No more cash for the NHS now, please Mr Hammond

We all know that the NHS will need more of our money but maybe not yet.  It should eliminate the huge sums it wastes first.  NHS England makes bold claims that it will improve productivity but is a bit short on the specifics. “Productivity” is usually defined as the ratio of output to the means of producing that output. There are two problems in using that measure for the NHS.  In the first place, there is no aggregate single number for NHS output.   Would using the operating theatre for two hip replacements rather than one tumour removal be more or less productive? 

Secondly, its does not distinguish “good costs” (directly increasing patient welfare) from “bad” (waste). The £20bn. 2010 productivity target[1] was largely to be delivered by restraining nurses’ wages.  We all know the negative consequences of that. The 2015 King’s Fund Report adds: “focusing on the monetary value of the [productivity] challenge risks missing the real essence of the task facing the NHS, which is about getting better value from the NHS budget. This means maximising the outcomes produced by the activities the NHS carries out, while minimising their costs. Framing the debate in terms of efficiency and costs also risks losing the opportunity to engage clinical staff in the challenge of changing the way in which care is delivered.”

In short “productivity” in the NHS context is a bogus word used to show good intent and justify demands for more expenditure.  The layers of supervisory hierarchies form one example.  Legal costs and the time nurses and junior doctors spend on their (outmoded) computer terminals rather than attend to patients are others. Eliminating waste immediately provides time and money for better patient outcomes.  Eliminating waste should be the target, not productivity.  Waste not, want not.

The King’s Fund uses a number of indicators of performance, as distinct from productivity, and this month’s Quarterly Monitoring Report makes grim reading.  Performance is down and going to get worse. Naturally this will stoke public, media and political outcry. Simon Stevens, CEO of NHS England, is wringing his hands and citing decreasing performance to justify more funding.

The Chancellor should call it like it is: if the NHS does not eliminate the waste when it really needs the money, it will certainly not do so if HM Treasury removes the need to do so.  He should tell Mr Stevens to focus on eliminating waste first and only when that is done, will funding follow.  Physicians heal yourselves.

Just as importantly, the public must be brought on board.  At present, the government is seen as the villain withholding the resources the NHS deserves.  The Tory government’s austerity programme is cruel, uncaring and unbalanced.  The public needs to be told just how much the NHS is wasting, not the dribs and drabs that are reported but the whole picture.  It could easily be 10% of the total and that would transform NHS funding but we do not know.  The NHS will not publish the total as to do so would undermine its demands.

By saying “no” the Chancellor can shift the focus.  He can insist on a fully quantified list of areas of waste in the NHS and Department of Health, drawing from the claims made in recent years by academics, practitioners and the Care Quality Commission. Performance and cost data by treatment category for the best and worst Trust outcomes should be analysed.  Some Trusts will be better at some things and worse at others.  Most of this data already exists within the Department of Health.  The NAO should audit the conclusions.

It would be wrong to leave a wholly negative impression.  Some substantive reductions in waste have been achieved.  For example, the 2015 Kings Fund Report noted some successes:

A different and more positive picture emerges when changes in how specific areas of care are provided are analysed:

  • Increases in generic prescribing rates – up from 20 per cent in 1976 to 84 per cent in 2013 – have saved the NHS around £7.1 billion and allowed more than 490 million more items to be prescribed to patients.
  • Reductions between 1998/9 and 2013/14 in the time patients spend in hospital have enabled more patients to be treated and avoided the need to provide 10,000 extra hospital beds.
  • Increases in day surgery rates over the same period have generated savings of around £2 billion and enabled 1.3 million more elective patients to be treated.

Once most of the waste has been dealt with, then the Chancellor should indeed be more generous but we need to see a complete shift of focus first.

[1] QIPP 1 Quality, Innovation Productivity, Prevention initiative to generate productivity gains to the value of £20bn from 2010/11 to 2014/15 but “productivity gains” here means cost savings.