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Health Bill distracting NHS from making savings

By Mike Broad - 24th January 2012 11:12 am

Service integration to deliver the Nicholson Challenge is more important than NHS reform say MPs on the influential Health Select Committee.

The report on public expenditure, by the cross-party committee, says the reorganisation process in the NHS continues to complicate the push for efficiency gains. NHS chief executive David Nicholson wants £20bn of savings by 2015.

The MPs say that, although the push towards GP commissioning may have facilitated savings in some cases, it more often creates disruption and distraction that hinders the ability of organisations to consider truly effective ways of reforming service delivery and releasing savings.

The report expresses concern that trusts are currently making savings through “salami-slicing” existing processes and services instead of rethinking and redesigning the way services are delivered.

The Nicholson Challenge can only be achieved through a wide process of service redesign on both a small and large scale, the report says. These changes should not be deferred until later in the Spending Review period: they must happen early in the process if they are to release the recurring savings that will be vital in meeting the challenge.

Commenting on the report, Sir Richard Thompson, president of the Royal College of Physicians, said: “We agree that meeting the £20bn efficiency savings at the same time as dealing with the increasingly elderly population is a difficult challenge for the NHS. It is crucial that the proposed reforms help services meet this challenge, rather than distract from it. The government has failed to set out clearly how this will be achieved.

“While improving efficiency, the NHS must still at the same time invest in quality. A key priority is to provide consultant delivered care, which would both improve standards and patient experience, and save money. The health reforms must also improve the process for making decisions about service reconfiguration, for this will increase the availability of consultants, and facilitate seven day infrastructure to underpin consistent patient care. Clinicians and local communities should lead those decisions.”

The MPs says that more integration of services is vital. While the separate governance and funding systems make full-scale integration a challenging prospect, health and social care must be seen as two aspects of the same service and planned together for there to be any chance of a high quality and efficient service being provided which meets the needs of the local population within the funding available.

Dr Hamish Meldrum, chairman of BMA council, said: “Better integration of care is key to improving patient care yet many of the implications of the Health and Social Care Bill, including the government’s focus on competition, will make this harder to achieve.”

He described the Bill as a “distraction” and said it “is causing chaos on the ground even before the legislation has been passed. It is perhaps little wonder that those trying to make efficiencies are focussed on short-term issues, such as their job prospects, and making rushed decisions on savings rather than looking to the longer term”.

He added: “There is still time for the government to withdraw the Health and Social Care Bill - a bill which an increasing number of health professionals are opposed to - and work with healthcare professionals and others to agree a more pragmatic way forward.”

The MPs conclude that it is too early fully to assess the types of savings being made in 2011-12, the first year of the QIPP programme. However, the report says: “We are concerned that there appears to be evidence that NHS organisations are according the highest priority to achieving short-term savings which allow them to meet their financial objectives in the current year, apparently at the expense of planning service changes which would allow them to meet their financial and quality objectives in later years.”

Read the full report.

Read a blog on the Health Bill.

Tags: Cuts, Funding, Integrated care
Posted in Hospital Dr News | 3 Comments »

NHS cuts have affected patient care say doctors

The Guardian - 28th December 2011 12:09 am

The coalition’s pledge to protect the NHS is in fresh doubt after four out of five doctors said they had seen patient care suffer as a result of health service cuts during 2011.

A poll of GPs and hospital doctors challenges David Cameron’s promise to “cut the deficit, not the NHS”.

Doctors cite hospital bed closures, pressure to give patients cheaper, slower-acting drugs, cuts to occupational health support, and reductions in community health services as examples of recent cost-cutting measures.

Doctors.net.uk, a professional networking site to which almost all British doctors belong, asked medics: “Have cuts to staff and/or services affected patient care in your department, area or surgery during the last 12 months?” Of the 664 doctors who responded, 527 (79%) said yes and 137 (21%) said no.

Among 440 hospital doctors, 359 have seen cuts, while 168 of the 224 family doctors said the same.

Savings drive shouldn’t have started with syringes

By Caroline Whymark - 31st October 2011 10:42 am

Recently I arrived at work and began preparing for my list as normal. When I got to drawing up the drugs I noticed something was amiss. The 10ml syringes were now 12mls, the 2ml syringes now 3mls and so on. Confused? Yes, I was too.

The answer given to my queries was ‘national procurement’. It seems that on its cost cutting mission, NHS Scotland has decided this is the way to go on consumables. You can read all about it on their website but essentially national procurement delivers “less for more” allowing re-investment of savings into patient care.

I’m all for cost saving. We are asked about it every year. Management are always open to hearing ideas from foot soldiers on the frontline. Each year I propose a shutdown of the theatre suite for the first 3 weeks of the summer holidays (emergency, trauma and cancer work excepted) to bring about a win-win-win solution. Surgeons get the holidays they want, anaesthetists do too and management save massively on the time and effort usually spent trying to match - often unsuccessfully - different surgical lists to the few anaesthetists who are free.

Sometimes if I’m really brave I suggest this happens over the Christmas and New Year period also but to date no one who matters thinks this a good enough idea to implement (although the same idea seemed to work well a few years ago when management decided this was the most efficient way to re-floor the whole theatre complex).

But I digress. Saving money is the priority but this time it seems the stakes have been raised even higher - we don’t just need to save money, apparently we don’t have the money to spend. Each and every budget is slashed.

And therein lies the problem. Multiple budgets and increasing fragmentation of the costs of healthcare - each looking after there own. No-one, it seems looking at the bigger picture. Indulge me if you will…

The syringes have been changed to another brand because they are cheaper. Apparently clinicians were asked for their views on this change but I must have been blinking at the time and missed the opportunity. Admittedly it didn’t take me long to re-learn to draw up drugs to the 10ml mark and not until the syringe was full but that became the least of the worries.

Some colleagues have taken the tone of “things change, quit moaning and get on with it”. I would direct them to any of several drug manufacturers who have tried to market newer, better, anaesthetic drugs in recent years only to find they never take off because they have failed to appreciate the induction agent MUST come in a 20ml dose and muscle relaxants must fit into the 5ml syringe.

We anaesthetists are simple creatures of habit, and for very good reason. The potential cost of a drug error made in patient care is not easily measured (so cannot be reduced by the required percentage). Clinical risk is a different department and not concerned by the cost of syringes.

Shortly after introduction someone realised the new syringes were not accurately compatible with our universal syringe drivers. Action: old syringes should be used with syringe pumps and only 50ml syringes should be used. These will continue to be sourced from original manufacturer. The new syringe, while recognised by the syringe drivers, could lead to over or under infusion and it’s consequences. Cost saving? Not in the face of any potential episodes of patient harm (not to mention increased costs of buying reduced quantity of only large syringes from original manufacturer).

Next I realise that my emergency drug (1ml of atropine) usually carried around by me and most anaesthetists for the duration of the list like some sort of comfort blanket, was being discarded by the excellent anaesthetic nurse after each case.

“Why do you keep throwing out the atropine?” I ask puzzled.

“It looked like you’d used half of it and therefore the syringe was dirty,” came the reply.

Fair point except I hadn’t used half of it. It was just that the usual 1ml took up a smaller proportion of the 3.5ml (2ml) syringe and gave this impression. Any cost saving from the syringe purchase was rapidly diminishing when offset by the increased drug usage cost.

Anyway, despite it all we get the first patient into theatre. Midway through fixing the ankle the surgeons drops a screw on the floor. It can no longer be used.

“How much does that screw cost?” he asks the charge nurse.

“£85,” comes the reply.

I feel my blood pressure rising. Any potential syringe saving is dwarfed by the orthopaedic consumable overspend. Perhaps it shouldn’t matter to me, after all it’s coming out of the orthopaedic (or perhaps the theatre) budget. But that’s not helpful.

An umbrella approach to budget management is required. Savings will only be made when costs are considered in context of the overall delivery of healthcare rather than by each department’s budget.

It’s a shame only the measurable costs are deemed important and this is a rare case of looking after the pounds before the pennies.

To be continued…

Tags: Cuts
Posted in Caroline Whymark | 2 Comments »

Many NHS nurses in England fear losing their jobs

Guardian - 3rd October 2011 10:00 am

Almost 75,000 nurses expect to lose their jobs, have their hours cut or see their roles downgraded in the next year, according to a survey that highlights the growing impact of the NHS’s financial squeeze.

Five per cent of the NHS in England’s 410,000 nurses - some 20,500 in all - believe their posts will disappear in the next 12 months. Another 24,600 anticipate a cut in hours, while another 28,700 expect to have their jobs reassessed as involving fewer responsibilities.

The findings, extrapolated from a Royal College of Nursing (RCN) poll of 8,000 of its members, have prompted renewed claims that the coalition is not honouring repeated promises to protect the NHS frontline from cuts.

GP referral cuts a “catastrophe” for hospital finances

Pulse - 28th September 2011 5:27 pm

Hospitals are suffering a “catastrophic” loss of funding because of plunging rates of GP referrals as NHS managers block access to services.

That’s the view of Dr Mark Porter, chair of the BMA consultants committee, who said the fall in referrals coupled with other factors such as tariff restrictions was forcing hospitals to consider mergers or cut access to “whole parcels of services”.

GP referrals dropped by an average of 4% in the last quarter compared with the same period the previous year, with falls of up to 37% in areas with controversial schemes to restrict referrals.

Porter said: “This is proving a catastrophe. I know of hospitals coming off the FT pipeline, hospitals being forced to consider merging, hospitals being forced to restrict whole parcels of services, and many of the reductions in referrals are to do with the low-priority procedure lists.

“Some of the reconfigurations will be appropriate. But it’s impossible to know which are appropriate and which are prompted by inappropriate resource restrictions.”

“Rationing by stealth occurring across the NHS”

By Mike Broad - 14th September 2011 10:02 am

A row has broken out over whether access to healthcare is starting to be rationed due to the NHS cuts.

Department of Health statistics for activity suggest that GP referrals are down 4.7% this year. These referrals had shown a 3.5% increase at the same stage last year.

The data also shows that first outpatient attendances have also declined (by 2.7% compared to the same period last year), and there has been a slow down in the growth of elective admissions.

Professor Norman Williams, president of the Royal College of Surgeons, said: “These data provide further evidence that rationing by stealth is occurring across the NHS. Such a steep reduction in the number of referrals by GPs suggests that patients are being given limited access to specialist clinical advice and could be missing out on treatments. If correct this is extremely concerning for surgeons across the NHS.

“Stopping referrals is only storing up problems for the future - a time-bomb which will end up costing the NHS and taxpayer more in the long-term. The rise in waiting times for orthopaedic surgery is an indicator that demand for surgery is not reducing and that the issue of rationing needs to be addressed - it will not go away.”

GPs in England referred about 3.6 million patients for a first hospital consultation between April and July, according to the data.

The BMA agreed that access to healthcare was being restricted.

“The NHS is under a lot of pressure to do less, for example through referral management initiatives, which seem to be on the increase. These may save money but for every lost referral there is a patient who is not getting diagnosed or treated, and a hospital that is more likely to encounter financial problems,” a BMA spokesman said.

However, the government said the stats indicated that the NHS was becoming more preventative.

A spokesperson said: “We would expect to see this trend as the NHS helps prevent more people becoming unwell and provides more services in the community, closer to patients’ homes. Alongside more day-case surgery, this is a clear sign that the NHS is working more effectively for patients and more efficiently for taxpayers.”

Tags: Cuts, Rationing
Posted in Hospital Dr News | 4 Comments »

MPs say PFI is expensive and needs significant reform

By Mike Broad - 24th August 2011 10:23 am

PFI is no longer providing value for money and requires significant reform, an influential committee of MPs has said.

The all-party Commons Treasury committee said the long-term costs of PFI deals were now significantly higher than conventional government borrowing and it urged ministers to use them “as sparingly as possible” until new rules are in place.

The committee said that while PFI was attractive to departments on restricted budgets as the initial costs were lower, the impact was much longer lasting with the build up of big commitments against future budgets before they were even allocated.

Chairman of the Treasury select committee, Andrew Tyrie MP, said: “PFI means getting something now and paying later. Any Whitehall department could be excused for becoming addicted to that.

“We can’t carry on as we are, expecting the next generation of taxpayers to pick up the tab. PFI should only be used where we can show clear benefits for the taxpayer. We must first acknowledge we’ve got a problem. This will be tough in the short term but it should benefit the economy and public finances in the longer term.”

Tyrie called on the Treasury to remove the “perverse incentives” which encouraged government departments to use PFI rather than more efficient means of financing.

He called for PFI liabilities - which are currently treated as ‘off balance sheet’ - should be recorded in the national accounts, even though this would add an estimated £35bn to the deficit.

“PFI should be brought on balance sheet,” he said. “The Treasury should remove any perverse incentives unrelated to value for money by ensuring that PFI is not used to circumvent departmental budget limits. It should also ask the Office for Budget Responsibility to include PFI liabilities in future assessments of the fiscal rules.

“We must also impose much more robust criteria on projects that can be eligible for PFI by ensuring that as much as possible of the risk associated with PFI projects is transferred to the private sector and is seen to have been transferred.”

Since 1997, most large-scale public capital investment in the UK has been through PFI purchasing schemes where investment banks and building companies raise the finance for public infrastructure projects.

In England, 101 of the 135 new NHS hospitals built between 1997 and 2009 were paid for under PFI (90% of the £12.2 billion committed under successive building programmes).

Early this year, a leading public health academic called for PFI deals to be re-opened and renegotiated.

Professor Allyson Pollock, director of the Centre for International Public Health Policy at the University of Edinburgh, said: “NHS PFI contracts are not good value and are endangering patient care.”

In a briefing paper last year, the BMA pointed out that between 2011 and 2014 - during a period when the NHS is being expected to make significant savings - repayments for NHS PFI projects will reach £4.18 billion, an increase of almost £1 billion from current levels.

The Treasury committee concludes that higher borrowing costs since the credit crisis mean that PFI is now an “extremely inefficient” method of financing projects. Poor investment decisions are being made by government departments “without due consideration for their long-term budgetary obligations”.

The committee has not seen any convincing evidence that savings and efficiencies during the lifetime of PFI projects offset the significantly higher cost of finance. Indeed, the report raises concerns that the current Value for Money appraisal system is biased to favour PFIs. It identifies a number of problems with the way costs and benefits for such projects are currently calculated.

Investment could be increased in the long run, the MPs point out, if government capital investment were used instead of PFI. The average cost of capital for a low risk PFI project is over 8%, double that of government gilts.

Analysis commissioned by the committee suggests that paying off a PFI debt of £1bn may cost taxpayers the same as paying off a direct government debt of £1.7bn.

The committee recommends that:

- the Treasury should consider scoring most PFIs in departmental budgets in the same way as direct capital expenditure, adjusting departmental budgets accordingly;

- the Treasury should discuss with the OBR the treatment of PFI to ensure that PFI cannot be used to ‘game’ the fiscal rules;

- the Value for Money assessment process should be subjected to scrutiny by the National Audit Office;

- the Treasury should review the way in which risk transfer is identified.

Read the full report.

Tags: Cuts, PFI
Posted in Features | No Comments »

Climate is ripe for a perfect storm in the NHS

By Stephen Campion - 29th June 2011 10:14 am

In our response to the NHS ‘listening exercise’, the HCSA warned that the climate is ripe for a perfect storm.

It is all very well reforming the NHS - most commentators agree that reform is necessary - but even the most ardent supporter of the government’s plans must surely see that today’s problems must take priority over tomorrow’s NHS.

Like the tragedy in Staffordshire, the NHS is in real danger of losing sight of the ball. The experiences reported about the financial crisis in Leicester are not unique.

Many trusts are openly saying that they can’t pay the bills and are resorting to draconian measures to balance the books. At the same time NHS staff remain under a pay freeze, redundancies are becoming the norm and staff are being asked to accept higher pension contributions in return for a lower pension income. Morale is low; and goodwill rapidly destroyed as the NHS is forced to manage a financial crisis not of the staff’s making.

Where does patient care stand in this mess? Many treatments are being put on hold or restricted. Care of the elderly is regularly reported as being sub-standard. Waiting times are lengthening; tensions within the NHS increasing.

Reform can only be built upon a solid platform and I fear that the sinking sands will inevitably lead to structural collapse. Raiding surplus pension funds to bail out the business is Maxwellian, dangerous and ill-conceived. How often are we told: “Staff are the greatest NHS asset?” Well now is the time for politicians to put their support for the NHS to the test.

The perfect storm is not a cheap sound bite. Until or unless NHS staff are valued, respected and treated fairly, the storm clouds will loom large.

Tags: Cuts
Posted in HCSA | 1 Comment »

Reality bites - the candid views of THAT CEO

By Mike Broad - 8:30 am

The chief executive of University Hospitals of Leicester NHS Trust, Malcolm Lowe-Lauri, has sent a controversial email to his senior staff warning them of the consequences of tackling a £6m overspend.

The trust needs to make savings of £158m over the next five years due to government spending cuts.

The communication said: “The overshoot on our Income and Expenditure account lies somewhere between £5m and £6m. This can only be described as catastrophic.

“There’s a real issue about whether we will be able to pay our staff by August or September.”

In a bid to ensure the trust can pay its staff, health bosses have agreed to an immediate freeze on all but essential locum, bank and agency expenditure. There will also be a recruitment freeze on all but essential posts, and a new system of theatre management.

“That deals with the today issues. As for tomorrow, this is the bigger job,” he said.

“The divisional teams, led by the divisional directors and as part of the work to complete our five-year plan, will be bringing their teams together, especially their consultants, to take a long hard look at the way their services operate.

“Many of the questions I’ve had over the last few days have been about wages.

“Will staff be paid come September? Here’s my answer. Yes. We will put the brakes on and sort this, but only if we pull together and resolve some of the issues I’ve talked about.”

He concluded: “I’m writing this because I want no-one to be under the illusion about where we are.”

Was he right to be so candid?

Tags: Cuts
Posted in Dr Blogs | No Comments »

We’re all in the same ‘efficiency savings’ boat now

By Kathy Teale - 7th June 2011 9:56 am

“We may have all come in different ships”, as Martin Luther King famously commented, “but we’re all in the same boat now”.

Trouble is, with 5 or 6% savings to be made every year, it feels like that boat is the Titanic, and while some passengers are rushing around reorganising deckchairs, others are sitting with their eyes closed, and yet more seem to be beckoning the iceberg over.

Cooperation and motivation are notoriously difficult things to achieve in any large organisation, as fellow blogger Caroline Whymark very accurately describes.

Motivating staff to work quickly and efficiently when they perceive nothing ‘in it for them’ is an extremely difficult problem to solve. The knowledge that they are helping patients and avoiding the trauma of cancelled procedures is, sadly, not effective. Especially when patients on the receiving end are conveniently distant and faceless.

So, do we need some carrot? Since our theatre budget is shrinking faster than Nick Clegg’s Christmas list, financial rewards are going to be difficult.

If we worked in a purely elective set-up, with infinitely flexible staff, we would introduce a system where we simply go home when the list finishes, whether that be early or late - as we do for weekend waiting-lists which notoriously run more efficiently (partly, of course, because you’ve got a group of staff who’ve volunteered to do it…). The problem is that all staff aren’t flexible - some can’t stay late if the list overruns because of caring commitments - and this has to be the deal, because in this system there won’t be any ‘late’ staff to take over from them. And of course few of us have the luxury of working in an elective-only set-up. We’re stuck with having to staff emergency theatres and trying to squeeze urgent cases into gaps on lists at times of heavy demand - and who can argue with that if the alternative is letting the patient with a broken arm wait for two days on the ward, starving, while the theatre team waltzes off at 3.30?

A tempting approach is the ‘John Lewis strategy‘, whereby staff have a financial investment (i.e. are shareholders) in the parent company. There is at least one example of this currently, Circle Health, one of the UK’s most prominent private health providers, where 49.9% of the company is owned by clinicians, and 51.1% by other shareholders including, incidentally, some extremely generous donors to the Conservative party.

Unfortunately for this model, the value of shares may go down as well as up, and the papers allege that Circle is experiencing financial difficulties, including the loss of two substantial NHS contracts. Let’s just say the jury is still out on the success of staff-ownership in healthcare and its ability to motivate.

So what’s the answer? There’s no quick-fix I’m afraid, except convincing all staff that our actions make a difference to outcomes - and that involves continuous feedback, communication, and clear leadership from all the management teams, and is extremely hard work. But it’s exactly what we must have to prevent the ship going down.

Tags: Cuts
Posted in Katherine Teale | No Comments »