Paul Stephenson examines the details of the Wanless report, which outlines the financial options under three possible scenarios

Published:25/04/2002, Volume II2, No. 5802, Page 12 13

Derek Wanless travelled around the globe to produce his report on resourcing long-term healthcare, and it includes a description of a health service that works as it should.

It is a system in which 'healthcare workers are highly valued and well motivated', where 'modern and integrated information and communication technology [ICT] is being used to full effect', where 'primary care delivers an increasingly wide range of care, including diagnosis, monitoring and help with recovery', and where 'the majority of general and less specialised medical and surgical care has moved out of large hospitals'.

It is a system in which patients who need hospital care wait 'within reason - weeks not months, days not weeks, hours not days and minutes not hours' - and treatment is provided in clean, modern surroundings with less than four patients per room in most hospitals.

However, this is not Europe, Australia or the US, but the NHS in 20 years' time. This is the vision set out by Derek Wanless for the next two decades. It involves radical change, an enormous increase in the number of doctors, nurses and health professionals, and is based on assumptions about modernisation proceeding apace.

His report sets a target of waiting no more than two weeks for both inpatient and outpatient appointments by 2022. For this to happen, it assumes increases of around 5-6 per cent a year in the number of inpatients treated over the next five years, and increases averaging 3 to four 4 per cent a year for the remainder of the 20year period.

The review's estimates of how much the new NHS will cost are based on three scenarios, seemingly designed to take account of all possibilities for how well the money is spent over the next 20 years. The 'solid progress' scenario is where good progress is made, the 'slow uptake' scenario is where there is little change, and the 'fully engaged' scenario is where great advances are made.

All models assume ICT spending doubles in real terms by next year in the solid progress and fully engaged models, and by 2007-08 in the slow uptake. There is a 17 per cent reduction in outpatient attendance among 225,000 people using self-care in the solid progress and slow uptake models, and among double that number - 450,000 - in the fully engaged model.

Productivity growth rises from 2 to 2.5 per cent a year in the first decade to 3 per cent in the second in the solid progress and fully engaged scenarios, and from 1.5 per cent a year in the first decade to 1.75 per cent in the second for the slow uptake.

The difference in the funding implications between the three scenarios is huge, with a gap of around£30bn - around half today's NHS budget - between the fully engaged and slow uptake scenarios.

The vision of the future workforce is one in which many of the first and routine contacts between patients and the health service will be provided by nurses or other health and social care professionals in community-based settings. The services might cover minor injuries, minor surgical procedures, counselling, laboratory work and care of the elderly.

Major acute hospitals will focus on providing 24-hour intensive and high-dependency care.

The report lays out the difficulties likely to be encountered along the way to this new workforce.

Some organisations, including the Royal College of GPs, it says, are 'concerned about the changes in primary care envisaged'.

On pay, the review has assumed that total pay rises by 2.4 per cent a year in real terms, and on price inflation, 2.5 per cent a year is assumed across the whole of health and social care. It is debatable how realistic the price inflation assumption is, and the figure may well raise eyebrows among finance directors up and down the land.

Gordon Brown's response, allocating a 7.4 per cent increase in NHS spending, gives managers the maximum amount possible without wasting it due to capacity constraints.And the report makes clear, spending these sums will prove very hard. It says: 'Indeed, to be wisely spent, they would represent a very considerable management challenge. The risks of spending being ineffective rises within the spending growth rate.'

Perhaps the biggest challenge is that the healthcare workforce might need to increase by almost 300,000 over the next 20 years, with at least two-thirds more doctors and up to one-third more nurses. If existing workforce plans are met there would still be a shortfall of around 25,000 doctors, especially GPs, by 2020.

Although the demands vary according to the way the service changes, the solid progress model assumes 62,000 more doctors, 108,000 more nurses, 45,000 therapists and scientists, and 74,000 healthcare assistants.

Primary care activity will increase substantially and, if working practices do not change, 29,000 new GPs will be needed by 2020.

The interim Wanless report, produced for the Treasury last November, said nurse practitioners could undertake at least 20 per cent of the work of doctors while maintaining the safety and quality of care. The final report says that if 20 per cent of the work of GPs and junior doctors was shifted to nurse practitioners, 'this would eliminate any potential capacity constraint in doctor numbers'.

Mr Wanless has gone beyond his original remit and considers social care - and some of the recommendations are radical. He says 'appropriate financial incentives' are required to sustain a viable nursing and social care home market in the face of councils and care home owners arguing for higher fees.

He also calls for the government to examine the merits of employing financial incentives such as those used in Sweden to help reduce the problems of bed blocking. This involves local councils paying hospitals for care of patients whose discharge is delayed.

If it all works, the NHS will be unrecognisable in just 20 years' time. However, we will know how we are doing well before then, as Mr Wanless has called for a further review in five years' time to 'reassess future resource requirements'.

That, he says, should not only benefit from more detailed information, but could also incorporate the effect of health inequalities on resource requirements, while research on how socio-economic and health need are related will be complete.

By then, too, the government will know whether Mr Wanless' vision for health spending - and Mr Brown's commitment to it - are sufficiently palatable to the electorate for them to carry on their vision for the NHS for a third term in office. l Devil in the detail: are the assumptions realistic?

The report says the 'results are very sensitive to the assumptions made about productivity'and that if productivity is 1 per cent lower every year than assumed it will mean 2 per cent more GDP being spent on the NHS after 20 years.

NHS Alliance chair Dr Michael Dixon says: 'There are some productivity gains, particularly by looking at the interface between health and social care, and by getting better social care and by improving skill-mix in primary care.However, there are limits to this.We have been looking for increases in productivity in the NHS for years.We have been scraping the fat off now for a long time, and we are scraping the knife against bone and not meat.'

King's Fund health systems programme director John Appleby thinks the assumptions on productivity are realistic, but believes there are significant worries about staffing levels and demand management, particularly 'the massive increase in doctors and nurses, with an increase of 30 per cent over the five years up to 2008'.He is also concerned about demand rising as supply is increased and that this is not taken into account.He says: 'By increasing spending, you increase the demand to go with it.Doctors start changing their thresholds for treatment.For example, in London the winter before last, there was no flu but all the emergency beds were used up.'

The Wanless report: factfile l Derek Wanless, former chief executive of NatWest bank, was asked last year by chancellor Gordon Brown to look into the long-term resource requirements for the NHS over the next 20 years.His final report was published on the same day as the Budget, Wednesday 17 April.

l His interim report in November backed the existing funding arrangements, rather than a switch to social insurance or private insurance schemes.

l His final report calls for a vast cash injection in the NHS over the next two decades - up to a maximum of£184bn in 2022, at today's prices (nearly three times the current£68.1bn a year).

l The recommendations on spending levels vary, depending on which of the three models for the future pattern of healthcare develop.One is the 'solid progress'; the other is 'slow uptake'; the final one is 'fully engaged'.Each model is costed with a different total spend.

l In 2002-03, total NHS spend is£68.1bn, or 6.5 per cent.The proposed figures would bring it to between 10.6-12.5 per cent of gross domestic product in 10 years' time.The total spend per year by 2022-03 would be£154bn-£184bn.

l All his figures are based on the assumption of an annual growth in GDP of 2.5 per cent.

l He wants to see inpatient waiting times reduced to two weeks by 2022.

l He says social care funding should be in the review's remit and calls for more spending on it.

lHe suggests the extra money is front-loaded so that more is invested in the first five years.

l Investment in IT would need to double in that period, to 3 per cent of total NHS spend.

l Although enough nurses exist to cope with increased activity, there are not enough doctors. In addition to extra medical students entering the profession, more flexible working will be needed.

l Nurses could do more of doctors'work and healthcare assistants more of nurses'work.

l Improving NHS buildings should be a priority, lowering the average age of premises to 30 years.

l He says public health measures are important, but it is difficult to measure their effectiveness.

l He recognises the need for extra cash to be monitored to ensure it is well spent, but says there should not be too many different targets.

www. hm-treasury. gov. uk/Consultations_and_Legislation/wanless/consult_wanless_final. cfm