Beyond the annual round of institutional cuts? How does the NHS incorporate an attack on waste into its 10 year plan? 1

Having doctors and nurses do only what doctors and nurses need to do and having hospitals do only what hospitals need to do.

Just a quick word on what I am trying to explore between now and November, whilst the content of the new contract between the NHS and the people is being developed. I thought that enough pressure groups would be making a case for what should go into the contract so that it might be useful to spend a few weeks looking at how the new outcomes are to be achieved.

Last week I explored the changes that would have to take place to develop the necessary integration of the new outcomes. This week I want to look at how the new outcomes should deliver in such a way as to reduce waste in the NHS.

One of the main reactions to the British people being asked to dip into their funds to give the NHS more money, has come from some parts of the NHS commentariat, and is that an annual uplift of 3.4 % is not enough. Calculations were computed to demonstrate that on a good day this would be just about enough to stand still and that anyone who asked for more outputs on the basis of this money would be wrong. My reply to this is that taxation is real – for most of the public it takes away from their ability to consume – presents for kids’ weekends away. When taxes go up there is less money for the public to spend on themselves.

I am generally in favour of tax funded public services and I am specifically in favour of taxes going up in 2018 for extra money to go into the NHS. But I would hope that as that money is spent, one needs always to remember that it comes from real people having less to spend on themselves and their family. For the NHS it is free money. For the public it costs.

Waste attacks the NHS in two important ways. First it steals money from the core aim of improving the health of the population. That’s what the taxation is taken from the public to achieve and as we know the NHS needs every penny. Second, when the public sees its money being wasted by the NHS, it knows that that wasted money came from them. And that creates anger and a feeling that perhaps the NHS doesn’t deserve the money.

And that is one of the reasons why, in response to receiving the extra money from the public, the 10 year plan must demonstrate that the NHS will successfully attack waste in the way it spends public money over the period. And this needs to go beyond the annual QIPP round. (I remember when that set of initials was introduced and it was meant to look at all the things the initials stood for – Quality, Innovation, Productivity and Prevention. By the second year it was just about cuts. Now when you say this is in the QIPP programme we know it means one thing).

Genuinely and successfully attacking waste in 2028 will take more than annual shavings off the budget. It will need a complete change to the way in which we work. Most of the big changes that would save resources we already know – but because we deal with them on an annual basis, we don’t get round to doing them because they need long term planning.

Over the next 10 years a lot of waste will disappear from the NHS for the same reason it has been squeezed out of other services – better use of data and technology and better use of the workforce and its assets. I will have a week’s posts on data and tech in a few weeks’ time but here I want to deal with what in 2018 we already know about how we waste expensive clinical time and how we waste expensive time in hospitals.

Primary care is an area of NHS activity that is going to have to be expanded over the next 10 years even though there may be no increase in the numbers of working GPs. It is therefore surely time to ensure that GPs work to the very peak of their skills and training. It’s estimated that, at the moment, 30% of their time is spent on activities that could be carried out by staff with fewer skills and less training.

Given this figure is generally agreed upon today, a 10 year plan would seem to be the time to tackle them in a forceful way rather than just live with them.

Some of this is organisational – over the years those GPs who generally are at the professional apex of their practice – take responsibility for a wide range of work for which they don’t need training.

• Highly trained clinicians are carrying out administrative and organisational tasks when the NHS and patients need them to be consulting with patients.

• Despite creating the possibility of nurse prescribing in 2003, there are too many practices where GPs still carry out the bulk of this work.

• Many GPs are involved in follow-up work with patients that other professionals can carry out.

These issues will be dealt with in part by primary care being organised into bigger units, but most of them will need quite tough cultural and organisational change – where the profession will need help in chasing down the ways in which traditional working practices have GPs spending time carrying out work that others can do. But today, and most definitely by 2028, it wastes highly trained and rare resources.

Similarly most agree that about 25-33% of the people who attend in and out patient clinics in hospital do not need all of the intensive care services that are normally found in a hospital. When you go to one and look at the list of services that are a normal part of that organisation, there is always an astonishing list of activities. Having all of these activities in one place raises the cost of patients spending time in hospital considerably. When hospitals are trying to save money they refer to these as ‘trapped costs’ arguing that for very ill people you need all of those services in one place.

Yet many people spend their time in these really expensive establishments without remotely needing to spend time among such an expensive nexus of possible interventions.

They do not need to be in such an expensive place.

I have commented before about how outpatient clinics are oddly named since over 90% of people who go to an outpatient clinic go into the hospital to access their services. Some outpatient services do need to be alongside the full range of services – but most don’t and we can treat people just as well in much cheaper places

The same is true for some people in hospital beds. Both those who should not have gone into hospital in the first place, and those that should be out of hospital and somewhere different. Winter after winter the system tries to develop services that keep people out of hospital and/or get them home quicker.

These are difficult changes – and I am suggesting that a 10 year plan is the time and place to tackle them.

One of the certainties of the next decade is that an ageing population will mean that there are more very sick people. The 3.4% annual increase in funding is in part a recognition of that. My point is that over these 10 years we should make sure that people in hospital for in and outpatient treatment really need to be there. Before we build more, let’s use the ones we have for people who need them.

If, over the decade, the NHS doesn’t achieve that in a secure and strong way, we will be wasting money we are being given by the British people.