Declining health-care productivity in England: Who says so?
Reports that the National Health Service in England has been declining in productivity in the last decade appear to have been accepted as fact. However, a Viewpoint published Online First by The Lancet disputes this. The Viewpoint is by Professor Nick Black, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.
The conclusions that hospital productivity has declined by 1.4% a year, and overall NHS productivity by 0.4% a year, have been based on analyses by the Office for National Statistics (ONS). These figures are based on estimates of changes in the quantity and in the quality of NHS care. Although the assessment of quantity may have underestimated the increase in activity as it was restricted to three aspects of heath care, it was the estimate of quality improvement that is the major cause of concern. Quality was considered to have improved by 0.8% a year. Yet, as Prof Black demonstrates, for those areas of health care for which accurate data exist, the improvement was considerably greater. For example, deaths in adult critical care fell 2.4% a year and deaths following a heart attack improved 5.3% a year. As regards clinical practice, adherence to evidence-based guidelines for stroke patients rose 5.7% a year. And patients' experience rose steadily: those admitted to a single sex ward rose 11% annually and the proportion of people who felt the NHS was getting better increased 10.8% a year.
These data suggest that quality improved by considerably more than the assumed 0.8% a year. And as Prof Black points out, it is only necessary to assume an increase of 1.3% a year in quality to change the overall conclusion from one of declining NHS productivity to one of increasing productivity.
Prof Black says: "Until the election in 2010, debate as to whether productivity had fallen or risen was played out, predictably, largely on party lines. To justify the reforms to the NHS that the Conservative Party wanted to introduce, the claim of declining NHS productivity was necessary. During the election this issue remained a contested area; the myth was not yet established. [One] reason for the establishment of the myth was the apparent abandonment by the Labour Party of belief in the policies it had pursued in government since 2000. It was as if, exhausted from years in power and bruised by an election defeat, Labour's will to defend past achievements had gone. The absence of opposition resulted in a consensus that NHS productivity had indeed declined."
He adds that it is difficult for the government's Public Accounts Committee to scrutinise specialist areas, such as health, in which its members often do not have specialist expertise. He adds: "Experiences of improving the productivity of the NHS during a decade with increased expenditure were seen to have little relevance to the new situation of achieving improvement in productivity with a shrinking budget. Since the events of the past decade are perceived as having no current or future relevance, interest in defending past achievements has dissipated."
He concludes: "Declining NHS productivity in England between 2000 and 2009 is just one recent myth in health-care policy. Many other myths have arisen in the past and many more will do so in the future. We cannot prevent myths developing but we should remain vigilant, spot them as early as possible, and attempt to minimise the harm they can do in distorting understanding and misleading policy makers."
Dr Richard Horton, Editor of The Lancet, adds*: "One of the reasons the current government gives for its radical and widely unpopular health reforms is the decade-long decline in productivity of the NHS. As Nick Black shows, this alleged decline is a myth. In fact, a fuller account of the evidence reveals likely substantial gains in productivity-gains in evidence-based practice, patient outcomes, and patient experiences. If the main reason for the Health and Social Care Bill is a lie, the upheavals it will produce are entirely unnecessary. This is further evidence to kill this damaging and dangerous bill."