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A King’s Fund report shows waiting times are up, providing another challenging day for the government as it struggles to sell its controversial health reforms 1.36pm: foxtrotdelta asks: Is there evidence that patients really want choice beyond being treated at the most local hospital which has the best trained staff to deal with their condition/ailment? John Appleby replies: Various British Social Attitudes Surveys suggest that a majority of people do want choice of hospital. But they also want a good hospital on their doorstep, and they are not hugely happy with choice if it leads to less popular hospitals being closed. I think choice is good (try putting “no” in front of choice). But good not necessarily in an economic context but from point of view that this is a good thing for people in its own right. Also worth noting that there are many points in someone’s care/treatment where choice is a good thing – from the most basic level (consent for treatment) to things like choice of treatment etc. Choice in an economic context in healthcare is more problematic if we hope that through choices patients will start to alter the behaviour and practice of hospitals for the good. I do not think there is strong evidence so far that patients, through the choices they make, have had much impact on the quality of care provided by hospitals. 1.26pm: Randeep Ramesh, the co-author of this blog asks: Who can patients take action against if, as the NHS constitution makes clear, the health service does not take “all reasonable steps to offer you a range of alternative providers” if it is not possible to meet the 18-week target? From what David Flory was saying it seems that the government are happy with 10% of people made to wait longer but the department’s own figures show in some specialities one in five are waiting longer than 18 weeks. John Appleby replies: I do not know (any lawyers out there?) – but my assumption would be that the constitution offers a legal right and that redress is therefore through the courts. Along with patient choice (in particular – that patients won’t choose long wait hospitals and therefore hospitals have an incentive to keep waiting times short), the constitution is quoted by the Department of Health as the prime way waiting times will be kept short now that targets have in essence been abolished. Well, we’ll see. I think the constitution/choice incentives are relatively weaker than the target incentive. 1.21pm: Arkadiev asks: Are waiting time targets a good thing? John Appleby replies: I think the reason the NHS has been so successful in reducing waiting times over the last decade is partly down to extra funding, partly [to] practical help for hospitals in how to reduce waiting times and partly due to tough targets. Managers were sacked in the past for failing to meet targets – a strong incentive to meet targets! But I recognise that there is a balance between the terror tactics of targets and pushing so hard that for example managers start fiddling the figures or that other things get neglected. It’s a tricky balance. But let’s not forget how bad waiting times once were in the NHS and the huge value the public and patients placed on reducing them (more value, I suspect, than many consultants). 1.15pm: ReidAJ asks: Are “efficiency savings” merely cuts? John Appleby replies: Well, they might be. The task for the NHS is not simply to “save £20bn”. If it were, that would be easy: simply stop doing some things to the value of £20bn. The task is much harder: to make every pound the NHS is given produce around £1.20 worth of extra benefits for patients by 2014. I would be worried if the NHS simply assumed that closing a ward was an efficiency gain. It would only be so if the money/resources saved were then spent on things that generated more value for patients than keeping the ward open would do. A big problem for the government is that measuring productivity in this way is very difficult. The NHS may get to 2014 and not really know if it has improved productivity by £20bn … 1.10pm: John Appleby of the King’s Fund has begun his live Q&A about his thinktank’s findings ( see 9.45am ) below the line. Please post any questions for him below. John begins with this statement: To start, just some quick context for our NHS performance report today. The NHS is facing its tightest funding settlement for decades plus a huge organisational reform, plus a drive to improve value for money at levels unprecedented in its history. The outcome of these pressures/challenges – on the NHS and its performance on things that matter to patients and the public – are uncertain. So, our performance briefing is the first of a quarterly look at some key indicators such as waiting times, hospital infections, delayed discharges, and redundancies. We also have a small (26 – not statistically valid) panel of NHS finance directors from whom we have responses to questions mainly about their organisations’ productivity pressures. With this information we hope to track performance over the coming few years. 12.50pm: James Ball has expanded his take on waiting times. He says using the government’s own figures waiting times have been creeping upwards. Excluding Wiltshire primary care trust, which had 11 surgeries, only one of which was within 18 weeks, you find that last February one in 12 patients was waiting more than 18 weeks. By January 2011 it had hit 9.9% (just under one in 10). The February 2011 number is 10.8%, which is actually nearer one in nine than one in 10 – but, yes, has definitely exceeded that limit. Especially damning when they’re doing less surgery, which is a new trend (January 2011 had 1,000 more operations than a year ago. February 2011 had 12,700 fewer). It’s also much worse when you break it down. In trauma and orthopaedics, it’s one in five. And the worst performing areas in England are: _ 12.39pm: Colin Leys, honorary professor at Goldsmiths College London, who has been studying and writing about the NHS since the late 1990s, is launching his new book with Stewart Player tonight, The Plot Against the NHS. In this Audioboo interview , he gives Rowenna a taste of his arguments: There was a project on the part of a small group of people to turn the NHS from a public, universal service and replace it with a healthcare market … That was in the minds of people like the Public Health Authority back in the 1990s. To call it a plot is: in pushing it through, everyone involved knew the public hadn’t been consulted and if they had been there would have been massive opposition because of the love of the NHS … So it was done as far as possible out of the public eye from 2000 onwards. _ 12.10pm: US healthcare giant UnitedHealth has sold off its network of GPs’ surgeries and pulled out of the UK primary care market in order to concentrate on offering GP commissioning support, according to Pulse, the magazine for health professionals : UnitedHealth now plans to refocus its UK business to concentrate solely on commissioning support, as it seeks to exploit the opportunities presented by the government’s NHS reforms. The move signals an end to UnitedHealth’s controversial tenure as a provider of GP services in the UK, with their take-over of practices in Derbyshire, Leicestershire and Camden in north London attracting vehement opposition from anti-privatisation campaigners. Instead, it plans to expand its commissioning support in areas such as data analytics, demand management and medicines management. It is already working with a number of PCTs and GP consortia, including pathfinders in Hounslow who recently signed a deal with the firm to run a major crackdown on GP referrals. 11.35am: Blogger Andy Cowper makes an intriguing point about the legal rights of patients under the NHS constitution ( see 10.38am ). He emails: My understanding is that, theoretically, the responsibility for funding care in event of an 18-week breach would lie directly with the commissioner of the patient’s care (currently, the primary care trust – PCT), and ultimately with the secretary of state for health, to whom the commissioner is accountable via line management by the strategic health authority (SHA) and the Department of Health. However, the NHS constitution is very clearly worded: “You have the right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of alternative providers if this is not possible” ( see page five here ). Interesting lack of definition of “all reasonable steps”. 11.23am: At 1pm John Appleby , chief economist and health policy specialist at the King’s Fund, who led the research on waiting times out today, will be live online to answer your questions. John previously worked as an economist with the NHS in Birmingham and London and he is currently researching the impact of patient choice and payment by results. Please post your questions for John in the comments below. Here are a few suggestions: • Why are waiting times the highest they’ve been for three years? • Why does the government dispute the King’s Fund figures? • What’s likely to happen to waiting times if the government’s health reforms go through? • What is the impact of increased waiting times on patients and the health service? • What can we do to reduce waiting times? 11.14am: The anti-cuts website False Economy has published this post this morning claiming that the prime minister has broken his promise to ringfence NHS funding, according to House of Commons data. “Richard Blogger” writes: David Cameron claims that NHS funding is ringfenced and will increase in real terms. But even if we take government figures at face value, NHS spending is set to grow at a slower rate than during the Thatcher years of chronic underinvestment and lengthening waiting times. 10.38am: The government has challenged the King’s Fund’s figures out today , but my colleague who specialises in data and investigations, James Ball, points out that waiting times have increased even by the government’s own figures: The government has challenged the King’s Fund, which claimed 15% of patients waited longer than 18 weeks for treatment. Ministers stated that under their preferred measure, which excludes patients who have delayed their own surgery, only 10.2% of patients wait longer than 18 weeks. But even the government’s favoured figures show the slide in waiting times: the latest figures, which cover February 2011, show the number of operations dropped by 13,000 versus the year before, while the number of people waiting over 18 weeks jumped 28%. In 23 NHS trusts, more than 20% of patients wait longer than 18 weeks for surgery. Royal Cornwall Hospitals NHS trust had the most long waits of any major NHS organisation, at 41.8% of patients. Trauma and orthopaedics was the sub-branch with the longest waits, with more than one in five patients waiting over 18 weeks on the government’s favoured measure. We will have more from James later – including a table of the longest waits in England. Under the NHS constitution, brought in by Labour and left in place by the coalition, patients have a a legal right for treatment within 18 weeks. The question is: who is liable if this is not met? Can anyone out there help? 10.31am: Will the health reforms undermine democracy in the NHS? My colleague Peter Hetherington has an article in today’s SocietyGuardian discussing the role of the new statutory health and wellbeing boards. He points out that if the boards are given sufficient powers over GP consortia, this could be an opportunity to give local councillors greater oversight over health services. Lib Dems see accountability as a “key concession to be dragged out of the prime minister” in the pause, but whether they get it remains to be seen. 9.45am: Good morning. Welcome to another day of our continuing coverage of the coalition’s controversial proposed health reforms. We have a great line-up for you today. With news out from the King’s Fund showing waiting times at their longest in three years , we’ll have chief economist and author of the report John Appleby (left) online between 1pm and 2pm to answer your questions. For now, here’s a round up of today’s news on the NHS reforms: Dominating the headlines is the news from the King’s Fund, which shows 15% of patients in February waiting more than 18 weeks for treatment – the highest level since 2008. The FT points out that this is partly due to a budget squeeze , but it is also a response to the health secretary’s decision to axe Labour’s waiting time targets last summer. The fund also interviewed 26 NHS finance directors, almost half of whom said that closing wards and reducing services were among the main ways they would make savings over the next year. Eighteen of them said that they were uncertain they would make the 4% efficiency target set for this financial year. Here’s James Meikle’s story on the report : With some hospital waiting times the worst for three years, A&E departments overstretched, and surgeons warning that patients are being denied key treatments, the first in a series of planned quarterly monitoring reports highlights “significant concern” among some of those responsible for contributing to £20bn of “efficiency savings” in the NHS over four years and for ensuring that new bodies taking over services in the next three years do not start with deficits. Most say they are unlikely to meet productivity targets this year. The challenging picture painted by the report, from a respected independent analyst of the health service, comes during the government’s two-month “pause ” in trying to push through its controversial legislation. Nigel Edwards, who runs the NHS Confederation, and David Flory, the NHS’s deputy chief executive, discussed how the £20bn of efficiency savings will be made to the protected NHS budget on BBC Radio 4′s Today programme this morning. The Times also has an interview with Steve Field , a GP and chairman of the “listening exercise” devised to rescue the reform programme. Field insisted that his report, to be completed in the first week of June, was entirely independent and had the full backing of David Cameron, whom he had already met four times. In his first interview since starting the job, Field said that the feedback had emphasised the need for greater protection against the “cherry-picking” of NHS services by private companies and “very strong” concerns about the protection of workforce training. He added that he would be going through the 6,000 responses to the white paper sent to the health secretary last year. We’ll post more details of our Q&A shortly. Health NHS Public sector cuts Public services policy Rowenna Davis Randeep Ramesh guardian.co.uk