Saturday 26 June 2010

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 The £700 a year or so that is potentially spent on every doctor in the country could be withdrawn.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

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