme, much funded by PFI, to replace and modernise the aging NHS estate, half of which dated from before 1948. Matters were now better, it was now down to 20 percent with 100 schemes completed and many others underway at a cost of £12 billion.  Department of Health (and Scottish) guidance now suggested that new hospital wards should contain at least 50% of accommodation in single rooms.

Medical Education and Staffing

Responding  to the independent inquiry into Modernising Medical Careers (MMC) the Department of Health published its response to Sir John Tooke's report and set up a new advisory body to operate at arms length from Ministers. NHS Medical Education England (MEE) would be established on 1 January 2009 to provide independent expert advice on training and education for doctors, dentists, health care scientists and pharmacists.  It would be a non departmental public body supported by a secretariat from the Department of Health.  Not quite the body proposed by Sir John Took in his report, it would be concerned with postgraduate training and would need to relate to the GMC.

Nursing

Nurse education and staffing

Different university nursing courses varied significantly in their quality and in the percentage finishing their course.  London's SHA examined the outcome of the courses, finding one at which only 8% of a cohort completed their training.  Chelsea and Westminster Hospital withdrew nurse student placements from one course where the support to students was poor.

Nursing practice

In line with the attempt to measure the quality of care, stressed in the Darzi reports, Alan Johnson (the Health Secretary) suggested that in the nursing field treating patients with compassion, reducing the number of falls on wards and good hand-washing were the indicators that could be used to measure the quality of nursing care in the NHS.  Compassionate care -  whether patients are treated with compassion and whether they are fully kept informed of what is happening with their treatment; effectiveness including the nutritional state of patients, minimisation of pain and results of hand-washing audits.  Safety could encompass indicators such as the number of falls on a ward or infection rates

Policy

The 6th decade saw the a programme of system reform that included four important innovations—the creation of foundation trusts, greater NHS use of the independent sector, provision of more choice for patients, and payment by results.  R G Bevan _{BMJ 2008;337:a935}  wrote that 'healthcare systems had  three main goals, to control total costs, to achieve equity in access by need and to achieve excellence in performance (short waiting times, satisfied patients, and good outcomes).  To achieve these three goals three economic instruments were needed. Since 1976 the NHS had controlled costs with a cash limited budget and sought equity by distributing funds to populations in relation to their needs. The problem was improving the performance of providers. Before 1991 the NHS had a hierarchical integrated model in which the same organisations were responsible for meeting the needs of their populations and for running providers. Such organisations could be funded equitably for their populations or for the performance of providers, but not both. The internal market with a purchaser-provider split in which purchasers are funded for their populations and contract with independent providers was an attempt at an answer. England had tried four variations of this model in its efforts to improve provider performance, competition between 1991 and 1997; partnership in a "third way" between 1997 and 2000; publishing performance in "star ratings" between 2001 and 2005; and again competition, from 2006 with the system reform programme.

In its report in June 2008 "Is the Treatment Working" the recent innovations were examined by the Audit Commission .  It was perhaps too early for judgement, for the development of foundation trusts and patient choice was behind schedule; detailed information was lacking on choice; and the scale of independent sector treatment centres was limited.  The Commission provided a summary of its findings.

The assessment of the results of the last initiative to reform the system was followed closely by the next - the Darzi initiatives.  This sought to improve  quality in three ways, by publishing information on clinical performance, by varying tariffs according to quality, and by piloting ways to achieve better integration of primary, community and hospital care.

Organisational Change

Foundation Trusts

By the end of 2008 109 Foundation trusts had been established, about half of all acute trusts (46%) and mental health trusts (54%) having gained foundation status.  William Moyes, the executive chairman of the regulator, Monitor, felt that their performance had been impressive, though he regretted that more trusts had not gained this status.  He was concerned that the Department of Health would need to learn how to operate in a world in which it could not issue instructions.  Whether the performance was due to foundation status, or whether it was the best trusts that had achieved this, was not clear.

Finance

As the 2008 financial crisis bit, and billions were poured into banks such as Northern Rock, HSBC and RBS, the Treasury looked at the possibility of clawing back much of the £1.6 billion under spend in 2007/08. In a pre-budget report in November 2008 the Chancellor announced that "efficiency savings" would be increased reducing tariff costs and reducing public sector growth.  Pay awards to staff were low, save (according to the Conservative Party)  in the Department of Health where some senior staff received (including performance bonuses) double digit increases.

The likelihood of financial stringency revived discussions on rationing, prioritisation or allocation of resources, effectively three synonyms.  Should clinicians take the lead, should conditions be excluded that did not seem to work to concentrate on those that did,  should one look at the "reasonableness" of decisions, and what part did the market have to play?  If the starting point was evidence that something worked safely and provided value for money for society and the individual, where did that leave complimentary medicine?  The UK's only professor of complementary medicine wrote that some within that field were ready to resort to intimidation and legal action in a way that was downright scary.

Quality

Continuous improvement of quality of health care was an international movement.  Quality and safety was increasingly part of the framework of UK health care, though the US remained in the lead in organisational and theoretical terms.  Organisationally the Joint Commission introduced patient reports on the safety of care and examined patient care pathways, alongside its 50 year old accreditation programme. Its annual report showed steady improvements.  (see also its fact sheets and video on line)

The final Darzi report in 2008 placed emphasised quality as "at the heart of everything we do".  Patient safety, patient experience and effectiveness were key. It became policy to be clear about what quality looked like, to measure it and publish quality performance.  High quality medical teams shared certain characteristics, high morale, clinical leadership, low turnover and an emphasis on measurement. Quality should be safeguarded, recognised and rewarded, standards should be raised and innovation fostered.  Darzi hoped that the Quality Care Commission and quality observatories within SHAs would help. It was planned that from 2008/9 up to 2% of acute trusts' income would be affected by quality measured. Quality could not be asserted, but must be measured, compared and published.   The quality of care should drive the decision-making of commissioners and the remuneration of providers.  But the measurement of quality was an emerging science, care was needed in choosing the measurements which had to command wide agreement.  The Department of Health opened a four week consultation in November 2008 on a new group of indicators of quality of care, 350 in number.

The Healthcare Commission

In October 2008 the Commission published its third and last health check assessment. For the second consecutive year, annual improvement is evident. In particular, there was roughly a 10 percentage point increase in both the proportion of trusts scoring excellent for quality of services, and the proportion of trusts scoring excellent for use of resources.

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Waiting times for cancer treatment, a significant problem for the NHS, had come down.  Ambulances were responding faster.  MRSA rates were falling, though not all trusts were improving as they should.  Problems remained in primary care, such as access to GPs and the provision of choice.  Regionally, performance in most areas had improved, less so in London.  Sir Ian, in a letter to staff, regretted that relationships between the Commission and the Department of Health had been fraught. 

"Given the highly politicised nature of any discussion of the NHS, government both saw the need for the regulator and at the same time felt uncomfortable about it, particularly when it brought bad news." Sir Ian said.  "Regulation was sometimes seen as part of the problem rather than part of the solution".

The Care Quality Commission (CQC)

Following the consultation by the Department on the proposal merge the  Healthcare Commission, the Commissions for Social Care Inspection and the Mental Health Act Commission) into the Care Quality Commission, further consultation on the system of registration was undertaken in March 2008.  Baroness Young (Barbara Young) was appointed Chair and the Commission would operate in shadow form from October 2008 and fully from April 2009. A draft CQC manifesto, rooted its principles in transparency, independence and risk-based inspection. Outcomes would be a major focus and the CQC would judge its own success against them. The Darzi reports and the NHS Constitution were in line with the new accent on quality. The NHS constitution gave patients the right to receive any treatment deemed by NICE to be cost-effective.  Performance-related pay was another way to get NICE standards adopted, Baroness Young said. "I'm a great believer in performance pay."

From April 2010, all providers of health care in England, including NHS providers, foundation trusts and independent providers, will be legally bound to be registered with the Commission in order to provide services. The government has proposed that from 2011 this requirement will include NHS primary care providers, including GPs, who had not previously been subject to regulation by the Healthcare Commission. (King's Fund Brief on regulation)

The National Institute for Clinical Excellence (NICE)

Though now firmly established, NICE remained under ressure. Sometimes decisions were reviewed and revised as in the approval of ranibizumab (Lucentis) for age-related wet macular degeneration.  Sometimes patients wishing to receive life aiding drugs found that they were denied them by NICE guidance.  When with the support of their doctors they tried to purchase them they were sometimes denied NHS treatment as government did not wish to see a difference between those who could pay, and those who could not.  Public outcry at the refusal to let people spend their own money on their health led to the commissioning of a review.  In 2008 draft guidance by NICE that four drugs, which could prolong life but not cure, should be denied on cost effectiveness grounds rarer cancers was criticised by oncologists who felt that any restriction of prescribing on the grounds of cost was reprehensible, and that NICE should be abolished.  Other commentators, professional and lay, believed that there had to be some limit to the costs the NHS was expected to pick up.  The Chair of NICE, Sir Michael Rawlins, wrote "It really is time that some of my clinical colleagues woke up to the realities confronting all healthcare systems. An ageing society, technological advances and public expectations are placing demands that all countries are struggling to meet. Countries do not have infinite sums of money to spend on health and the amount they can afford is largely governed by their wealth as reflected by their gross domestic products. The debate is not about whether - but how - healthcare budgets can be most fairly shared out among a country's citizenry."_{(HSJ 18 August 2008)}  He thought that the prices charged by drug companies were excessive - so others - in support of the pharmaceutical industry - replied with some justification that only an industry with the profit incentive would produce new drugs, quoting the steadily appearance of drugs for AIDS.

NICE was caught, inevitably, in a media storm.  On the face of it firm implementation of national guidelines might ensure a consistent deal for patients across England, if not in Scotland, Wales and Northern Ireland.  But the consistency might be refusal for, as its Chairman Sir Michael Rawlins said, NICE had to take account of all who depend on the NHS (not just patients suitable for treatment by the drugs it considered).  PCTs wished to retain their right to decide what was and what was not an exceptional case to avoid tying up resources that would otherwise be used on better value therapies.