Is the NHS three times better than in 1979?

Richard Smith can be relied on to write stimulating and amusing
pieces but this week his observations about the development of health care
over the last thirty years(1) paint a negative picture that is simply not
supported by the evidence.

Just the other day, over a glass of wine, a friend of mine reflected
on how lucky he was to have been born in the 50’s and not in his parents’
generation. As he went on to explain, had he been born 30 years earlier,
both he and his wife would have been dead years ago but, because of
advances in medical treatment, both of them were leading full and healthy
lives.  In the 1990s his wife had received a liver transplant for
cholangiocarcinoma and, in 2001, while only in his 40s, he had suffered a
serious heart attack which had been treated with immediate percutaneous
angioplasty and the insertion of three stents. (His lifestyle and exercise
ECG are totally normal today.)

While it is not unreasonably to ask whether the increased expenditure
on health care over the last thirty years has produced value, this is
largely an empirical question that needs to be answered by reference to
the evidence. However, Richard Smith fails to give any facts or research
evidence to justify his scepticism about whether health care has added
much to life expectancy. With little effort he would have been able to
identify tremendous advances in medical and surgical treatments (and
improved health service organisation) over the last thirty years which
have clearly saved tens of thousands of lives and increased the quality of
life of patients, returning many to full health.

Let us simply consider the evidence from my friend’s example. The
first liver transplant was not even performed until the 1960s and in 1979
there were less than a score of liver transplants undertaken in the UK.
Today, not only are there are thousands of liver transplants performed
each year(2), but rejection rates have decreased and survival times have
increased dramatically(3). And it is not just length of life, but quality
of life too: after a successful liver transplant, most people go back to
their normal daily activities. The same is true for other organ
transplants.

In 1979, treatment for those who had had a heart attack was mainly
supportive (despite the fact that research had established some six years
earlier that using clot-busting drugs would save lives(4)). This failure
to get research evidence into practice meant that in 1979 (and over the
next decade) the health service was systematically failing nearly all
heart attack patients with the unnecessary loss of thousands of lives.(5)

So to answer Richard’s question: yes, NHS care for patients who have
had a heart attack is easily more than three times better than thirty
years ago. Moreover, it is continuing to improve with statistically and
clinically significant improvements year on year in the proportion of
eligible people receiving thrombolysis, which was negligible in the early
1980's but around 73% in 2008.(6)

Does this improved care add to life expectancy? It certainly does -
it has led to a dramatic saving of patient lives with 30-day mortality
rates for patients with ST-segment elevation  STEMI) myocardial
infarctions falling annually, to well under 10% by 2008.(6)

As new diagnostic modalities and effective treatments are discovered
more health personnel are needed to use them as there is simply much more
that can and should be done. Moreover, the much criticised increase in
managers has been an important factor to promoting the reorganisation of
care pathways needed to ensure that new technologies are taken up into
practice. The populist notion that the NHS has not improved despite
increased resources is simply not founded in fact and, while there is
always room for improvement, we should celebrate and not belittle the
incredible improvements that have been achieved.

References

1 Smith R. BMJ 2010;340:c1769

2 Adam R. et al 2003 Evolution of Liver Transplantation in Europe:
Report of the European Liver Transplant Registry. Liver Transplantation
2003 Dec 9(12): 1231-1243

3 Dickson R C. et al. Improving Outcomes in Liver Transplantation for
HCV and Non HCV Recipients. 60th Annual Meeting of the American
Association for the Study of Liver Diseases (AASLD 2009). Boston. October
30-November 1, 2009. Abstract 505

4 Antman E. et al A Comparison of Results of Meta-analyses of
Randomized Control Trials and Recommendations of Clinical Experts –
Treatments for Myocardial Infarction. JAMA 1992 268(2):240-248

5 Packer C. et al Diffusion of Thrombolysis for Acute Myocardial
Infarction from 1981 to 200 in England: Trend Analysis and Comparison with
Need. International Journals of Technology Assessment in Health Care 2004
531:535

6 MINAP (Myocardial Ischaemia National Audit Project). How the NHS
Manages Heart Attacks. Eighth Public Report 2009
http://www.rcplondon.ac.uk/media/Documents/press-release-
documents/public_report_2009.pdf Access date 6/04/2010

Competing interests:
None declared

I don’t dispute that medicine has increased life span, although, as
Paul Glasziou knows, there are continuing disputes over by how much. But
Paul has neglected an important part of the overall equation—medicine’s
capacity to increase unhealthy life span. Is it not possible that that
increase, which undoubtedly is there, may outweigh the increase in healthy
life span?

Competing interests:
I'm the author of the original paper and something of a Cassandra.

Dr Pounds asks why I didn’t mention managers in my article on the
increase costs of the NHS since 1979. The simple answer is that I didn’t
think about them beyond making the point that all staff have increased. I
didn’t either mention technical staff, professions allied to medicine, or
support staff.

A “wise after the event answer” might be that managers make up only
3.5% of the workforce and so don’t make a lot of difference one way or the
other. Dr Pound’s implication may be, however, that I am too sympathetic
to managers, and he isn’t wholly wrong.

I hope that Dr Pound might be impressed that I’ve spent something
close to an hour trying to find out the number of managers that there were
in 1979, but he won’t be impressed that I’ve failed. What I have learnt is
that there are now 44 600 managers in the NHS in England , and in 1996
there were 20 050—so that’s more than a doubling in 14 years. I’ve also
learnt that the Department of Health plans to cut management costs by 30%
by 2013/14, and I’ll be interested to see if they succeed and what the
consequences will be if they do.

Although I couldn’t find the number of managers in 1979, it seems
highly likely that there were far fewer than now. The Griffiths report of
1983 concluded in the most broad terms that the NHS wasn’t managed and
needed to be.

There is a deep popular fantasy—supported by most politicians and
perhaps by Dr Pound—that if the NHS were simply to shake off managers and
concentrate on “frontline” staff then the service would be both better and
cheaper. Unfortunately this is a fantasy because as organizations become
larger and more complex management becomes more important--and has the key
to making big improvements and increasing value and productivity in a way
that is impossible for frontline staff even if they can make big
improvements within their own part of the system.

That’s why there is such a competitive market for successful senior
manager leaders in the broader world if not in the NHS.

Competing interests:
I'm the author of the paper and have both a medical and a management degree. But I've done much more managing than doctoring--making me a suspect figure to many doctors.