More4Less: The public sector spending challenge

In response to the Department of Health's call for ideas from public servants on how to cut costs and improve efficiency within the various public services, Red Dolphin has submitted a blueprint of 10 ideas, the implementation of which would unquestionably save money, improve efficiency and raise staff morale. It remains to be seen whether the government is courageous enough to implement it.

Dear Mr Cameron, Mr Clegg and Mr Lansley,

"More for Less": Ideas for cost savings and efficiency improvements in the NHS

1. The European Working Time Directive

Whilst no one would wish to see a return to the 'bad old days' of the 100-hour week and the tiredness-induced mistakes that this bore, the pendulum has swung too far the other way and opting out of the EWTD would allow junior doctors achieve decent amounts of training during their time whilst still capping the hours worked for safety reasons. After all, consultants are not subject to this constraint and for them it is currently entirely possible for one to be on call from Thursday morning until Monday afternoon these days and this is not illegal. Whilst that is not tolerable as a junior doctor we are currently in a situation where good specialist registrars deliberately fail their final year assessments in order to get a further year of training: more doctors does not equate to better doctors. A better training experience (the apprentice style is still the best) creates a higher quality of doctor. The New Labour tactic of throwing money at the problem was in fact counter-productive. So: train fewer doctors but train them more intensively thus saving salaries.


2. Study Leave Budgets

As in the airline industry it should be the responsibility of doctors to arrange and fund their own Continuing Professional Development, whether it be courses, meetings or sabbaticals. The £700 a year or so that is potentially spent on every doctor in the country could be withdrawn. With revalidation due to come on line in 2012 this is a good opportunity for the profession to demonstrate it's own professionalism and no longer rely on the public purse to pay for updating it.


3. Clinical Excellence Awards

Bonuses in the public sector should be all but unnecessary and this divisive set of awards should be dramatically pared down to reward only the most deserving. One criteria should be that the recipient does no private practice work. The negative effect that CEAs have on the profession far outweighs any incentivisation that they induce as the majority of consultants who do plenty of 'extra' work receive no points and feels doubly aggrieved when not awarded one in any given year. The exaggerated and even bogus claims that are made in the application rounds should make these an early target for cuts and, as they are pensionable, will make for significant savings. A national, independent panel including members from outside the profession should judge the very few remaining cases against stringent standards of merit and achievement.


4. Middle management

Partly, but not entirely borne of the era of New Labour targets, there are too many people engaged in meaningless exercises of counting what does not need to be counted - and furthermore not even understanding what it is they have counted due to a lack of understanding of the system. Great swathes can be cut through the reaches of 'assistant project managers' and similar to save millions at a stroke. Allowing clinicians more freedom to govern themselves - and this might include some more education in the history and running of the Health Service at medical school - will end their disenfranchisement of recent years and end the 'counting culture' that currently abounds.
Remember the adage that "not everything that can be counted counts, and not everything that counts can be counted."


5. Reduce generic working

Whilst the introduction of generic working - that is for work of a general nature to be performed by anyone within a particular department rather than a named individual - is useful for the reduction of waiting lists, the principle when applied too rigidly can be obstructive. Clinicians value the personal link and the ability of an individual consultant-secretary combination to prioritise and manage appointments is immeasurably valuable and more efficient than a rigid adherence to the generic principle. This would increase efficiency by reducing waste both in terms of unnecessary appointments being issued and the small 'team' understanding the particular abilities and limitations of any given service.


6. Budgets within the Internal Market

Whilst the concept of the internal market appears set to stay for now it must be recognised that the myriad of small, notional micro-budgets held within every department and managed almost in isolation creates a cottage industry of accountants and administrators who merely hamper the smooth running of a hospital or primary care facility. Internal 'purchasing' of services within a large hospital, for example, is meaningless as the is no competition (the idea behind the internal market) to drive any change. Meanwhile non-clinical managers push spreadsheets of inaccurate figures around the organisation, basing decisions on these data that affect clinical care. Whilst disciplined spending of an annual budget in any department is of course mandatory, clinicians should have more involvement in the process, it needs to be greatly simplified and far fewer people need to be involved in it's management.


7. Strategic Health Authorities

These leviathan organisations offer very little value for money. The majority of their budget is spent on education and this 70-80% could be devolved directly to the Deaneries, thus saving the 'middle man'. Whilst the role for Public Health is of course vital this should become a stand-alone speciality, especially as the SHAs add little or no strategic thinking to the process. The cut in personnel and sale of the resultant plush real estate currently given over to them would result in huge financial and efficiency gains for the NHS as a whole.


8. Postgraduate education

This aspect of medical life has become needlessly bloated over the last decade with courses existing for multiple unnecessary topics. As discussed in point 2 the profession needs to take responsibility for it's own clinical and non-clinical updating. The release of Trusts from the fear that every action needs accountability to the n-th degree would make unnecessary the many "compulsory" courses that are now the norm prior to undertaking any extra work. If indemnity from consequences could be assured in many areas then these box-ticking exercises could be usefully abolished with the consequent saving of salaries and gains in clinician productivity.


9. Cancer networks

Whilst the cancer multiple-disciplinary team (MDT) are an essential and irreversible innovation the bureaucracy to which they are currently answerable should be significantly slimmed down. The cancer networks as they currently exist are yet more circular middle management jobs the output of which serves more to obstruct than to help the frontline staff.


10. GP commissioning

Currently this is a highly complex process involving yet more accountants and middle managers and it need not be so. GPs are well placed to inform secondary care Trusts what services they need but again, infinitely dividing their notional budgets simply creates more administrative work rather than helping the process. Broad quotas and plans for when these are significantly exceeded or unreached, agreed by the relevant clinicians, are all that is necessary to avoid the current 'death by spreadsheet' system that obfuscates rather than clarifies the need for any given service.


Yours faithfully,

The Red Dolphin

Common sense... 1 Theorists... 0

The announcement today of changes to the NHS Operating Framework including the scrapping or softening of many targets has breathed new hope into the clinical body, an organism that has been sorely tried by the last decade of over-management. Told time and again that we were not trusted to deliver a fair and efficient service by the then government such that we needed the yoke of these targets in order to perform, the resentment has grown and grown. As much time was given to ways of circumventing the more ridiculous diktats as was given over to useful innovation with the public purse the inevitable loser. Clinicians were left to battle with the unforeseen consequences of the targets and then blamed for them too.
Whilst the patients' views are clearly valuable to any health planning exercise they lack both the knowledge and the detachment to be able to offer the final say, whereas the clinicians that work day in, day out at the medical coalface understand the issues, the strengths and limitations of the service and - contrary to New Labour's rhetoric - care deeply about the people they serve. There are rotten apples in any basket, but not many in this one.
So now, rather than introducing a headline-grabbing target of 4-hour A&E waiting time and not know, care or worry about the patients who were unnecessarily moved onto an inappropriate ward to avoid breaching the target, now we can concentrate on making parameters that are meaningful, achievable yet challenging and above all, practical.
Move over theorists, common sense has arrived.

Take a 180 degree look around

On my way to London on the train this morning I was momentarily confused by a double illusion of motion and stasis. To explain - the train was stationary at a platform alongside another when this second one moved off giving the familiar sensation that my own train was pulling off. However, this was not mirrored by the expected simultaneous sensation movement that ought to come with this and for a few moments I was disorientated, not to say actually quite dizzy. Only when I looked through the opposite window to see a branch of a well known coffee shop reassuringly static On the platform did my equilibrium return as my brain was able to make sense of the conflicting messages that had previously been passed to it.
And this got me thinking as we all relentlessly plunge into the daily routine, having and giving little time for reflection on even the most major issues that affect us in the longer term. The reason I was on the train in the first place was to attend a conference at The King's Fund on the implications of the election result on the NHS. Speakers from both the Fund and outside outlined their views on the times ahead - but in truth of course nobody knew anything for sure. There was a fair degree of consensus that the pledge to cut administration would be enforced somehow but, understandably, there was anxiety in the air in this management heavy audience. Many views on how to improve efficiency and the same for achieving quality in commissioning but surprisingly nothing about the proposed independent board. Much food for thought but little to aid the digestion, one might say.
And so I thought about my train analogy: perhaps we need to look in completely the opposite direction to achieve some clarity of thought. Rather than try and modify the system we currently have we should rethink it root and branch. The internal market, in place for nearly two decades, has not brought about the revolutionary change that was expected by the introduction of free market principles into a closed market. It should not feature as a part of our future. Rather, let us focus on the patient's journey along disease paths and fund these accordingly using well validated incidence and cost data and thus end the artificial division between primary and secondary care, surgeon and physician, acute and chronic care. Like it or not, the next generation of doctors and nurses will need to be well versed in the nuts and bolts of how the service is run and funded. This is not unique and applies in other countries so we should not be afraid of a slimmer, more accountable and transparent service that has patients at it's heart and healthcare workers as the drivers for change. Those who work within the service are best placed to advise on the way to change it for the better. This way we can achieve more agreement on what constitutes best practice and how to roll it out across the country. And the management infrastructure that has manifestly not succeeded in this to date can hence be drastically slimmed down.
If we miss this opportunity to revolutionize the way the NHS functions we may not have the chance again as then either the service will fail due to lack (or waste) of funding, or survive in some fiscally healthier future climate that allows this wastage to go unchecked again. We should not put ourselves in the position of seeing the train of opportunity leave without us being on it.
"The train now leaving ...." are not words we want to hear from the platform; rather we should seek to shout: "The old stations are behind us" as we travel down a new track.

The past is a foreign country

My daughter came home from nursery a couple of weeks ago singing a new song that she had learnt that day. After the initial parental pride and pleasure at discovering that she had memorized it so quickly it made me think of the healthcare that she might expect in her dotage. The lyrics are worth repeating here - you will see why.

Miss Polly had a dolly that was sick, sick, sick
So she called for the doctor to come quick, quick, quick
The doctor came with his bag and his hat
And he knocked on the door with a rat-a-tat-tat.
He looked at the dolly and he shook his head
And he said "Miss Polly, put her straight to bed."
He wrote on a paper for a pill, pill, pill
"I'll be back in the morning - yes I will, will, will.

Doubtless you can already see where this is going. The utopian vision presented to the children here is of a rapid resonse personal service to the home - note the use of the definite article 'the' doctor: not any old doctor - her own family doctor. The traditional Victorian image of the frock coated physician persists as does the diminishing skill of clinical acumen - the ability to recognise sick patients is now no longer an assumed, not to say real part of the modern doctor that juniors are sent on compulsory courses to learn this vital art.
The part about treatment at home fits in well with the modern notions of healthcare so that is one area of which the old DoH doyens would approve but a paper prescription? Hardly the Connecting for Health ePrescribing on an electronic patient record, is it? As for the idea of continuity and follow up that is very rare these days. Shift patterns and the diminishing professionalism borne of clock-watching have seen to that.
So whilst we still wait to see what plans the coalition government has for our future and hope against hope that the top-down micromanagement goes with the legions of unnecessary administrators, I propose a modern version of the same song.

Miss Polly had a dolly that was sick, sick, sick
So she called the approved emergency number for out of hours consultations
A locum said: "Can you come to the local walk-in centre?"
Where he sat with his arms bare below the elbow and no tie.
He entered the dolly's vital signs into his computer and said:
"She doesn't fulfil the criteria for antibiotics so give her Calpol instead",
"I'll arrange for one of the nurses to ring you up in the morning to see if she is any better."

Not all change is progress.