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Of splits and differences
- February 7, 2012 posted by Andrew Wilkinson
In the week that the NHS Commissioning Board Authority unveiled and approved its proposed structural design, comment has been split between those castigating its bloated costs and those fearing that management cuts will adversely affect patient care. According to the Board’s own figures, management costs will be halved, in part through the wonders of matrix working. Its success remains to be seen.
Elsewhere in the NHS, moves to drive down management costs are widespread. CCG management allowances per head of population have been similarly meagre, hinting that CCGs will need greater scale to be able to function economically. This could either be achieved through mergers or by reliance on the 40 or so Commissioning Support Organisations being helpfully established by the NHSCB out of the remnants of the PCTs.
One area of management cost that the reforms don’t recognise, for obvious reasons, is the cost incurred by the purchaser-provider split. The split has enabled something of a provider market to operate, injecting competition into the heath service to improve service provision. It has also helped the NHS realise many costs which were historically hidden to view. Yet the policy has also had some less beneficial consequences.
For example, the split creates an unconvincing dichotomy between ‘purchasers’ and ‘providers’ in the NHS, with both sides seeking the best deal from each other. In the zero-sum context of a taxpayer-funded health service, where a loss for either side of the split is ultimately a loss for all, the purchaser-provider split may simply have the consequence of driving management costs higher while shifting problems between commissioners and service providers
The jury is out on whether the split has been successful in driving up standards of care compared to other parts of the UK. With such a focus on management costs in the reformed NHS, it seems inevitable that the debate on the purchaser-provider split will open up once more.
Nursing the wounds of the Health and Social Care Bill
- January 23, 2012 posted by Rosie Beauchamp
Last week the Royal College of Nursing and the Royal College of Midwives joined ranks with the BMA in calling for the Health and Social Bill to be dropped completely, stating their “outright opposition”. At this stage in the Bill’s progress it seems unlikely that it will be defeated. The colleges know this and we can only assume that their change of heart embodies a protest about pay and pension as much as a desire to distance themselves from the Bill itself. Moreover, anyone working with the NHS knows that administrative change is now too far advanced for the clock to be turned back.
But there is a serious challenge attached to the RCN and RCM’s decision to oppose the Bill, which the government ought to heed. Implementation of NHS reform is currently threatening to consume the NHS. The need for genuine clinical buy-in cannot be ignored. Nurses are on the frontline when it comes to patient care and experience and they received their share of bad press in 2011. Most nurses, who routinely deliver high levels of care, currently have little faith that the reforms are going to help them to do their jobs better as resource becomes more scarce.
The RCN’s “outright opposition” to the Health and Social Care Bill may not affect the Bill’s safe passage but that will mark the end of the beginning not the beginning of the end. At some point the government will have to confront the need to win back the support of those on whom the NHS ultimately depends.
New year’s resolutions: the challenge of change…
- January 16, 2012 posted by abriceno
Having resolved to ‘do more exercise’ in 2012, I spent the morning having a swim and hoping that I would be one of the 12% who actually manage to keep their new year’s resolutions. Some might put low success rates down to unachievable targets being set. However, trawling through lists of top ten resolutions, most of the favourites (get fit, cut down on alcohol, quit smoking, save more) appear to be quite realistic. So, why aren’t these goals being achieved? Too often, the degree of will and determination required to change a habit, or start and sustain something new, is underestimated.
As such, the Future Forum’s suggestion that health staff routinely speak to patients about their diets, smoking, drinking and exercise habits in an attempt to reduce NHS spend on lifestyle-related illnesses seems futile. Discussing lifestyle with a patient who is at heightened risk of a heart attack makes sense and the benefits of change are clearly demonstrable. Talking to a patient about doing more exercise when they visit their doctor with an ear infection and are at no immediate risk from their current lifestyle choices, is more likely to irritate than spur someone into action.
Discussing lifestyle with patients where there is a clear risk to health makes sense but to achieve higher success rates than those embarking on new year’s resolutions, the NHS needs to develop a holistic approach that goes beyond exhortation and shows patients how to make sustainable improvements in their lifestyle. This probably requires investment but spending on public health to save NHS expenditure will be a difficult proposition in these cash-strapped times.
A perilous journey with an uncertain destination
- January 9, 2012 posted by John Murray
2012 marks the start of a momentous year for the NHS. During its course a frightening number of plates need to be borne aloft. The chances of one or more crashing to the ground are substantial. Those with the NHS’s best interests at heart look on with trepidation, while a sense of expectation is evident amongst those convinced that demographic and financial forces doom it to failure.
Certainly, the need for financial grip, as Sir David Nicholson describes it, is paramount. At this stage in the QIPP programme some significant savings have been claimed on the commissioning side of the fence but if this simply puts acute trusts into deficit, little will have been achieved. And, as Stephen Dorrell has frequently pointed out, we are only at the beginning of an unprecedented period of austerity. To what will be the mounting horror of MPs, hospital closures therefore look like an unavoidable necessity but even if the political courage is summoned to see such rationalisation through, PPI deals may erode the benefits.
Meanwhile, the transformation of PCTs into CCGs will also be fraught with risk. To mitigate this, the PCT clusters are being positioned as a necessary port of call for commissioning support. The result could, however, be disillusion on the part of those clinical leaders who feel that the liberation promised by Andrew Lansley has been strangled at birth. Meanwhile, industry will be similarly puzzled about whether it’s all change or no change where the identity of customers is concerned.
So are there any grounds for optimism, despite the gloom? A lot hinges on whether NHS leaders are genuinely capable of doing things differently and given the leeway to see it through. As a consultancy, JMC Partners is much involved in specialised commissioning where there are certainly opportunities to combine improved standards of care with greater efficiency. The specialised arena will also be at the forefront of the government’s drive to support innovation.
So Happy New Year to everyone we work with. As staunch supporters of the NHS, we look forward to proving the doubters wrong.
The NHS and innovation – any different this time?
- December 5, 2011 posted by John Murray
The DH and NHS have published so many initiatives on innovation over the years that it’s easy to view today’s Nicholson report with a jaded eye. Certainly, the content on NICE uptake on its own looks depressingly familiar but, taken as a whole, there may be grounds for more optimism. In particular, there’s a coherence about the package which looks more promising though, in true NHS fashion, many of the bells and whistles, such as the gimmicky collaboration with Which?, could have been dropped to good effect.
Nevertheless, there is a core of solid proposals which have real potential, as ever subject to the all-important detail. There’s also an unusually tight timeline to put that flesh on the bones. In particular:
* The procurement strategy is due to be published in three months; a real opportunity for the NHS to show that whole life value will genuinely be weighted alongside price;
* Similarly, decommissioning will be given renewed impetus in short order, absolutely crucial to a credible plan to adopt more innovation;
* First up in the 3-9 month category, is the launch of the specialised services commissioning fund which has been so vigorously championed by JMC over the last few months. This has exciting potential to bring commissioners, clinicians, patients and industry together in getting new technologies into use, alongside the data collection needed assess their longer term potential;
* In the medium-term, the proposals on managerial and clinical curricula have much to commend them in addressing the cultural resistance to innovation in much of the NHS, while the proposed changes to tariff around diagnostics and assistive technologies will provide critical underpinning.
Why it’s smart to get fat
- November 16, 2011 posted by John Murray
Confectionery companies rightly espouse the merits of a balanced diet and would doubtless say they are doing their bit for people in hard times but the price propositions in stores only point in one direction – buy more, eat more.
The latest example I came across in a petrol station offered one bar of a well-known brand for 75p or two double bars for £1.25 giving a unit price comparison of 75p versus 31.25p. If I only want one bar, I really have to steel myself not to buy more because economic common sense tells me I’m a fool. Equally, I know that if I buy four bars, I’ll eat more than I intended.
This type of pricing proposition tells us something interesting about the marginal costs of production and suggests the major companies will need to change their business model if their customers’ waistbands are once again to coincide with common sense. A cash-challenged NHS, facing the rapidly rising costs of obesity, diabetes and all the associated complications, might also heave a sigh of relief.
Keeping an eye out
- November 3, 2011 posted by Rosie Beauchamp
The Health and Social Care Bill is currently at Committee Stage in the House of Lords. Accordingly, it is drawing lots of media and analyst attention once again, with commentators eager to stay one step ahead of any significant amendments as they are debated.
While the Bill is undoubtedly crucial, there is a risk that attention is being drawn away from other ‘live’ reforms in the health service. These other reforms have the potential to drive transformation alongside the Bill itself.
For example, the Innovation Review, established in the Treasury’s Plan For Growth, closed its period of consultation at the end of August, and has not yet reported its findings. As the Bill makes clear, a duty to promote innovation will be enshrined at national and local level in the reformed NHS: the recommendations of this review are therefore vital to how the new system will work in practice.
This is just one of many internal reviews and consultations that are proceeding apace. Their conclusions, just as much as amendments being debated in the Lords, will have a direct impact on England’s future NHS. It remains more important than ever, therefore, to keep a close eye on developments in the Department of Health and the NHS, in addition to any attention paid to the House of Lords.
By Andrew Wilkinson
How did we forget to care?
- October 14, 2011 posted by Rhiannon Barker
Following recent spot checks of 100 hospitals the Care Quality Commission found that one in five of the hospitals visited were neglecting the elderly to such an extent that they were breaking the law. In more than half of those inspected there was cause for concern. Unacceptable care has become standard in some trusts, with doctors and nurses talking down to, or over patients, ignoring their calls for assistance and failing to help them eat, drink or wash. Florence Nightingale, a great champion of patient-centered care would, would no doubt be shocked at how often patients are overlooked under pressure from paperwork, and the growing targets that have to be met.
Andrew Lansley ,talking on Radio 4 on 13th October, encouraged the NHS to learn from these findings. Perhaps we need to look more widely than the NHS and reflect on some of the values on which our health care system is built? Project 2000 which moved nursing from the ward to the classroom is often cited as causing a decline in care as the profession became more technocratic. Keeping up with beneficial advances in technology is vitally important to the NHS but must be combined with care and compassion if patient-centred rhetoric is to have any meaning.
How to beat a hedge fund
- October 5, 2011 posted by John Murray
While JMC’s clients all appreciate the value delivered by well-targeted investment in understanding and informing healthcare policy, colleagues from other disciplines can sometimes be harder to persuade, maybe preferring more familiar marketing techniques.
An article in this week’s Economist (1st October 2011) therefore demands attention. This reports on an index of 50 companies produced by the investment-research firm Strategas, looking at the intensity of lobbying expenditure as a percentage of assets. It finds that the returns have been stunning, outperforming the S&P500 by 11% a year since 2002. The outright return on lobbying costs according to one of the studies which inspired Strategas was $220 for every $1 spent.
The nature of lobbying in Washington is not directly comparable with Westminster. The message is, however, clear that it makes sense for organisations operating in highly regulated environments like healthcare to invest in better public policy.
The full article can be found at http://www.economist.com/node/21531014
Patient data and choice
- September 29, 2011 posted by Rhiannon Barker
Rosie Beauchamp, wrote on 30th August of the importance that data which swamps the NHS helps inform analysis of service provision and outcomes. One area, where data collection remains inadequate, despite a groundswell of good intent, is patient experience and patient outcome measures, recorded both during and following hospital interventions. The difference between the quality of readily available data relating to our local schools, in terms of both outcomes, pastoral care and student and parent satisfaction (readily available to all in downloadable Ofsted reports,) compared to data on outcomes and patient satisfaction at local hospitals is startling.
The National Patient Survey, overseen by the Care Quality Commission (CQC), and conducted by individual Trusts, is an annual survey which has run since 2002 and reports on a number of different areas/pathways; inpatients, outpatients, emergency care, maternity care, mental health services, primary care services and ambulance services. The DH suggests that results from these surveys are used:
- By the NHS to track performance over time and inform local improvement activities
- By the DH to measure progress against specific policies and for the overall measure of patient experience
- By CQC to assess how well NHS organisations are meeting the needs of patients
The group not mentioned are the general public. Given that the Health and Social Care Bill continues to espouse patient choice and the importance of putting the patient at the centre of care it may be time to focus more on providing clear and robust information that patients can use to make informed choices. To facilitate this, methods must be chosen which distinguish between patient satisfaction and patient-reported outcomes and reflect Lord Darzi’s advice that quality should encompass not only clinical indicators but the need to treat the individual with dignity and respect. It may be time for the Department to trim down the number of measures of patient experience that it uses, ensuring that a lesser number of standardised measures are used more routinely across all areas of NHS treatment and that the data which is captured as a result, is clearly and widely communicated to patients to inform their journey through the care system. Most importantly, the end result should reflect what really matters to the patient.
Views expressed are those of the author, not JMC Partners.
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