Keep It Clinical

Saving money in the NHS is an age old problem. Even when there was money to spend there was still a cost improvement/efficiency/saving programme in operation somewhere in each organisation. The usual national approach to this conundrum is:

1. Promise to give more power over funding to Doctors (usually G.P.s).
2. Give lots of money to management consultants in sharp (expensive) suits to help the existing managers to find more savings.
3. Re-organise the bureaucracy by giving NHS bodies different names, so:
   1. Regional Health Authorities became Regional Offices, which became Strategic Health Authorities, and now they become Commissioning Boards
   2. Health Authorities became Primary Care Groups, which became Primary Care Trusts and now they will be Clinical Commissioning Groups

But despite all this heroic structural change people still get sick and medical technology continues to advance, and spending goes on rising. Putting G.P back-sides on the re-arranged chairs around the meeting table makes very little difference to the cost or type of services provided.

The way to reduce spending is to block book real expensive hotels a week at a time and make sure you put plenty of money behind the bar. Not to send the poor managers clutching their P45s on one last beano, but to gather the local clinicians together so they can really change services.

Put representatives of all the clinicians involved in caring for a particular patient group in a nice hotel a long with some high class...facilitators and give them a week to re-design how the patients receive their care and treatment. Let them at the A La Carte menu, and give them a free bar, the only provisos are that the result of the week's deliberations must be the most effective and practical care pathway they can devise in 5 days (or you send them the hotel bill) and no-one can mention money. You will not get an effective pathway if everyone is worrying about the money.

Rather than getting clinicians to play at being budget managers you will have them together where they can focus on designing the best way to care for their patients. With free reign of the facilities and the alcohol they will relax,which will allow everyone involved to have their say. This is not a new idea, the Persians would only finally agree on a battle plan if they all agreed on it whilst drunk. Hopefully our care givers will not plot to over-turn Western democracy under the guise of redesigning the Diabetes pathway. Instead, given the space and time to talk about their favourite subject, they will come up with radical change.

The other thing this radical change will do is save money. The most effective pathways will make sure the patient is seen by the right clinician at the right time more often, reducing duplication and waste which will save money.

So dig out the hotel directories and get booking.

The £20bn Question

The NHS has to find £20bn worth of savings over the next 3 or 4 years.  So everyone is asking how you save what is, even to an investment banker, a large sum of money.  Whatever way is chosen will have to lead to services being provided in radically different ways, as the savings target is so large.

I can think of two ways to find £20billion:

1)             Ask every member of staff in the NHS to look down the back of their sofa.  This would need an average of £20,000 per sofa; which is unlikely unless lots of staff are all living with senior banking executives.

2)             Increase car parking charges at every NHS property.  This would lead to hourly charges equivalent to the weekly wage of an average senior banking executive.

Or there is the Government’s preferred option:

3)             Give 80% of the NHS budget to GPs without formal training in budgetary control and cross your fingers.

1) &  2) are very unlikely to find you £20bn

Certainly 3) is better than either of the first two options, but not really a sound basis for reducing expenditure by 4% per year for the next 3 years.  As we have seen recently, GPs are not keen on being the Government's human shield when it comes to deciding where to cut budgets. 

It would be surprising if students queue up on their first day at Medical School and decide, “I’ll skip basic anatomy this term and take an introductory course on ‘Budgetary Techniques for Managing Cross Programme Finances’ instead.  After years of training in the medical sciences you can see why GPs are not keen to fill their diaries with contract meetings or spend time analysing over-complicated financial spreadsheets.

The taxpayer has spent a lot of money training doctors, nurses, radiographers, physiotherapists, social workers etc.  We then want them, and in this case specifically GPs, to work out how to save £20bn.  That is the wrong use of their training.  We should get them all to answer a completely different question:

What sort of health services do we want to provide in 3 or 4 years’ time?

That is a pretty big question and also one that all of our highly trained clinicians should be equipped to answer, if they can work together on the solution.  What we don’t need to do is throw finance in the mix as well, certainly not at the start of the process.  If you make money the question, you will get an answer that is built around spreadsheets and financial analysis, not one focussed on patient care.

We have a market structure in the NHS – Primary Care Trusts (soon to be GPs) buy services and hospitals, community services and mental health trusts provide care.   With any market you have the need to compete, so if you tell all these organisations that in effect the market has just got smaller (by £20bn), then Primary Care Trusts will try and buy less from the providers who will fight to maintain their income levels as best they can.  Organisations defending their budgets are unlikely to generate innovative solutions to the question of how we provide patient care.  We need to accept that the NHS does not act like a proper market. I can't pop into town and see if one GP will sell me their services cheaper or offer more frills than their opposite number across the road.  You can't get your hip replacement cheaper in Croydon than in Crawley.

We need to get clinicians out from behind the organisational walls and talking as equals about what is the best way to provide patient care.  You need to involve all shades of clinical and social care disciplines, otherwise the debate will be unbalanced.

Time to ask clinicians the question they are trained to answer, you never know it may unearth the £20bn we are looking for.

Next step how we get all the clinicians in one place….