Some Simple Steps on Paper, A Few Giant Leaps for the NHS

Trawling the BBC health site for some inspiration after a realised I’d not written anything for 2 weeks, I came across the headline ‘Simple steps could save NHS £5bn‘. Given that Simon Stevens, NHS Chief Executive, thinks the NHS can save £22bn by 2020, I was pretty interested to see where this £5bn would come from. As Lord Carter’s actual report has not been published yet, I’m relying on the BBC article being correct.

  • Carter found that heating costs varied from hospital to hospital, and money could be saved on ‘estates’

Now not to start blaspheming against the good Lord, but this sentence smacks of an accountant looking at numbers from afar and not taking into account any context. Dundee spends £X thousand pounds a month on heating compared to Plymouth? Must be ineffeiciency, couldn’t possible be the fact Dundee is a snowy hellscape and Plymouth is warm most of the year…

To be less sarcy, I can see where efficiency gaps could exist i.e. different heating systems, heating wards/areas that aren’t open, but the BBC hasn’t done Carter any favours by opening with the hardly groundbreaking news that heating costs vary across different buildings.

  • One hospital lost £10,000 a month through giving staff too much leave. £2bn could be saved nationally

Which hospital is this and how do I work there? I jest of course, but giving staff too much leave is not a problem I’ve ever seen.

However, staff management is a problem. Here’s 3 of my favourite anecdotes off the top of my head:

1. An incident where a Consultant 1 was off on leave, and Consultant 2 offered to cover the fast track cancer clinic, instead of doing his own clinic. Obviously, NHS managers being what they are they read ‘instead of’ as ‘in addition to’, and he turned up to see 24 patients waiting to be seen in 3.5 hours. Luckily, there were two registrars free to help out, and even I ended up taking histories of patient to make sure everyone was seen. Yes, you read that correctly – the fact that a medical student was around was actually helpful.

2. The time a review was being conducted into a patient’s death and all staff involved were interviewed. Do we need to arrange on call cover for when the registrar has her slot? Of course we don’t. On this occasion, the on-call consultant became the on-call registrar as well.

3. I turn up to surgery to ask to observe, all is well and good. 20 minutes later, I’m scrubbed in and assisting as the junior rostered to help is still having to do jobs on the ward because there’s no one else to do those jobs. Once again you’ve read that correctly – having a medical student was actually necessary. In this case, it really was as I’m not quite sure where they were going to magic a doctor from. Probably the same magic tree, David Cameron is going to get all his extra nurses and GPs from.

Now those are just three situations and I’ve never seen any of them repeat themselves, but each one put patients at risk and irritated the staff involved. Not a good way to make NHS management more efficient, and I definitely agree that NHS management needs improving.

  • One hospital saved £40,000 a year through using a non-soluble version of a liver failure tablet rather than a soluble one

As long as steps like the one above don’t put patients at increased risk then I’m pretty much in favour of them. Of course if the patient has trouble with a non-soluble tablet and a soluble one would work better for them, then that option has to be there. It’s not really a feasible cost cutting measure for a lot of in-hospital treatments such as chemotherapy, anaesthetic or antibiotics, however, in a GP context, I can see room for safe savings.

  • Carter recommends an electronic catalogue for simple items such as syringes and aprons to create standardised buying, as prices can vary as much as a third

Unless the NHS is massively restructured, this is going to be difficult to enforce. People like to think of the NHS as a monolithic structure. If you’re one of them, brace yourself and look at the picture below. Still think it’s one big simple thing?

The result of multiple governments 'simplifying' the NHS
The result of multiple governments ‘simplifying’ the NHS

The NHS is too divided to enforce bulk buying and judging by the current governments plans, it is only becoming more so with the net for tendering of services being cast wider and wider. In principle, I agree that if the NHS bought identical stuff nationwide, savings could be huge. Imagine the multibuy savings you get on a billion aprons! However, I can move from Barnsley to Sheffield to Rotherham and potentially see three different blood-taking sets, three different protocols to do so and three gloves to wear as I do it. Unless the NHS becomes more of a monolithic structure, then it’s fragmentary nature will really hamper savings. And as becoming more monolithic heralds problems of it’s own, I’ll leave this one to cleverer people to sort out

  • Some hip replacements cost twice as much and last less than cheaper alternatives

Ah, put this one down to surgeons and their love of new toys. Just kidding, put it down to a problem that cuts across most of humantity. We assume new is better, when quite often it isn’t. We at least don’t know if it is. This illustrates the need for integrating clinical trials alongside gold-standard clinical care on a routine basis.

Imagine we know exactly how to best care for those with hip replacement ‘A’ (the old one). Hip replacement ‘B’ comes out and we want to know if it’s better. Every patient that comes in we randomise using a computer program to either ‘A’ or ‘B’, and we do this for as long as it takes to get the data we need. We then follow up the patients for however long we know ‘A’ lasts for and see if ‘B’ is matching this. We can also compare death and complication rates, and anything else we check for. At the end, we either stick with hip ‘A’ as it is clearly better, switch to ‘B’ as it’s better, or we’ve found A works better for certain patients and B for others. Whatever option, we’ve improved our gold standard care, and whilst we’re at it , we can save the NHS money spent on treatments that are sub-standard,

Obviously written out, it’s a lot more simple than real life clinical practice. However, it’s not impossible. Childhood leukaemia tretaments have this approach, continously improving their care and now survival rates for the commonest type is around 90%. 

Lord Carter’s report is coming out soon, along with his description of an efficient model hospital, so I’ll be looking out for that and if he says anything groundbreaking you might see me return to this topic. So far, his ideas seem quite short of groundbreaking, but perhaps that’s what is needed. If the NHS is to get its financial house in order, the simple steps will need to be done first and anything we can save by making medications better value for money, prevents the cutting of essential front line services.

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