Dr Phil Hammond, GP and broadcaster

Is the NHS worth £184 million a day? It’s a fair question but alas there are as many answers, or rather opinions, as people using it. With a general election on the horizon, patients who have had operations cancelled have been in the news again, and their answer would doubtless be ‘no’. However, it could be argued that the NHS is doing some of these patients a favour. Sometimes a two year wait for surgery can increase your life expectancy by … er … two years.

There are 67 000 cancelled operations each year, which should give Tory politicians plenty of ammunition. Or maybe there’s just one person out there who’s had the same operation cancelled 67 000 times (now that really would be front page news). Either way, the debate in an election run up is likely to be as puerile and simplistic as ever. What interests me more is how frontline NHS staff see things. Are these improvements sufficient to justify the billions of pounds going in?

Many doctors are better off financially. Those who signed up for the new consultant and GP contracts should notice a welcome swell in their monthly income, but there’s a nagging suspicion that this will only be temporary.

For GPs, cash strapped PCTs may raise the quality bar so high that maximum quality and outcomes framework payments will be as rare as hen’s teeth. For consultants, signing up to the contract means sacrificing what little independence they have. When the management insists on weekend operating lists to fight off the threat from treatment centres, it’ll be hard to resist.

As for patients, it all rather depends on what they’ve got. The obscenely long waits for surgery have been eliminated (except in Wales – a convenient control group for the NHS reforms). And survival rates for heart disease and cancer are improving (but the trend started before all the extra investment). However, those with chronic physical or mental ill health may well not have noticed a huge improvement. And for all the extra money, it’s still proving fiendishly hard to keep hospitals clean.

In a media-obsessed government, focus and resources tend to be thrown at what hits the front page (so it’s just tough if you have dementia). And as well as a hugely increased wages bill, a lot of the extra investment has gone on pensions, increased prices for drugs, goods and services, the new managerial structures of the NHS and the ever increasing negligence claims. Hence some economists argue that the real increase in money spent directly on patients is 2-4% per year. So although NHS spending went up by 31% (after inflation) between 1999 and 2004, only 11% more patients were treated.

Labour’s bold reforms have turned out to be a damp squib. PCTs were supposed to be about devolved healthcare, but they just haven’t delivered. This isn’t for lack of effort, but more because of inadequate manpower and an inability to escape the top-down hectoring from Whitehall and the strategic health authorities. Now PCTs are all merging and becoming the district health authorities they replaced in the first place. The only people left to grasp the nettle of devolution are GPs.

So after eight years, Labour has reached the same conclusion as the Tories: that patients would be best served if budgets and commissioning power were given to GP practices. As with fund-holding before it, the entrepreneurs will be fast out of the trap to take control of their local communities and keep as many patients as possible away from expensive, dirty hospitals.

That’s the theory, but success depends on whether a critical mass of GPs has the stomach and expertise to take on this huge task. Practice-based commissioning is the one real chance the NHS has to improve, but my fear is that in such a politicised system it won’t be allowed to flourish.

Guidelines in Practice, April 2005, Volume 8(4)
© 2005 MGP Ltd
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