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london Ministerial vision versus NHS reality in the UK
THE LANCET
DISPATCHES
LONDON
Ministerial vision versus NHS reality in the UK
S
tephen Dorrell, the politically ambitious Health Secretary, is trying to reverse the traditional roles of the two main parties in the UK. The Conservatives have always lagged far behind Labour in opinion polls on health policies. Indeed, in a famous memo, which was leaked to the media 2 years ago, a former vice chairman of the party said the best policy for Conservatives on health was silence. The party could not win. Stephen Dorrell disputes this. Earlier this year he privately briefed journalists that he was going on the offensive. And he got a public promise from the Prime Minister for “year on year” increases in National Health Service expenditure when Labour was still saying that any extra spending on patient care could come only from savings on administrative costs. In June, he published a primary-care policy paper, which unlike earlier changes called for consultation and trials rather than imposing the new structure. But his main pride and joy was to be an overall review of the NHS, A Service with Ambitions, which appeared last week before the Budget (see p 1510). Billed as a white paper that would set tough objectives for the service, the paper in fact proved to be big on vision but extremely short on detailed policies. Dorrell defended his avoidance of immediate problems, the worst cash crisis for 5 years, on the need to look at medium and long term goals. It rejects the doom-mongers’ analysis, set out by Sir Duncan
NEW YORK
Nichol, the former chief executive of the NHS in a report last year, that the health service would run out funds and require extra private resources. The paper notes that real resources have increased by 3% per year in real terms since the Conservatives came to power 17 years ago and puts all the traditional
“But his main pride and joy was to be an overall review of the NHS. . .” cost pressures—demography, medical advances, public expectations—into perspective. The next decade sees “lower demographic pressures than for many years”. Health spending on the elderly has risen no faster than spending on all age groups. The past 20 years suggest that “the extra years of life have not been years of severe disability, but of mild to moderate health problems”. It is equally sanguine about medical advances, noting new procedures and drugs that save money although others require more funds. There was “no evidence of an acceleration in the overall pressure on expenditure”. Public expectations will continue to rise, not least because of the government’s patient’s charter but also because users want more say over services and standards. But more information would enable people to make more appropriate use of healthcare. Five objectives are set for the NHS: a well-informed public, a seamless service, decision-making
based on clinical evidence, a trained and skilled workforce, and a service that responds to needs. Working parties will be set up to examine three issues: new ways of providing patients with more information, of measuring effectiveness, and of breaking down the barriers between hospitals and family doctors. The paper rules out rationing but it does want what it calls more specific “priority setting”. This would not extend to prescribing at national level, because it would require handing over decisions that ought to be taken by doctors to others who lack the expertise. Labour criticised the £178 000 cost of this “pre-election stunt” and made fun of the nine fictional cases in the paper setting out best practice. More seriously, health managers were sceptical about future prospects. Philip Hunt, director of the National Association of Health Authorities and Trusts, said the NHS would have to win public support for change if the government’s ambitions were to be realised. “We are having real problems in persuading the public that the centralisation of some services and the transfer of others to local settings will provide much better services. I’m very doubtful that the internal market is sufficient in itself to power such changes.” Meanwhile, a major survey of finance directors of Trust hospitals and health authorities shows the NHS is in its worst cash crisis for years. Malcolm Dean
Scandal erupts at New York blood centre
T
he US Food and Drug Administration and the District Attorney for the Southern District of New York are investigating alleged improprieties at the New York Blood Center in the wake of an investigation published by New York magazine. According to the article, employees at the Center, which provides threequarters of the blood supply to New York hospitals, knowingly falsified test results that may have allowed blood contaminated with hepatitis viruses and HIV to be given to patients. Over the past few years, the FDA has inspected the Center’s two facilities in Manhattan; after one
Vol 348 • November 30, 1996
inspection in late 1994, the agency sent the Center a warning. Center management agreed to make improvements in an April, 1995, meeting with FDA. But another inspection in late 1995 of a different facility revealed more concerns, including technicians’ difficulties interpreting western blots. The New York article alleges that Center management invited sloppiness and shortcuts by promising productivity bonuses to employees. The Center, a non-profit organisation, found in the late 1980s that it was struggling because of the increasing number of tests required. The article also alleges that senior managers urged work-
ers to skip tests or falsify results, and that some conspired to hide test records from FDA inspectors. In a press conference on Nov 18, John Adamson of the Center strongly refuted the article, stating that it “relied in large part on unverified statements made by exemployees”. He added that the Center is conducting its own internal investigation. FDA spokesman Larry Bachorik says that the agency is continuing inspections, but has not acted to halt Center operations. The agency also says that it has “referred allegations of misconduct” to the US attorney. Alicia Ault Barnett
1507
DISPATCHES
LONDON
Ministerial vision versus NHS reality in the UK
S
tephen Dorrell, the politically ambitious Health Secretary, is trying to reverse the traditional roles of the two main parties in the UK. The Conservatives have always lagged far behind Labour in opinion polls on health policies. Indeed, in a famous memo, which was leaked to the media 2 years ago, a former vice chairman of the party said the best policy for Conservatives on health was silence. The party could not win. Stephen Dorrell disputes this. Earlier this year he privately briefed journalists that he was going on the offensive. And he got a public promise from the Prime Minister for “year on year” increases in National Health Service expenditure when Labour was still saying that any extra spending on patient care could come only from savings on administrative costs. In June, he published a primary-care policy paper, which unlike earlier changes called for consultation and trials rather than imposing the new structure. But his main pride and joy was to be an overall review of the NHS, A Service with Ambitions, which appeared last week before the Budget (see p 1510). Billed as a white paper that would set tough objectives for the service, the paper in fact proved to be big on vision but extremely short on detailed policies. Dorrell defended his avoidance of immediate problems, the worst cash crisis for 5 years, on the need to look at medium and long term goals. It rejects the doom-mongers’ analysis, set out by Sir Duncan
NEW YORK
Nichol, the former chief executive of the NHS in a report last year, that the health service would run out funds and require extra private resources. The paper notes that real resources have increased by 3% per year in real terms since the Conservatives came to power 17 years ago and puts all the traditional
“But his main pride and joy was to be an overall review of the NHS. . .” cost pressures—demography, medical advances, public expectations—into perspective. The next decade sees “lower demographic pressures than for many years”. Health spending on the elderly has risen no faster than spending on all age groups. The past 20 years suggest that “the extra years of life have not been years of severe disability, but of mild to moderate health problems”. It is equally sanguine about medical advances, noting new procedures and drugs that save money although others require more funds. There was “no evidence of an acceleration in the overall pressure on expenditure”. Public expectations will continue to rise, not least because of the government’s patient’s charter but also because users want more say over services and standards. But more information would enable people to make more appropriate use of healthcare. Five objectives are set for the NHS: a well-informed public, a seamless service, decision-making
based on clinical evidence, a trained and skilled workforce, and a service that responds to needs. Working parties will be set up to examine three issues: new ways of providing patients with more information, of measuring effectiveness, and of breaking down the barriers between hospitals and family doctors. The paper rules out rationing but it does want what it calls more specific “priority setting”. This would not extend to prescribing at national level, because it would require handing over decisions that ought to be taken by doctors to others who lack the expertise. Labour criticised the £178 000 cost of this “pre-election stunt” and made fun of the nine fictional cases in the paper setting out best practice. More seriously, health managers were sceptical about future prospects. Philip Hunt, director of the National Association of Health Authorities and Trusts, said the NHS would have to win public support for change if the government’s ambitions were to be realised. “We are having real problems in persuading the public that the centralisation of some services and the transfer of others to local settings will provide much better services. I’m very doubtful that the internal market is sufficient in itself to power such changes.” Meanwhile, a major survey of finance directors of Trust hospitals and health authorities shows the NHS is in its worst cash crisis for years. Malcolm Dean
Scandal erupts at New York blood centre
T
he US Food and Drug Administration and the District Attorney for the Southern District of New York are investigating alleged improprieties at the New York Blood Center in the wake of an investigation published by New York magazine. According to the article, employees at the Center, which provides threequarters of the blood supply to New York hospitals, knowingly falsified test results that may have allowed blood contaminated with hepatitis viruses and HIV to be given to patients. Over the past few years, the FDA has inspected the Center’s two facilities in Manhattan; after one
Vol 348 • November 30, 1996
inspection in late 1994, the agency sent the Center a warning. Center management agreed to make improvements in an April, 1995, meeting with FDA. But another inspection in late 1995 of a different facility revealed more concerns, including technicians’ difficulties interpreting western blots. The New York article alleges that Center management invited sloppiness and shortcuts by promising productivity bonuses to employees. The Center, a non-profit organisation, found in the late 1980s that it was struggling because of the increasing number of tests required. The article also alleges that senior managers urged work-
ers to skip tests or falsify results, and that some conspired to hide test records from FDA inspectors. In a press conference on Nov 18, John Adamson of the Center strongly refuted the article, stating that it “relied in large part on unverified statements made by exemployees”. He added that the Center is conducting its own internal investigation. FDA spokesman Larry Bachorik says that the agency is continuing inspections, but has not acted to halt Center operations. The agency also says that it has “referred allegations of misconduct” to the US attorney. Alicia Ault Barnett
1507