Evan Davis interviewed Sir David Nicholson, the Chief Executive of the NHS on The Today Programme on Radio 4 about Nicholson’s projection that the NHS will be £30bn short of funds by 2020. (Listen again here for 7 days).
As they were talking about the £30bn funding gap the interview went like this:
Evan Davis: So this means reconfiguring services, finding savings in the way things are done now so you can deliver as good a service at a lower cost.
David Nicholson: Yes. We want to provide a better service , of course, and for most of the rest of the economy that’s exactly what people do. The dichotomy that’s often said in the NHS about you can’t improve quality without spending more money is simply not borne out by the reality of what happens, and certainly not in the rest of the economy. So, we think we can do both of those things.
He has nearly got it, but it doesn’t go far enough. He says that that the idea that you can’t improve quality without spending more money is a dichotomy and that he wants to do both (improve and spend less money). I would go further and say that the only real way to spend less money is to, first, improve services to the patient. That is the only sustainable way to save.
Davis asks for an example and Nicholson talks about three ways to do this:
- Centralisation and specialisation. With the example of stroke services in London moving from 31 hospitals to 8 with much better outcomes.
- Prevention. Providing services in the community for people with long-term conditions and the elderly that prevent admission to hospital.
- Efficiency and productivity.
There is an option totally missing from that list and it is one that would come before any of those. It is, again, to improve care of the patients at every point in the system, while still taking the system as a whole into account. So this would mean that every doctor, nurse, cleaner and other members of staff would have ideas to improve the service to patients every day. They would test those ideas and implement them. At the same time the senior staff would be monitoring and communicating the service to patients and the system as a whole.
This would be done before we start another round of reconfigurations and shuffling the deck of organisations. Imagine if every one of the million or so staff in the NHS had one idea this year that made things better. The majority would be very cheap to implement and taken together would save millions. And what if they had an idea a week? One per day? And what if they worked together in teams to learn from each other’s ideas? Now you are talking about saving the billions that is needed. Then when you came to reconfigurations, not only would you have a much simpler system to change but you would have a body of staff who are skilled and experienced in making changes that improve patient care that in turn save money.
A quick note about “efficiency and productivity”, if you aren’t doing the right thing by patients then doing it efficiently and productively won’t help much.
Sir David is almost there but as usual in the NHS, as has been happening for decades, he his jumping to macro changes when instead, focusing on the core purpose of care for the patient, is more effective than more large changes.
The FDA union‘s Public Service magazine kindly reviewed my book, ‘Beat the Cuts – How to Improve Public Services and Easily Cut Costs‘ in their recent Spring 2013 edition (link to pdf). See the review below.
The only comment I’d make is that if what is described in the book is “a little too obvious”, then why are so few people doing it?
The Guardian reports that ‘Bedroom tax’ prompts surge in pleas for council aid.
Notwithstanding that the article repeatedly compares April this year to April last year, it seems that applications for discretionary housing payments (DHP) has jumped from 5,700 to 25,000. Cutting costs always leads to costs going up and this seems to point in this direction.
The article goes onto mention that,
The Independent reported that in some areas the influx of people seeking help had forced councils to hire extra staff. Birmingham saw the number of DHP claimants rise from 496 in April last year to 2,601 last month, and the city council said many of those hit by the welfare reforms were turning to “last-resort services” such as food banks.
Hiring extra staff can’t be saving money, neither can having to deal with all the extra DHP claims. And the increasing pressure on food banks is just passing the costs and problem off central and local government and onto the charity sector.
Is this really helping to cut costs?
Addenbrooke’s Hospital in Cambridgshire has introduced cash incentives to reduce bed blocking, says the BBC news website. From the article:
Addenbrooke’s Hospital wards will get £1,000 if they discharge two patients by 10:00 each day for a week and £5,000 if they manage it for a month.
The “Two out by 10″ programme has been introduced by Dr Keith McNeil, who took over as the hospital’s chief executive this year.
This is a classic example of an arbitrary numerical target made worse by offering a monetary reward. The focus of the ward managers and staff every morning will be identifying the two patients they can ship out as fast as possible so they can get the cash. It may very well lead to some people being discharged before they should be which may cause unnecessary admissions or further treatment.
Moreover, staff will go hell for leather for the first two patients to meet the criteria and other patients will fall back into the old system. By focusing on the discharge plans of the first two patients, it may be the case that everyone else’s plans receive less effort, worsening the problem as a whole.
Dr McNeil says,
“The idea is to get everyone involved in improving patient flow in a pre-emptive way, rather than leaving it to the last minute.”
These are the right words but entirely the wrong actions.
If they want to improve discharges to free up beds, they should understand the factors that cause the current performance, understand what is important to patients about discharge and then measure the variation to see what they system is capable of. Then and only then can they start to make improvements to the whole system of care, not just the discharge procedure, so that both care and discharges are improved.
A link to a very short article in the Independent today, NHS ‘should operate seven days a week’.
When you stop you stop to think about this, it is amazing that this has taken so long to come to the top of the agenda. Granted, there are medical issues that can wait until Monday and elective surgery times can be chosen by definition. But broadly, people can’t chose what day of the week they have their accident, heart attack, onset of labour or other unpredictable event. Also those who have a long stay in hospital will be there over the weekend and they should expect the same standard of care and medical cover every day of the week.
The NHS should have been set up from the beginning to serve the need of the public, at the time they need it. Not to mention the waste of the theatres and diagnostic facilities that must lay dormant between Friday evening and Monday morning.
However, is this an easy thing to change, given how entrenched a five-day week is in the NHS? No, of course not.
The other thing to point out is that Sir Bruce Keogh, medical director of the new NHS Commissioning Board, is quoted in the article as saying that “the NHS had to learn from private sector companies such as Tesco”. Pointing to private sector companies may be a way to justify a change but it shouldn’t be the driver for action. In this case the NHS only needs to look at the requirements of its patients. What Tesco or anyone else does is irrelevant. It is your own system that should be the primary place to learn how to improve your own system.
Quick one from me today. Just thought I’d point out this nice little comment piece called There are two worlds in the NHS: policy and practicality on the Guardian website. One little quote to whet your appetite…
Last month, I accompanied a frail 85-year-old neighbour to a pre-op session in a sub-hospital of one of the local trusts. This place seemed to be entirely made up of half-empty WW2 barrack rooms like the ones where I did my national service 66 years ago.
The nurse told him that he needed blood and urine tests, and an echocardiogram, none of which could be done in that hospital. He presented himself at the main hospital the next day, and was told he would have to book the echo test for the following week. Thus, he had to take three bites at getting a simple pre-op done. Is this a cost-effective or humane use of using NHS resources?
The charger for my Apple laptop conked out this morning. The laptop has a good battery life so I was able to do a morning’s work before calling my local Apple reseller to see if they had one in stock. They did, so I headed into town all ready to pay for a new one.
When I arrived I asked if I could test both the charger and the laptop to make double sure it was the charger and not the charging point on the laptop itself. The assistant was very helpful and said, “Of course,” and helped me to test both bits of kit. It was the charger. (I was relieved it wasn’t the laptop.)
I asked her to help me make sure I was buying the right type of charger, but before we got to that she stopped and asked, “Do you have AppleCare?” I do have AppleCare on this laptop, I always get it for business machines, it is really just an extended warranty. “Great,” she said, “Your charger will be covered by that.” I was very happy. She had saved me a considerable amount on the cost of a new charger by asking if I were covered, when the store would profit by me buying a new charger. Excellent service.
So we went over to the computer to double check my AppleCare status, which was fine, and she said that the new charger would arrive by Saturday. I asked if I could just take a new charger from the store. She said that they had sale stock and repair stock and they couldn’t turn one into another. But, I asked, they are going to just send a brand new charger, just like those on your shelf? “Yes,” she said. I said that I really needed a charger now, and she was happy to loan me one, which is more good service. But actually, it only good service because they couldn’t give me a new one straight away.
So this is a perfect example where a store gives excellent service, given the dumb system that they have to work with. They did everything they could to solve my problem, (and their repairs system has already sent me two texts to keep me up to date with the “repair”) but if they had a more sensible system then I wouldn’t have to go back to the store on Saturday to pick up my new charger and give back the loaner. Moreover, they would have an even happier customer and have to spend less time with me. This would save them money and give them more time for other customers.
As always, better service costs less.
If you have an example of a similar experience, then feel free to leave a comment below.
May your charger last longer than mine,
The BBC website reports on NHS hearing services being ‘cut’ all over the country after a report by Action on Hearing Loss. Apart from the loss of services like follow-up appointments to ensure that hearing aids are adapted and used correctly which may mean that a hearing aid is less effective, Paul Breckell, the chief executive of Action on Hearing Loss said,
“Making savings from hearing service cuts right now is a false economy because it will only lead to higher NHS and social care costs to support people with untreated loss in the long run.”
This is the crux of problems about cuts to public services, that they will lead to higher costs next year and in the years to come. This is true in Greece, true of diabetes and true of youth services.
It won’t get any better while we focus on simply cutting cost, we must turn to improving services.
There is a very worrying article in the Independent about the treatment of Kay Sheldon, who is a whistleblower and a non-executive director of the Care Quality Commission (CQC). It seems her mental health was called into question after she raised concerns about leadership of the CQC.
This raises issues about how we treat whistleblowers in public life. However, the real problem is not that whistleblowers are treated poorly, but rather that they feel they need to blow the whistle at all.
People who end up as whistleblowers nearly always go through the proper channels first to try to raise concerns within an organisation. It is only when that organisation ignores or as in the case above, blocks and harasses them, that they feel the need to go outside and broadcast what they see to the world.
Now, are there a very few people who are trying to damage their organisation for some personal reason? Of course, but the majority realise they are risking their reputation by going public. It is these brave people who we are thinking about here.
If an organisation has a whistleblower, that shows two problems:
- The situation that the whistleblower points out, and
- That the organisation is not capable of listening constructively to its staff to resolve serious situations
And it is inevitable that any situation that a whistleblower raises is going to be serious because they wouldn’t take that risk for something minor.
So having a whistleblower is a double damning of any organisation and should be treated as such.
If an organisation can ignore and deny the most serious of situations then it really need to be changed drastically, both to prevent that situation happening again but also to be open to internal scrutiny such that people don’t feel the need to ever reach for their whistle.
Just a quick post to point up Atul Gawande’s article,
“Big Med – Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?”, in the New Yorker. A very interesting exploration of standardisation and tele-control centres in healthcare and how hospitals could learn from restaurants.
I’m not sure I agree with everything in the article but one quote caught my attention.
“Patients won’t just look for the best specialist any more; they’ll look for the best system.”
That is true whether or not the changes described in the article come to pass on a wider scale.
Do you think the innovations described are the future or the road to ruin? Please leave your comments.