More for less in the NHS

By Thomas Cawston, Researcher, Reform

With perfect timing, the British Medical Journal devoted this week’s issue to ideas on how to cut the NHS budget.  Clinicians, managers and patients put forward ideas to save money at the same time as improving patient care.  The best ideas were:

• Keep patients out of hospitals, as a new report from Reform argued last week.  The poor management of patient referrals and slow discharge can keep patients in hospitals for weeks more than necessary.  This is expensive and bad for patients.  Professor Adam Timmis, a consultant cardiologist at Barts and the London Hospital argues that rather than keeping a patient in bed for four weeks waiting for a consultation from a social worker, the patient could receive the consultation at home: “every day spent in hospital is a disaster as patients lose their independence and are at risk of hospital acquired infections."  And according to Carl Heneghan of Oxford University “40 per cent of walk-in patients to accident and emergency could be seen and managed by GPs”

• Help patients help themselves.  Graham Rich, former Chief Executive of University Hospitals Bristol NHS Foundation Trust,  argues that the NHS still makes patients dependent on doctors and hospitals. Greater focus on self care and patient networks is vital, especially for people with long term conditions such as diabetes: “A lot of people with chronic conditions, who are the heaviest users of the NHS, benefit from practical and emotional support from others about how to cope and live with their conditions.”
  

• Make clinicians accountable. Both Graham Rich and Jonathan Fielden, an intensive care consultant, Royal Berkshire NHS Foundation Trust, make the case for service line management, where clinicians are organised into self governing units. This makes gives doctors autonomy to deliver improvements in quality care and make spending decisions transparent. Service line management can “improve consistency of care, decrease unnecessary treatments, and investigations and bring better value for money.”

• Use IT.  As many of the clinicians claim, waste is endemic in the NHS. Dr Smellie, a consultant pathologist at County Durham and Darlington Acute Hosptials NHS Trust, suggests that 30 per cent of NHS tests could be avoided. Many of these are repeat tests because results have got lost or patients have demanded to be retested.

• Cut the payroll.  As Phil Leonard, a Senior Manager at Ernst & Young,  recognises, the inescapable truth is that “the greatest cost in NHS organisations is people, and reducing the payroll has to be part of the response”. He goes on to argue: “Perhaps predictably in a large system like the NHS, the productivity of employees, including clinicians, varies widely. Many doctors, nurses, and other professionals work extremely hard; however, others do not. Almost every hospital at which I have worked has used internal benchmarks to analyse the work of professional staff. Without exception, they show differences in performance. A combination of pay related to performance, more reporting transparency, and focused training programmes should be used to ensure that the NHS, in paying staff more money, receives the benefits of a consistently high rate of output.”

Giving evidence to the Health Select Committee yesterday, Andrew Haldenby argued that the cost-cutting ideas are well understood in the NHS (which is why managers are confused by the Conservative pledge to ring fence the services’ funding).  He argued that what is left is to make managers properly accountable for performance and value for money (particularly managers in Primary Care Trusts who control most of the resources of the services) so that they actually implement those ideas.

He proposed giving patients choice of PCT as a basic step.  That would encourage managers to deliver on their responsibility for changing NHS services in the interests of patients instead of sticking with the status quo as politicians often urge them to do.