Using routinely collected data to demonstrate where the NHS is going wrong

 This is someone else’s work, it’s amazing. Genuinely amazing. And deserves wide coverage. 

In some ways a macro analysis of the history of NHS problems, using lots of readily available NHS data with a heavy dose of  intelligence and interpretation 

It’s Scottish. Is Scotland like England – ie questions of generalisability. I think many of same lessons are but appropriately caveated.

Authors clearly indicated in the slide set. They deserve all the credit.

This is from the Deep End research group.

Summary – self explanatory


I was asked for a considered opinion on this one today. It’s below. Don’t just use my quick and dirty bullets – go and look at the full mashing for yourself and get your own views on it too.

My take was- 

This is an excellent paper. Id sent it round a while ago, but just re looked……. It really is good!

 I don’t disagree with any of it

I think it’s the closeset we are going to get for a business case for GP and community nursing being a solution to current problems. It’s a bit NHS facing, and doesn’t quite nail the social care angle, but still



It’s well worth a read
My take on key points


· Slide 3 and 4 are the key slides for me – 1) problems not due to too little funding overall. 2) elective issues – sort worried well, target over diagnosis, 3) treatment, mismatch of hospital provision and need. Issues around steep aging of ED attendance – linked to long term reduction in GP and DN capacity and inability of community health partnership to control ugent care. 4) solution = Downsize hospitals, invest in non hospital care.

· Slide 8 – inverse care law in planned care. demand rising fasted in the most affluent Slide 13 plots rise in em admits with key events in time. Targets and supply drive activity.

· Slide 19 – spend on GP and community services. This is counter intuitive to what I thought was going on (admittedly Scotland isn’t England) – ie that resources being diminished in ‘community care’ which basically encompasses GP and comm nursing as a share of the total and resources being concentrated in hospital sector. I’m sure I’ve seen England data to this effect. HSCIC may have.

· Slide 20 – actual spend going up, rate of increase year to year slowing. Real terms spend flat at v v best.

· 21&22 – can supplant the excellent kings fund and Nuffield data on workforce here. Consultant growing quickly, GP growing v v slowly.

· Slides following are about GP numbers. Interesting Slide 29 – insightful on workload per headcount, comparing consultant to GP. Recent data from the study published in the Lancet would give additional insight into GP workload. Can’t recall the ref off hand, but was an amazing study giving insight into GP workload pressures with real data Slide 32 – good insight into community mental health. Ignore the spike, artefact.

· 33&34 social care spend. Caution as I don’t know what’s going on re local govt spending in Scotland, though assuming same as England Slide 39 – Scotland vs England analysis. In our case, England v Scotland. Nutshell = many of same broad issues.

· Slide 43 – the business end. Basically engaged and resourced general practice is a critical part of the solution, perhaps the critical part.

· Slide 44-47 recommendations. I’d say largely same in England.


So all up, this is the best macro level analysis I’ve seen on the big picture around health and care.



Repeating it

Don’t underestimate the effort that would have been taken to undertake this.

Looks like min multi month full time analytic with lots of ph consultant input. That’s probably an under estimate.

I wouldn’t pitch to do similarly locally (despite the Scottish context being very different to England) as 1) it’s a major analytic exercise and we don’t have the capacity and

2) I can’t see we’d reach wildly different conclusions – data points might be different, overall story probably wouldn’t.


Some excellent and erudite comments from Rory O’Connor


These comments include the opinion of the author, and are not necessarily supported either by the above analysis, nor should be taken to reflect the view of any organisation for whom the author works.

This is a very interesting analysis. I have not yet found any significant flaws in it.

It does appear to clearly show:

• The influence of the “inverse care law” – greatest health resources consumed by those with least need (as evidenced in graphs of age-sex standardised emergency department attendance by deprivation quintile)

• The adverse impact on health system financial sustainability of political ideologically driven policies which have resulted in:

o More inequitable provision of services

o Reduction of key front-line services such as General Practice and District Nursing (and non-health Social Services), resulting in inevitable increased demand on more specialist services

o Inability to match increasing demand for specialist services even with increased finances

• The need for almost any health analysis to be almost automatically sub-analysed by deprivation (as well as by age and sex). Significant barriers such as the inability of analysts to access the full postcode (needed to determine deprivation) (due to idiotic interpretation of data confidentiality rules), and the unwillingness of leadership to allow or publish challenging analysis, and the unstated aim of recent national leadership to increase inequity (even if it leads to responses such as Brexit). (Pickett, Marmott et al. show that increasing inequalities will lead to increased rather than decreased pressure on health spending).

• The need to carry out more analyses looking at activity / outcomes against clinical resource (GP, hospital consultant WTE). (Doctors tend to commit healthcare resources on a daily basis as they decide on investigations, referrals, operations, packages of care. More doctors in an area of care, more resources committed in that area.)

• The need to carry out more analyses looking at the source of admission (home, care home, nursing home etc), in relationship to healthcare use, particularly amongst the elderly, looking at preventable issues, and to look at source/housing issues for other vulnerable, high healthcare consumption groups, and to look at housing and social care issues much more strategically.

• I anticipate that many of the report’s findings are replicable in English health economies, and highly relevant to STP financial plans.

I anticipate that the solutions might include:

• Forced re-allocation of health expenditure upstream towards the underpinning services such as general practice and preventative services (in the face of universal outcry).

• Understanding of how to manage social care and housing needs, and the impact of underfunding in these areas on healthcare expenditure (with particular reference to some key groups – eg frail elderly)

• Adequate funding of important but non-urgent, cost-effective preventative services

• Managing the aspirations and demands of the articulate and politically influential whilst providing an equitable and cost-effective universal service with financial limits

• Greater attention to outcomes and equity (including in STP plans)

• Long-term investment in skilled, front-line (upstream) knowledge workers (clinicians)

• Avoidance of the short-term seductive appeal of new fads and gimmicks dreamt up by management consultancies

• Robust equity analysis of policies, which are capable of challenging politicial determination.

• Careful evaluation of efficiency options such as “deskilling” where the reduced management of risk and uncertainty may perversely lead to inefficiencies rather than efficiencies.

• (Far) Better access for all appropriate analysts to the (already existant) data they need in order to conduct the relevant analyses

• Evidence based policy rather than post-expert Trumpian dystopia

Rory O’Conor


on repeatability, and whether there is merit in redoing this in your STP

“re generalizability…. Yea point taken….Scotland is different, is it THAT different??

My stock line on those sort of things is we could do local version but would burn quite a lot of time, and I don’t think it would change the central message……”


2 thoughts on “Using routinely collected data to demonstrate where the NHS is going wrong

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