Health service audit

It's generally agreed that the future of this government is likely to be determined by its success in making Britain a better place in which to live.

The buzz word is "delivery". After six years of Labour in power we've commissioned four films to find out whether or not they're making any difference to the public services. We'll examine Crime, Education and Transport over the next few weeks.

But on the eve of the publication of the NHS's annual report, Dennis Sewell began his series with this analysis of the state of the health service in England and Wales.

UNNAMED WOMAN 1:
..Not enough doctors, nurses, therapists.

UNNAMED MAN 1:
..More money, but we're being asked to do a lot more.

UNNAMED WOMAN 2:
..I know you've got more money. I had to get her to tell me where it's coming from and I'll chase it.

DENNIS SEWELL:
This Labour Government has pledged to transform the NHS. It's poured in extra cash and set scores of targets to which it's holding staff accountable. But is the NHS better, worse or about the same as when Labour came into office in 1997? We're asking, is Labour delivering on health?

To find out, we've come here to the Royal United Hospital in Bath, a hospital the NHS's new trouble-shooter has spent nine months turning round. And to Hackney, one of the most deprived areas in the country, where the local Homerton Hospital has three stars.

Labour swept into Government determined to scrap the internal market the Tories had set up. Out went competition between hospitals - now they'd co-operate. Out too went GP fund holders. Instead, GPs were teamed up into local primary care trusts. They'd hold the health service's platinum cards, buying care from hospitals. But inevitably this meant that for the 16th time in a generation, the NHS had to redraw its own organisational chart, leaving doctors, nurses and managers somewhat dazed.

SIR ANDREW FOSTER:
I do think the level of politics that is in the health arena almost mesmerises people, and stultifies sensible action from happening. And the amount of administrative and organisational change, I think ended up delaying some of the improvements coming through. For a small number of years we did not see some of the improvements that we might have expected because people were taken up with changes to the Department of Health, Strategic Health Authorities, with Primary Care Trusts and the rest.

DENNIS SEWELL:
Labour has kept its promise to spend more on health. Under the Conservatives, spending rose at an average of 3.1% a year. Under Labour, that's already climbed to 5.4%. Pour in the extra money the Chancellor announced in last year's budget, and from now till 2008 the average will reach 7.4% a year, the largest sustained increase ever.

But we in the UK have always been cheapskates when it comes to health. In the year 2000 we were still spending only 7.3% of GDP, compared with an EU weighted average of 8.7%. That year, the Prime Minister made a pledge, quickly scaled back to an aspiration, that we'd reach the European average. Pledge or aspiration, it doesn't matter now. We're already at 8%, and boosted by Gordon Brown's extra money, we'll be at 9.6% - second only to Germany. But have we noticed?

BEN PAGE:
This is the current perception of public services: underfunded, but bureaucratic, but also hard working. Now let's see, all this money's been pouring in, or so we've been told. What did we think five years ago? There's been absolutely no change in the proportion who feel that it's underfunded.

DENNIS SEWELL:
The price of this new money, and it really is there, is reform. Targets are one element of that. The other is a new structure that puts primary care first. Managers have to think ambitiously about the quality of care and about improving the nation's health. But how tough is Hackney's Primary Care Trust prepared to get if the local hospital is providing a third-rate service?

LAURA SHARPE:
The theory goes that we could remove our money from that hospital and buy that service elsewhere. I'm not yet convinced of that theory, except for elective care, is going to work. You have to ask the question what does that do to the hospital, as it were, left behind? Are you destabilising it in a way that you wouldn't like? What's the impact on other services?

DENNIS SEWELL:
Hackney is trying to move some care, like physiotherapy, out of the hospitals and into local clinics. But that process can stall if money doesn't follow the patients.

HILDA WALSH:
We have been very successful and have managed to reduce the waiting list for orthopaedic consultants. We've doubled the number of referrals that we receive here in primary care and our waiting lists have actually reduced. Unfortunately the resources haven't come through this year. Government targets seem to be centred around secondary care.

PROFESSOR JULIAN LE GRAND:
There's a problem with primary care trusts being in some sense street smart enough to be able to do the work they're expected to do. The worry is that secondary care, which has always dominated the health service, is still doing so.

DENNIS SEWELL:
Poor health is not evenly distributed. The poorer you are, the sicker you're likely to be. The Government says it wants fairness, but Hackney is still short of 30 GPs.

DR PETER KENWAY:
In 1998, the Green Paper "Our Healthier Nation" flagged up the gap in health inequalities as something of great importance. I think the real worry is that, as attention has really shifted to the health service - the amount of money going into it, its performance in terms of waiting lists and so on - so the focus has shifted away from health and it's shifted even further away from this health gap. These health inequalities are not acts of God. They do have complex roots but they're social roots. That means they need to become again, and remain for a very long time, a high priority and I don't think that's been the case in the last two or three years.

DENNIS SEWELL:
The Government is clear what it wants. To reinforce the new structure it's set targets to ensure delivery of national standards, shorter waiting times and better care.

MAGGIE CROWE:
I think there's a sense in cancer care that we know where were aiming for. We have a direction, I think. It's changed dramatically in as much as cancer care was very ad-hoc. A huge amount of disparity in the country in terms of what services were available to people, locally and at their cancer centres. Now, I think we have much greater standardisation of care, much fairer distribution of the money, and a much greater understanding of where that money should be spent.

DENNIS SEWELL:
Some of the toughest targets to meet are about bringing down waiting times for operations. Better planning and booking systems have helped virtually end the 15- and 12-month waits. But the typical wait remains somewhere around three months. That hasn't changed in 40 years. By the time this surgeon finishes his operation, he'll find that two out of his five cases are cancelled. In the operating theatre next door, the figure will be seven. Why? Because there aren't any beds. 70% of Bath's admissions are emergency cases. If too many come at once, patients coming in for pre-planned surgery are sent home. Hours of consultants' time and theatre capacity are wasted.

JAN FILOCHOWSKI:
Only a couple of years ago people in my hospital were waiting up to two years for serious things, but now no-one in any hospital is waiting more than a year. No one is waiting five months for an outpatient appointment. I think these are things to be terrifically proud of. The problem is you achieve these targets, the Government sets new ones, and you feel, "Oh God!".

DENNIS SEWELL:
Hospitals that meet targets are awarded stars. The Royal United Hospital, Bath has no stars. Yet it was in the top ten in England for clinical excellence. It failed because of its long waiting times. Three stars bring more money and autonomy. Everyone at Bath is determined to win some stars next time. Doctors have been operating at weekends to clear their backlog. Hundreds of cases have been sent to private hospitals, and bus loads of patients to Lille in France to have their surgery there.

JAN FILOCHOWSKI:
I've been saying that in a place like this we should be judged on what we've achieved at the end of the year, because we were stigmatised in July of last year, The important thing for our staff is that we've moved on a lot. It will raise our morale tremendously if that's recognised, and depress us if it isn't.

DENNIS SEWELL:
Here in the RUH cancer unit they now have brand new equipment bought with Lottery money. They have enough radiotherapists, but are short of the specialists who manage chemotherapy. Some doctors point out that even sensible- seeming targets like those for cancer can have a downside. Trying to ensure meeting the targets for first referral can mean the real emergency who needs to be seen next day has to wait longer. And, in a study at one London hospital, most patients referred under this two week target turned out not to have cancer at all.

Hackney's general practitioners have targets too. One is that everyone should get an appointment inside 48 hours. That's hard to achieve and controversial.

LAURA SHARPE:
Some GPs in Hackney were pretty anti, actually. They were concerned that it was going to compromise the clinical priorities and that focusing entirely on a target wasn't going to be helpful to the way they assessed priorities within their patient case load. I think there's an increasing acceptance that people should be able to get to see a GP in a reasonable amount of time. For us in Hackney, that also requires people to be able to register with a GP, and quite often local people say they can't even get on a GP's list because they're already so full.

DENNIS SEWELL:
The targets regime is strictly enforced from Whitehall. At Hackney's Homerton Hospital even the medical director complains about the endless form filling needed to report progress. It's a problem everywhere, even in a hospital's casualty department.

DR JOHN COAKLEY:
Particularly over winter times, when the pressures on the A&E department are significant, we have virtually a whole time, very senior member of the nursing staff reporting on our data in the A&E department, the times to admit to wards and so on. And this...a whole time, as I say, very senior nurse, spending time doing something which is not directly beneficial to patient care is unhelpful. But it's not the target, it's the monitoring towards achieving the target that's the problem.

DENNIS SEWELL:
The target says no patient shall wait over four hours in A&E without either being admitted to a hospital bed or discharged. In April, a team of NHS inspectors arrived at Homerton Hospital, stop-watches and clipboards in hand. The hospital knew they were coming and drafted in extra doctors and nurses from other departments.

DR JOHN COAKLEY:
We met the target in the week that it was measured, and as expected our performance against that target has fallen away since then.

DENNIS SEWELL:
So the whole thing is a bit artificial?

DR JOHN COAKLEY:
The whole thing is a bit artificial if you look at it one way. Because it was...clearly it was artificial, and we put in a lot of additional resources. I think one thing that has been very helpful, is for that week we've actually measured what additional resources we put in.

DENNIS SEWELL:
Some hospitals cancelled all elective surgery the week monitoring took place. At Bath, they decided to play it straight and missed the target.

BERNIE EDWARDS:
I feel quite strongly we shouldn't be seen as non-performer, or chastised for not achieving that. We should be celebrating success to get to 80-85%. What we've not to lose sight of is that it's not just about a target. For some patients it is not in their best interests to move them within the four hours. I feel quite strongly that as clinicians we should be given the option to make decisions in the best interests of the patient, without the trust being thought of as non-performer or being penalised for missing four hours. This is fantastic, this is state of the art...

DENNIS SEWELL:
Bernie Edwards is one of the NHS's new modern matrons. She and her team will soon be moving into this £7.5 million wing, tricked out with all the kit you've seen on ER. But where an equivalent facility in Chicago would have 14 consultants, Bath will make do with three.

The Royal United Hospital is close to two motorways, so this A&E deals with more serious accident cases than an inner city A&E. But the target system doesn't take account of that. One target fits all.

PROFESSOR CAROL PROPPER:
Targets only measure a limited number of aspects of what people do. If those are the most important aspects, then all well and good. If they're not, then we do know that people distort activity to meet those targets. They distort activity away from areas that are not easily measured, and they might also distort activity in order to treat people who allow them to meet the target more easily.

DENNIS SEWELL:
But if clinicians are under pressure to tailor their judgements to meet targets, the pressure on managers is so great that some actually cheat.

SIR ANDREW FOSTER:
There was an example of a date the GP had referred the patient to the hospital was changed. That was clearly grossly unacceptable. There was another whereby the hospital was contacting patients to offer them in-patient treatment with such short notice so they would not be able to accept. The clock was restarted as a result. Those are both unacceptable.

PROFESSOR JULIAN LE GRAND:
I think there's one real problem in the health service, and certainly over the past few years, which is a climate, to some extent, of fear and of bullying because of the target culture and the heavy degree of centralised control, that many people feel has come down from the Government. So you've had chief executives who've been afraid of losing their jobs, who feel they're being bullied by their superiors, to make sure they reach their target.

DENNIS SEWELL:
NHS staff are incredibly cautious about what they say on the record. They're anxious to avoid giving a "career-limiting answer". That's because targets have become politicised. It's always the Government that's failed to meet this target or that. One consequence is ministerial machismo.

PROFESSOR CAROL PROPPER:
No politician wants to be associated with a policy that has a gain in ten years or in five years. A politician wants to be associated with a policy that has a gain now. This means that many of the targets that are set are targets that people expect to be met in a very short time period. If they're not met, then there's a problem that everybody sees the policies as failing.

DENNIS SEWELL:
The Government tells us the health service is meeting most of its targets, but everyone on the front line seems to agree that the underlying problem of the NHS is one of capacity. You'd think that with all that new money the NHS would be performing many more operations. But is it?

PROFESSOR JULIAN LE GRAND:
If you look at the numbers of operations - that's been flat for quite a long time, it has not been increasing at the same time as the resources have been increasing. So it looks as though productivity has fallen quite dramatically. Indeed, if you look at the number of operations being done by surgeons in certain specialities, orthopaedics for instance, you do get a fall in the number of operations being done.

JAN FILOCHOWSKI:
Yesterday I think we had more patients admitted to the hospital in a day than ever before. That's yesterday. We admitted 105 patients. And we only have 600-odd beds. So that's an incredible amount. Probably five years ago we would have been admitting 60, 70 a day. But emergencies have gone up phenomenally. In this hospital they've gone up 15% compared to last year. This is real.

DENNIS SEWELL:
It may be real in Bath but is it true across the nation? Tomorrow, the NHS will claim a big increase in hospital activity, but the figures it's using don't appear consistent with last year's. At the ward level, there is clearly a mismatch between the number of new doctors joining the NHS and the amount of doctoring going on.

DR JOHN COAKLEY:
When I was a junior doctor I was working 80-odd hours a week - they're now working 50-odd hours a week, and that work has got to be picked up by other people. So you have to be a bit careful about interpreting just headlines, "There are this many more doctors," because at the other end there are many more doctors retiring early and working fewer hours.

DENNIS SEWELL:
And that lack of capacity is threatening to stymie all the other improvements staff have been struggling to make.

DR JOHN COAKLEY:
We don't have enough doctors, we don't have enough nurses, don't have enough other staff, radiographers, laboratory technicians and so on. And, although some of those staff can be trained up in less than ten years, perhaps some of the key NHS staff will take at least that time to develop - five or ten years.

DENNIS SEWELL:
Back in 1997, the UK had fewer than half the number of doctors per 1000 population as Germany. And only just over half the proportion in France. The Government says it has recruited thousands more doctors. Yet even its own projections suggest that by the year 2024 we still won't have reached those continental levels. How long will we wait?

BEN PAGE:
And if you look here, what you can see is quite interesting. Here, we've tracked the proportion of people who believe that these different services are going to improve, minus those who think they're going to get worse. And with the NHS, optimism peaked immediately after the May Budget of last year, where Gordon Brown announced that he was going to raise our taxes to pay for a better NHS. Now, since last May that optimism has somewhat declined, and we now have around a year later, slightly more saying, "Well actually it might not happen. "I'm a bit, starting to be a bit worried about whether... "when the this delivery is actually going to take place."

DENNIS SEWELL:
So, however upbeat tomorrow's NHS annual report is, it looks as if it may be at least another ten or 15 years before we have access to the kind of service other Europeans take for granted.

This transcript was produced from the teletext subtitles that are generated live for Newsnight. It has been checked against the programme as broadcast, however Newsnight can accept no responsibility for any factual inaccuracies. We will be happy to correct serious errors.