Rudolf Klein: If you want to know the future of the NHS, look to Scotland

'The Scottish case shows that spending more money is a necessary condition but not a sufficient one'
Click to follow
The Independent Online

The worse the news of abandoned patients and mishandled bodies in the NHS has become, the more strenuously the Prime Minister has promised a solution by the next election. But can he achieve a turnaround, let alone in this timescale?

One way of predicting the future of the NHS in England is to use Scotland as a crystal ball. For in one sense the promised future has already arrived there. Today's level of spending on health care in Scotland has achieved the target set for England for 2004 . At £1,059 per capita it is almost a quarter higher than the figure for England (£885), and roughly the same as, or even above, the European Union average, depending on how that is calculated. If England achieves the EU average, will Tony Blair's gamble have come off ?

The short answer is: be cautious in laying your bets. Scotland certainly demonstrates that if you spend more money, you can provide more doctors, more nurses and more beds. You can treat more people, at a less frenetic pace, and offer a more relaxed environment to both patients and staff. But it also suggests that more resources do not automatically transform a provider-dominated service into a consumer-driven one, which is the aim that ministers have set themselves.

The national compendium of UK health statistics confirms that, surprisingly, Scotland translates extra money into extra provision for its population. Scotland has a third more acute hospital beds per 1,000 population than England, with a correspondingly higher number of doctors and nurses. The disparity in the number of mental illness beds is even larger: Scotland has double the number. The average list size of Scottish GPs is lower than in England, and they dish out more, and slightly more expensive, prescriptions. Scots are more likely to end up as hospital in-patients than their English counterparts and visit their GPs more frequently. And once in hospital, they stay there longer.

But when we switch from inputs to outputs, the picture gets more complicated. Consider the kind of procedures that tend to feature in complaints and swell waiting lists in the NHS in England. Scots have a higher chance of getting coronary artery by-pass grafts (CABGs) and hip replacements than the English. Conversely, however, the English have a higher chance of getting knee replacements, their cataracts done and their hernias repaired.

Comparing waiting times is tricky, because the way they are calculated differs in the two countries. But, for what they are worth, the official figures (for 2000 ) suggest little difference in the time patients spent waiting for their first hospital appointment, except that a slightly smaller proportion of Scots (5.2 per cent as against 6.3 per cent) waited more than six months. And once on the waiting list, the Scots were processed more quickly, with a mean waiting time of three months as against four and a third in England. However, since these official figures were published, the NHS performance in England has improved somewhat, while that in Scotland has deteriorated slightly.

Overall, then, these figures would suggest a rather more accessible and less pressurised NHS in Scotland, though stopping well short of a demand-led service fit for the 21st century. But the Scottish crystal ball is flawed in one crucial respect. The reason why the NHS in Scotland gets more money – under a formula devised in the 1970s – is that its population is less healthy than England's. The Scots have a shorter life expectancy and higher rates of illness and disability, reflecting both social conditions and lifestyle. There is therefore, it is argued, a greater need for health care.

Differences in the populations make it difficult to extrapolate from the Scottish present to the English future. But there are some clues, which suggest that more money will not of itself do the trick for Tony Blair. Consider just one aspect of the Scottish performance. One explanation why more Scots are admitted to hospital, and stay there longer, might be that they are more ill. But another reason could be that it is politically difficult to close beds and once there, the beds tend to be filled: in health care, supply creates its own demand. In other words, high admission rates and leisurely lengths of stay do not necessarily mean a high quality service for patients.

Such a sceptical conclusion is reinforced by the findings of a recent study published in the British Medical Journal. This compared the performance of the NHS and California's Kaiser Permanente, a not-for-profit health maintenance organisation providing comprehensive health care for a population of six million (compared to Scotland's five). Adjusted for differences in prices here and in the US, and for the composition of the populations served, Kaiser Permanente's per capita spending was only 10 per cent higher than that of the UK NHS as a whole: ie lower than that of Scotland.

But it delivered considerably more. Thus 80 per cent of patients referred to a consultant are seen within 13 weeks and 90 per cent are admitted to hospital within three months. It has a much higher rate for angioplasty and coronary bypass grafts. And so on. The average patient spends 20 minutes per consultation with his or her GP, as against eight minutes in the UK.

The trick, it seems, is to concentrate on keeping people out of hospital. Kaiser Permanente's use of hospital beds (the most expensive part of medical care) is a third of the NHS's. The money so saved is spent on employing more community-based doctors operating in community-based multi-specialty clinics, with laboratory and radiology services laid on. Moreover, Kaiser Permanente appears to have solved one of the organisational challenges facing any health-care system: how to create conditions under which doctors will adopt high-quality, efficient practices while enjoying a large degree of autonomy, thus internalising organisational imperatives, rather than having them resentfully forced down their throats.

One conclusion can therefore be drawn from the Scottish case. This is that spending more money may be a necessary condition if, come the next general election, the NHS is to be a source of self-congratulation rather than self-flagellation for Tony Blair. But it is far from being a sufficient condition. Putting more money into the NHS is the easy bit. Changing the dynamics of the service is the more difficult, but essential, task.

The writer is the author of 'The New Politics of the NHS'

Comments