Leading Article: More is not always better

THE publication of a Compendium of Health Statistics by the Office of Health Economics serves as a reminder that the great debate on whether our health services are underfunded has never reached a conclusion. It was the squeeze on hospital beds in the winter of 1987 and the Labour Party's bitter accusations of underfunding that triggered the reforms of the NHS, including hospital opt-outs, which are still in train. The aim was to prove that with drastically improved management systems, far better value could be wrung from much the same budgets. Labour diverted its fire to the reforms themselves. The debate on funding became largely ritualistic.

According to the OHE statistics, spending on public and private health-care services in the UK is expected to exceed pounds 40bn, or pounds 697 per head, this year. Yet even if it reaches the expected 6.5 per cent of gross domestic product by the end of 1992, the UK will remain one of the smallest spenders on health among key industrialised countries, in relation both to population and national wealth.

Yet it is wrong to assume that if we spent more, we would have a better health service. That would be true only if it could be guaranteed that the money would be well spent. There remain huge variations in the efficiency with which hospitals use their resources: the gap between so-called best practice and the worst. Even a modest levelling- up to the national average would represent a huge saving.

Gains in the quality of service are far from being an automatic result of increased resources. To take the perennially sensitive topic of hospital beds: the Audit Commission has established a clear relationship between the number of beds in a unit and the length of stay of patients. The more beds there are, the longer patients stay, and the less seriously ill they need to be to be admitted. Does that make for better health care? In some cases, perhaps; but not necessarily. But it certainly increases the cost.

Astonishingly little is, in fact, known about what NHS jargon calls 'outcomes', meaning the results of treatment. Research can be misleading. It was found, for example, that in one hospital twice as many hip-replacement patients were dying after the operation as in another. In reality, they were simply staying in longer. Just as many from the other hospital died at home within the same time span. Deductions from known facts are also risky: most people attribute the growing longevity of the Japanese more to their diet than to their quite modestly funded health services.

In the present economic climate the Government is likely to adopt a minimalist approach to its election pledge 'year by year, to increase the level of resources committed to the NHS': no bad thing when a 1 per cent gain in efficiency would save so much. Decisions in the NHS are largely about priorities. To use existing resources to the best possible effect is crucial. Where there are obvious shortcomings, it is the allocation of funds that needs to be examined.