James Gubb: We still haven't started the real NHS debate

IN 2000, total public spending on the National Health Service stood at £46bn. Next financial year, it will top £100bn for the first time. That's £1,700 per person.

Yet still the NHS too often fails to provide the fundamentals of health care delivery; a patient-centred, clinically-led and safe service.

In the first quarter of 2007/08, there were at least 13,660 cases of C-difficile in NHS hospitals; last year, hospital blunders killed an estimated 90,000 patients. Emergency re-admissions within 28 days of discharge – a reasonable proxy for quality – rose by over 20 per cent between 2002/03 and 2005/06.

The Government will trumpet "dramatic" improvement in tackling the biggest killers – coronary heart disease and cancer – and yes, there

has been progress, but the sobering reality is that death rates have fallen no faster than before the massive hikes in funding.

The UK remains at the foot of international league tables on cancer survival, stroke care and deaths that are considered preventable by good health care.

Patients are, unsurprisingly, far from satisfied. In a pan-European survey conducted last year, the UK came 17th out of 27 European countries on a range of consumer satisfaction measures.

But the source of the problem is certainly not the doctors, nurses and health professionals that work in the NHS, nor even the much-maligned NHS managers.

The source, in fact, is the centralised, monopolistic and heavily politicised system in which they work; the system where clinical leadership comes secondary to management by tick-box. The system where re-organisation, targets and central "initiatives" rule over evidence-based medicine and clinical governance.

Senior doctors and nurses have been fettered into immobility. In a recent survey of around 3,000 doctors conducted by Hospital Doctor magazine, over 80 per cent said they wouldn't encourage their children to go into medicine.

This is a remarkable non-achievement for a government that has, over the past few years, handed out record pay increases.

Money, clearly, is no substitute for intrinsic reward. "Who wants their doctor to leave his/her brain at the door?" asked one despairing ex-chairman of the British Medical Association (BMA).

To add to the malaise, central direction breeds inefficiency and inequity.

NHS productivity has fallen by an average of one per cent per annum over the past 10 years, according to the Office of National Statistics. If it had been efficient, the NHS could have treated an extra one million emergency and elective patients in 2005/06 alone, according to King's Fund analysis.

And the fight for resources goes on. A person who gets cancer in Nottingham can expect to have some 12,000 more spent on them than if they lived in Oxford. Patients in deprived areas, despite greater clinical need, are much less likely to access secondary care than the middle-classes who know how to work the system.

Something, clearly, is going very wrong. Yet of all the major political parties, only the Lib Dems seem to have paid much attention to the roots of the problem. "Power resides where the money lies," said their health spokesman, Norman Lamb, in calling for locally elected health boards.

With pretty much all funding cascading from Whitehall, it's inevitable that the NHS is constantly looking upwards; and inevitable that government wants to interfere, to micromanage, direct resources, and direct provision.

This is the true source of the inefficiency, the inequity, the poor outcomes and why doctors and nurses feel so alienated.

Locally elected health boards are one answer. But there is no guarantee the same problems won't be mimicked at the local level. A better idea would be to take a serious look at some of the insurance-based systems in Europe that are equally attached to universal and comprehensive health care, but provide it much more effectively.

The Netherlands is an interesting case. In 2006, it faced up to a whole host of problems not so unfamiliar to the NHS with a suitably progressive solution.

Funding has been pulled from the state to the individual, with

mandatory health insurance, plentiful choice, and comprehensive top-ups for the very sick and those who cannot afford it.

With money coming from the patient, government interference is capped, and providers, insurers and the medical profession are free to focus on the "customer" rather than on an "omnipotent" centre. It is now being hailed as possibly the most streamlined, equitable and competitive system in the world.

Time, then, for the NHS to follow? Not likely. The Tories are too scared of discussing such options. They think it will be confused with threatening the principle of universal health care. It does not; Europe is not the United States.

Labour, meanwhile, is too busy trying to justify its policies through another "once-in-a-lifetime" review. The long-awaited debate on the future of the NHS has yet to begin.

James Gubb is Director of the Health Unit at Civitas and author of the report Why the NHS is the sick man of Europe.

Civitas is an independent social policy think tank.