Tipping the scales at a whopping 321 pages the Wanless Report published by the King’s Fund on 11th September is certainly a heavyweight.

Five years on from his seminal report which paved the way for the 50% real terms increases in NHS spending former NatWest Group Chief Executive Sir Derek Wanless’ latest review - Our Future Health Secured? - examines how that extra money was spent.

Prescriptions dispensed rose by more than a fifth (up by 135 million items) between 2002 and 2006, with drugs prescribed for cardiovascular conditions – particularly lipid-regulating statins – accounting for the lion’s share of the growth but at a lower-than-expected cost.

Increases in funding have delivered more staff and equipment; improved infrastructure; significantly reduced waiting times and improved care in coronary heart disease, cancer, stroke and mental health.

Unhappily the additional funding has not produced the improvements in productivity assumed in 2002. Hospital activity has increased, but the biggest increase has been in emergency, rather than elective, admissions. Problems and delays beset the National IT Programme.

More crucially, progress on influencing lifestyle has been slower than predicted. In particular adult and child obesity are now at much higher levels than the most pessimistic forecasts.

Higher levels of funding forecast

Sir Derek says: “Without significant improvements in NHS productivity, and much greater efforts to tackle obesity in particular, even higher levels of funding will be needed over the next two decades.”

“Despite these concerns, we conclude that the broad direction of government health policy is the right one, although it is still too early to evaluate its full impact. The radical structural changes to the NHS since 2002 have been costly, not just financially but in terms of disruption, loss of experienced staff and changes in working relationships.”

Given the high costs of service reconfiguration, the report highlights the need for detailed research into new models of delivery before they are implemented to assess their cost effectiveness.

Nigel Edwards, director of policy at the NHS Confederation, responds cautiously: "We would stress that research alone will not provide a definitive answer. There is a need for innovative solutions and bold experimentation at a local level, implemented in consultation with frontline staff and the public.”

But even if changes do make services significantly more productive, and if individuals do take greater responsibility for their own health, health spending will still need to increase from £68 billion in 2002/3 to £154 billion by 2022/3 (at 2002/3 prices). By contrast the least efficient, and most costly, future scenario envisages spending rising to £184 billion – real growth of 171%.

Productivity hampered by book balancing

Whether or not the NHS is able to pursue productivity improvements remains to be seen. Chairman of the BMA’s Consultants Committee, Dr Jonathan Fielden, says doctors needed to be free to innovate to improve productivity, commenting: “In the last few years the Government has been so determined to balance the books and bring down NHS debt that doctors have been prevented from introducing innovative practices to improve productivity”

The review warns that if the NHS receives a financial settlement much closer to its historical long-term average of around 3% in the upcoming comprehensive spending review, then by 2010/11, the NHS will fall short of its needs by between £7.2 and £15.2 billion.

Meanwhile a spokesperson for the NHS Alliance representing PCTs, GP practices and other primary care organisations claims that it already has the answer to Wanless: Practice based commissioning. According to the Alliance GP practices managing their own budgets are already using savings to transform healthcare. One GP practice in Lancashire has saved £500,000 in a year by employing its own pharmacist to advise on prescribing. Steve Ainsworth