Short measure

Published: 13/12/2001, Volume III, No. 5785 Page 24 25 26 27

Sean Boyle is visiting research associate at the London School of Economics. John Appleby is director of health systems at the King's Fund.

A simple question for those in charge of the NHS is this: does more money equal more activity? And the simple answer turns out to be: apparently not.

Data from various sources suggests that over the past few years, the NHS seems to be underperforming in a number of areas. But not only has the rate of growth of certain key activity measures fallen, the latest quarterly data suggests activity may even be decreasing.What is going on?

It seems unlikely that the NHS has - half a century later than expected - fulfilled Nye Bevan's, and others', original expectation that the NHS would conquer the mountain of ill health and reach some sort of equilibrium.

If demand for care has not levelled off, how do we explain what is a particularly troubling fact for the NHS plan and its waiting-time targets? As is so often the case, simple questions about the healthcare system turn out to be very difficult to answer. But understanding what is happening with activity is clearly very important, because meeting the NHS plan maximum waiting-time targets is likely to require large and sustained year-on-year growth in activity over the next four years. So how has activity been measured in the NHS, and what do the trends look like?

What the figures show A major component of NHS expenditure (and hence NHS activity) relates to treating patients in acute hospitals, either as elective cases or emergencies. Other key activities are running outpatient clinics for specialist appointments and accident and emergency departments for people who have an immediate need for care. On any measure of these activities, there has been a steady increase in NHS activity since 1980.

For many years, the 'finished consultant episode' was the usual way of measuring hospital activity (a separate episode of care was logged each time the care of a patient transferred between one consultant and another).However, this has been criticised, as it results in spurious differences in activity between hospitals (and over time), and tends to inflate overall activity figures. The government now presents activity in terms of spells of care or 'first finished consultant episodes', which cover the whole stay of a patient in the hospital.

Other services - such as A&E and outpatients - use different measures of activity (such as attendances).

How activity is measured - and in particular, changes in measures - makes it difficult to track changes from year to year. Nevertheless, reasonably consistent trends for inpatients, outpatients and emergencies can be pieced together.

For inpatients - split between patients admitted as emergencies and those admitted as electives - activity since 1992 has been on a rising trend. The growth in emergency activity was high through most of the 1990s (between 1993-94 and 1998-99 it increased at an average rate of 3.1 a cent a year) but has tailed off to just 1.2 per cent in the two years to 2000-01. A similar pattern is observed in elective activity. In the two years to 2000-01, activity increased by an average of just 1.8 per cent a year, compared with over 5 per cent in the previous six years (see figure 1).

A similar pattern is observed for outpatient attendances.

There has been a decline in the rate of growth since 1997-98, with growth in outpatient activity in the three years to 2000-01 at just 2 per cent.

1An important aside arising from these activity trends is their impact on a measure of NHS efficiency used by the Department of Health.

The 'cost-weighted activity index' combines various types of NHS activity (inpatient and outpatient activity count highly in this index) which, when compared with the amount of real resources going into the NHS, provides a measure of efficiency.

Growth in spend is now outpacing growth in activity (see figure 2, overleaf ). Between 1991-92 and 1996-97 real spend increased by an average of 3 per cent a year while activity increased by an average of 3.4 per cent - crudely, an increase in efficiency.

2However, in the three years between 1996-97 and 1999-2000, real spend increased by 4.7 per cent a year while activity increased by just 1.6 per cent. In other words, the NHS became less efficient (albeit on a crude measure of efficiency 3).

Elective admissions While the high-level figures for inpatients, emergencies etc provide a broad picture of what is happening to activity in the NHS, this data is at a very aggregate level. To start to understand the implications for the NHS plan waiting-time targets, more detailed figures are needed. The key factor will be what happens to elective patient activity.

Most non-emergency care is elective (where a patient has been waiting for treatment), and includes patients admitted from the waiting list, booked admissions and planned admissions. This last patient category is not counted in official waiting list/times data, and includes patients making regular trips to hospital over time for a course of treatment (for example, chemotherapy) and 'bilateral' patients (for example, those having double hip operations who for the second hip replacement are counted as planned admissions rather than being taken off the waiting list).

Elective admissions have increased year-on-year since 1992 but, as figure 1 shows, apart from 1998-99, the rate of increase has actually slowed down since 1995-96.

We can look in more detail at quarterly changes in activity.Quarterly changes in general and acute elective activity (in percentage terms) reveal disturbing falls in activity in recent quarters, at precisely the time when more money has been going into the NHS and when the service needs to start increasing this type of activity if it is to make inroads into its waiting-times targets (see figure 3).

Perhaps more worrying still is a change in the balance of types of elective admission. In particular, it is planned admissions - which have no direct impact on waiting lists or times - which have tended to grow (doubling since 1996-97). As figure 4 shows, admissions from the waiting list and booked admissions fell in the year to 1999-2000.

The effect on waiting lists So if activity is slowing down (and in some instances going into decline), what has been the impact on the number of people waiting for treatment and the average time they wait? From 1993 to 1998, the number waiting for treatment increased but has since fallen back to where it was in 1993.However, the most recent quarterly data shows an upturn in numbers waiting since March 2001.

The key NHS plan targets now relate to waiting times for inpatient and outpatient care. Figures for March and June this year (other months have not been published) show that outpatients waiting more than 13 weeks and inpatients waiting longer than six months went up by 26 per cent and 9 per cent respectively.

4And as figure 5 shows, there has been virtually no change in the average waiting time for inpatient treatment since December 1991 (whether the mean or median average is used). As meeting the new maximum waiting times is likely to mean reducing the average wait for the whole list, this suggests how difficult it will be to meet the new targets.

How do these findings square with what has been happening to activity in recent years? The number of patients waiting for treatment changes either because they have received the treatment they have been waiting for (admissions), because they are not able to take an operation at the time offered (selfdeferrals), because they are removed, generally for a clinical reason (removed), or because there are additions to the waiting list.

In the two years since 1998-99, there was a marked decline in each of the first three categories (admissions, self-deferrals and removals), but at the same time the number of people admitted on to the waiting list has also declined.

In the five years from 1991-92 to 1996-97, additions to the waiting list increased at an annual rate of 4 per cent, but in the four years since 1997-98 the rate of additions has fallen by an average rate of 1 per cent a year.

The implication is that any reduction in the waiting list in the last three years has been achieved not through treating extra patients, but through fewer people being placed on to the waiting list each year.

The figures show that there has been a fall in the rate of increase in NHS activity, despite a large increase in funding for the NHS.The most recent quarterly evidence suggests a decline in NHS elective activity.The reasons for this are not yet clear.However, there is some evidence to suggest that much of the annual 6 per cent real growth in expenditure is being eaten into by improved pay and working conditions, and efforts to improve the quality of the NHS - rather than increased activity.

The result is a divergence between the rate of increase in spend on the NHS and the rate of increase in the usual measure of activity.

The government's key problem is being able to show that its extra spending is working: that it results in extra activity that will begin to deliver the ambitious waiting-time targets.However, unless there is a significant redirection of cash into activitygenerating areas of the NHS which impact on waiting times, the service will struggle to meet its targets.

But ifmoney is redirected, other objectives may suffer. If reducing waiting times is the right thing to do, perhaps it is better to be open about the tradeoffs involved.A painful political decision, but no-one said that changing the NHS was easy - did they?

REFERENCES

1www. doh. gov. uk/hospitalact ivity/index. htm 2IFS/King's Fund. Pressures in UK Healthcare: Challenges for the NHS. ISF/King's Fund, 2000.

3Health Select Committee.

Memorandum received from the Department of Health containing replies to written questions from the committee.HC 882, 2000.

4Yates J. Lies, damned lies and spinners. HSJ 2001; 111 (5779): 29.