In the current financial climate, there has been a lot of talk about future finances of the NHS. Clearly, there is little chance of the NHS continuing to enjoy the sort of generosity in its funding of recent years. In fact, the NHS will be asked to start saving and self-finance.
What can the NHS do to improve its finances? My personal view is that for the NHS to succeed, it should become independent of political and central control and be managed like any successful business. The politicians are unlikely to concede control simply because they lack the courage to do so - but both managers and politicians believe in the idea of managing the NHS as a business.
How successful have they been? The vast majority of managers in the NHS have very little if any true business experience. Although some might argue that it is useful to have managers from within the NHS because they know the system, the problem is that they are likely to have many idiosyncrasies. They lack the wide experience and thinking that is available in business. This needs to change if the NHS finances are to improve. In fact, we have seen evidence of success in having outside business people investigating and turning around failing units. The experience of Sir Gerry Robinson is a recent example.
The other problem with the NHS is size. The combination of central control and bureaucracy have been paralysing the NHS and in the process preventing innovation that is so vital for the success of any business. This can be improved if the NHS is broken down into small units that are run locally. Market forces will continue to work stimulating incentives and innovation. Such smaller units are accountable to the local population and eventually to parliament.
The combination of advances in science and technology and an ageing population will continue to burden the NHS finances and, therefore, we need to look at how the system is funded.
There has been a lot of noise about hospital consultants’ performance but little about the performance of NHS managers. Over the last few years with the relentless changes in the NHS organisation and culture of targets, the number of managers has substantially increased but I have seen little data or evidence both in the literature and on the ground about their effectiveness or performance.
The NHS is an inefficient organisation that is full of duplication and wastage. A glaring example of this is the disintegration of services into primary and secondary care with little liaison or coordination. This is despite the obvious fact that both are inter-dependant and activity in one section is very likely to impact on the other. The other flawed idea is that primary care should drive secondary care. There is no logical or scientific basis for this.
Currently, there are two highly paid medical professionals, the GP on one side and the hospital consultant on the other doing the same job to a large extent. Take, for example, the referrals for inpatient and outpatient care from primary to secondary care. These activities can be reduced substantially if there is more liaison and coordination between primary and secondary care at all levels including training at junior levels of both sets of professionals.
The employers’ organisations complain that despite the substantial increase in the number of consultants, neither their efficiency or performance had not improved. Where is the problem? The problem surely is in the consultant contract the NHS had negotiated with the BMA. This is time-based rather than activity-based and therefore takes no account of clinical activity.
For many years the HCSA has recommended a work sensitive contract. This is based on what clinical activity is achieved by the consultant within a specified unit of time and therefore addresses both the time and work carried out at the same time. This was suggested by the HCSA but refused by the BMA at the time of the consultant contract negotiations.
My view is that NHS efficiency and finances can be significantly improved; but this needs some commonsense, true business mentality and independence.