England Vs Scotland

England vs Scotland England vs Scotland Does More Money Mean Better Health? Benedict Irvine Ian Ginsberg Commentary Kevin Woods Civitas: Institute for the Study of Civil Society London First published June 2004 © The Institute for the Study of Civil Society 2004 77 Great Peter Street London SW1P 2EZ email: [email protected] All rights reserved ISBN 1-903 386-35-7 Typeset by Civitas in New Century Schoolbook Printed in Great Britain by Hartington Fine Arts, Lancing, Sussex Contents Page Authors vi Acknowledgments vii Preface Benedict Irvine viii Summary xiii Introduction 1 Healthcare Funding and Expenditure 6 General Demographic/Environmental Indicators 23 Healthcare Benefits Package 40 Health System Resources and Organisation of NHS in Scotland and England 43 Healthcare Outcomes in England and Scotland 57 Discussion Benedict Irvine 152 Commentary Kevin Woods 167 Bibliography 177 Glossary 196 Notes 199 v Authors Ian Ginsberg graduated with a first from Trinity Hall Cambridge, where he also completed a Masters. He joined Civitas as a full-time researcher in 2002. He now works in the public health and performance directorate for a strate- gic health authority. Benedict Irvine is director of the Civitas Health Unit. After studying law he completed a Master’s degree in comparative European public administration at the Catho- lic University of Leuven, Belgium. Before joining Civitas he worked as a researcher in the European Parliament. He has managed a wide range of comparative projects on European healthcare funding and provision. Recent work has included a study of the relationship between healthcare funding systems and health outcomes. Current projects include an examination of the pricing and reimbursement of pharma- ceuticals in Europe. He is also secretary to the cross- spectrum UK Health Care Consensus Group. Kevin Woods has held a number of general management positions in the NHS in England. He was appointed to the Lindsay Chair of Health Policy and Economic Evaluation, University of Glasgow in August 2000. He established the Scottish Health Services Policy Forum, which promotes debate about health services in post-devolution Scotland. Previously he was director of strategy and performance management for the NHS in Scotland working with the Scottish Office (now Scottish Executive) Department of Health. In January 2004 he returned to the NHS in Eng- land. He has published on Scotland’s health and health services, social deprivation, resource allocation and healthcare planning. Ongoing research interests include health system integration and healthcare rationing. vi Acknowledgements This project was sponsored by Andrew Ferguson on behalf of the David Hume Institute. Staff at the ISD in Scotland and the NHS National Cancer Services Analysis Team in England were helpful. We would like also to acknowledge the vital comparative work of the OECD Health Team, and the devolution monitoring and analysis of the Constitution Unit based at UCL. The staff of the King’s Fund library were as helpful as ever. Further thanks should go to two referees for their helpful comments on an earlier draft of this report. vii Preface The purpose of this research exercise was to examine the thesis, propounded by the Blair Government in England, that the widely acknowledged problems and deficiencies of the NHS can be resolved by substantially increasing expenditure. Using the example of Scotland, where health expenditure per head already approaches the European average to which the Government aspires, we explore whether (with due allowance for any ‘Scottish effect’) increased expenditure has produced better health care for patients. We collated data on expenditure, treatment resources, activity rates, population and environmental inputs, the use of standard treatments, and healthcare outcomes. In light of this evidence, albeit with caveats regarding data quality and comparability, we find the case ‘not proven’. On this assumption, we further conclude that additional reform is likely to be necessary to deliver the improvements desired by patients, healthcare professionals and politicians. Per- haps structural change of healthcare funding is a necessary condition? And if the extra per capita spending in Scotland had been from another funding source, would outcomes have improved? The funding and provision of health care is a thorny issue because of the dual character of medical demand. On the one hand, severe pain or dysfunction may prevent people from leading a normal life, and in extreme cases life or death may be at stake. On the other hand, some demands for medical services are a matter of personal preference. No less important, some ill health is a matter of sheer misfor- tune and some a consequence of harmful lifestyle choices. Public policy makers continue to struggle with these conundrums in all countries, but I conclude that some have devised solutions which have proved more effective than others. In particular, countries with social insurance systems (Germany, France, the Netherlands and Switzer- land) have the most to teach us.1 So are our political leaders willing to learn from these alternatives? viii PREFACE ix In England, there has been a palpable shift; it is now possible seriously to raise questions about the NHS that would have been condemned as heretical only a few years ago. In October 2003, a King’s Fund report suggested that politicians should be taken out of the management of healthcare.2 In November 2003, LSE Health published a report showing that access to healthcare is better for the middle classes—who know how to ‘play’ the NHS system.3 Such reports illustrate a shift in the terms of the debate and in the latter case suggest that the myth of health care based on need, not ability to pay, is just that—a myth. The shift in the debate is especially noted by those working in the English NHS. Meanwhile, after 50 years of comparatively poor performance from the NHS in Scotland, it is surprising that (other than for clinical lessons), unlike their counter- parts in all political parties in England, Scots decision- makers do not appear to have made a concerted effort to learn from foreign healthcare systems. Yes, there are other state-run quasi-monopoly systems that seem to work better, most notably that in Sweden, though of course it is local government that is in the revenue-raising and management driving seat there, making for a much more transparent system. Nevertheless, bearing in mind evidence from the OECD, there is a compelling case for both Scots and the English to call for more radical reform of the NHS; ideally through the introduction of competitive social insurance—perhaps the most important element of which is the removal of national politicians from the day-to-day running of the system. Such a move may lead in time to long- overdue improvement in Scottish and English health outcomes relative to our neighbours. A solution? Civitas has studied healthcare systems in Europe and further afield. We take it as axiomatic that the basic building block of any reform must be ready access for all patients to a government-guaranteed high standard of care. Every country is wrestling with how to achieve this end and many have discovered alternative methods which have x ENGLAND VERSUS SCOTLAND secured a more responsive and demonstrably higher quality service than that provided through the NHS. While none provide a ready-made blueprint, we should be willing to learn from their experiences.4 We propose the following:5 • The primary role of government should be to create the legal and regulatory framework, to ensure that access to a high standard of care is guaranteed to all, and to ensure the supply of essential public health services. • Politicians should be excluded from management of healthcare. They must not override the professional duty of clinicians to act in the interests of patients. • The responsibility for financing health care should be divorced from the responsibility to supply. • Health insurance should be compulsory and patients should be free to choose from among a range of third- party payers. • There should be no compulsory patient charges at point of use—though they might be optional. • Health care should be provided by competing healthcare organisations (including for-profit companies, charities or non-profit trusts), thus enabling the efficiencies in supply provided by competing suppliers and allowing consumer choice. • A new ‘information agency’ would be useful to monitor standards and provide impartial statistical comparisons allowing effective choice based on outcome and real measurement of trends.6 • The Government should not own hospitals and all such institutions currently in the public sector should become independent at the earliest possible date. The simplest method would be to make them all foundation hospitals, whilst ensuring that their assets must be permanently used to provide health care. Existing NHS hospitals should not be transferred to the ownership of for-profit institutions. PREFACE xi • Hospitals should have complete autonomy from White- hall and the Scottish Executive. In particular, there should be no specific restrictions (beyond those that apply to all workplaces) on the ability of hospitals to recruit staff or on the conditions of their employment. • The Government has an important role in ensuring that hospital accident and emergency infrastructure is universally available. In the rare event of a hospital being in financial difficulty, the Government must be able to take appropriate action. • There should be no restrictions on the establishment of new hospitals, whether they are for-profit or not, as at present. As Kevin Woods (Lindsay Professor of Health Policy and Economic Evaluation at the University of Glasgow) suggests in his commentary, if this paper helps to facilitate an informed debate on reforming the NHS in Scotland and England, it will be worthwhile. Of course, as for most comparative research, our findings are subject to numerous caveats regarding the quality and comparability of data, differences between sexes and regions, and the different provider structures in England and Scotland.

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