So back to the original question: how can the ever spiralling costs of delivering a high quality NHS free-at-the-point-of-use be met? In true political speak, I think if we were to address some tough questions and make some unpopular decisions (and actually follow them through) there would be no need for budgetary panic.
1. Rationing:
Not by postcode or by local practice variations dependent on the prevailing wind direction, but by doing the big things first and then assessing what you are going to spend the left over money on. There is a well known adage about fitting stones in a jar - if the big ones don’t go in first they will never fit. The smaller stones always slot in around them in the little left over spaces. Surgery is like stones. Spend money on all the small frivolities and the budget will fall short for the big essentials. Use the budget with this in mind. Do the emergencies, the cancer, the trauma and forget about questionable cosmetic procedures treating self-esteem issues unless you have money to burn in March.
2. Stop robbing Peter to pay Paul:
Time-wise and budget-wise this repeatedly occurs. Let’s say healthcare costs X amount. Whether time and money is spent in pre-assessment clinics, ward bed days, or increasing day surgery capacity, the work required still costs X regardless of whether it is done by a doctor, a nurse or any number of advanced and extended roles. We often simply redistribute where the time is spent and which budget the money comes from. Stop wasting time, effort and more money trying to find more cost efficient ways of doing things. Savings in one area generally mean increased expenditure and reduced time available in another and false economies prevail.
3. Stop measuring things we already know and/or cannot change:
There must come a point when measuring any variable that the process becomes more costly than any potential savings that could be made from removing inefficiencies. Further, when measuring a load of variables (read theatre start time, end time, in between time) which finds we are actually pretty efficient, the actual process of the measuring is a cost which generates no reciprocal saving. Why keep doing it over and over again? Some systems by their very nature are slow. A trauma list finally deciding on clinical priority at 0830, after taking into account overnight admissions, will not start at 0845. This is not inefficient.
It is a fact of this type of work. Priorities change, theatre readiness of a patient changes. Long gone are the days of the instant orthopaedic patient (read ‘add water when ready to operate’). Measuring the ‘delays’ on this type of list goes no way to reducing them. They are not delays, they are the inherent time required in the system to follow due procedure and carry out repetitive safety checks. Measuring them will not change this.
4. Accept clinical risk is the nature of the beast:
Things don’t always go well and this may be no-one’s fault. Accept that complaints and litigation are more prevalent throughout society and not just in medicine. Stop investigating, escalating, referring and reviewing practice in the light of a complaint. Endless meetings and paperwork result from tiers of investigative staff tasked with determining what went wrong when often nothing did. Medicine is a risky business with no guarantees. Sometimes the outcome is not good. Accept that or get out of healthcare.
5. Staffing:
Approximately 80% of the total budget is spent on staffing. Approximately 50% of these are non clinical. Does 50% of Apple’s staff have nothing to do with producing an i-gadget? I think not. Many managers have necessary roles and do the stuff that someone has to do. But their numbers seem to be escalating and at the end of the day the NHS is in the business of delivering healthcare to patients and that should be the main focus of the organisation.
A high quality service free-at-the-point-of-use, encompassing modern medicine as it evolves is expensive. It would be easier to meet this cost if we stopped wasting money on wondering where the money goes.