All Whitehall departments want more money than is good for them but they cannot all have a bigger share of the pot. The bigger the spenders, notably Health and Defence, the more they demand. And, of course, the bigger the spender, the more they waste because, primarily, they have the money to do so.
In this autumn’s budget season, the clamour to increase the NHS England budget, sizably and immediately, has been intense, not just from the NHS but from almost all interested parties such as the chairman of the Commons Health Committee, the King’s Fund and the professions. In the event, the Chancellor provided about half the amount demanded but without any rationale for his decision. In the previous week, The Times had led us to expect the Chancellor to require that the NHS make good their promises of savings before they should expect their claims to be met. In riposte, NHS England asked which targets should be abandoned but they did concede that the NHS bill could be reduced by £200M p.a. if doctors stopped prescribing medications available over the counter. But we have heard that many times before - in 2012 for example. GPs are not employed by the NHS and are pretty much free to prescribe what they like.
No solid estimate exists for waste in the NHS. It could be as much as 10%, i.e. over £10bn p.a., but no one really knows. NHS England particularly do not want to know as it would undermine their case for more funding. The curious thing is that, after the Chancellor’s challenging words before the budget, there was no sign of them in his budget, no attempt to justify what most see as a miserly and inadequate handout. Why dumb? Why is the Chancellor shutting up without putting up?
The public deserve the truth. Waste in the NHS is in nobody’s interest. There have indeed been genuine improvements in the use of resources, such as reduced stays in hospital. There have also been unmet claims of increased future “productivity”. The Chancellor should insist upon a priced list, audited by the NAO, of the savings that can and should be made. As the Russians say “Doveryai, no proveryai” (trust, but verify). The waste within the Department of Health, those 30 or so quangos outside the purview of the NHS itself, would be quite a good place to start.
To help things on their way, here are a few examples of waste:
- Professor Briggs and his team “found huge variations in the cost and quality of common treatments, with low-performing hospitals routinely ignorant about superior methods adopted elsewhere. The NHS could save hundreds of millions, if not billions, a year if the best and most efficient practices were applied across the country.” And “More than 300,000 patients a year are needlessly admitted to emergency surgery beds when they do not need an operation.” Their report did not total its examples but it reveals billions rather than millions of waste.
- The under-use of expensive facilities such as operating theatres. The surgeons are willing but the bureaucrats are not.
- Anything that takes doctors away from the treatment and cure of patients is, prima facie, waste. Clinical Commissioning Groups are an example. There are far simpler and fairer ways of allocating funds to GP practices which would involve GPs is far less admin.
- Bed blocking. Adult social care is under-represented in the upper levels of the Department of Health and perhaps as a result the NHS gets more than its fair share. As a direct consequence, inefficiencies are introduced into the NHS. Having the value of the blocked beds, for example, passed to the adult social services would not reduce NHS capability whilst also providing more relevant help to the elderly.
- The NHS should focus on the treatment and cure of individuals and not distractions such as general health. Of course prevention and dealing with epidemics are important but the Department of Health has the 5,500 staff in Public Health England to do that.
- Similarly, the NHS should not duplicate the well funded Medical Research Council with its own National Institute for Health Research at a cost of over £1bn.
- Bureaucracy is endemic throughout the primary and secondary NHS: “Bureaucracy takes up 3-4 hours [a week], of which maybe 50% is of any clinical value”according to one experienced GP practice head. Bureaucracy is compounded by having too many targets.
- The number of managers, long a matter of complaint, has reduced somewhat but there are still layers of hierarchy in hospital trusts which may give respectability but do little for patient care. Budgets are not set by boards but by battling consultants. The NHS would save a lot by recognising reality.
- Anyone who has spent time in a public ward will get the impression that medical staff spend more time nursing their computer terminals than nursing their patients. Of course each shift needs to brief the next but this misalignment aggravates shortage of nurses. On 22nd October 2017, in the otherwise excellent Frimley Park hospital, a 97 year old in a six patient ward was reportedly dead for up to three hours before the staff noticed.
The Chancellor has not made the case for his funding decision and he will not satisfy public opinion if he remains dumb. Likewise, the government has rejected Norman Lamb’s request, supported by 90 MPs, for a non-partisan, cross-party strategic review of the NHS to cover, inter alia, what it should fund and the extent to which patients should contribute, as we do with dentistry and prescriptions. Again, no rationale has been provided. Surely a Tory government should be glad to get the topic off the table? Dumb and dumber.