Attempting to make a giant leap in order to deliver £22bn in efficiencies is futile. A sustained focus on delivering better value is the only way, writes Chris Ham

NHS England is at the midpoint of a decade of austerity.

‘A step-change in thinking is needed if the NHS is to get anywhere near finding £22bn’

Having risen to the Nicholson challenge in the last Parliament, it now faces the even greater Stevens challenge of delivering an estimated £22bn of productivity improvements by 2020-21.

A new report from the King’s Fund draws on past experience in the NHS and evidence on how better care might be delivered to suggest how this might be done.

Chris Ham

The core argument of the report is that the main policy levers used to deliver the Nicholson challenge, in particular national controls over pay and prices, will not be sufficient.

A step-change in thinking and action is urgently needed if the NHS is to get anywhere near finding £22bn of productivity improvements by the end of this Parliament.

This means focusing on improving value for every pound spent and engaging clinicians at all levels in delivering better outcomes at lower cost.

Value for money

Our review of past experience in the NHS demonstrates how this has been achieved through increases in generic prescribing, day surgery and reductions in the time patients stay in hospitals.

Evidence on how better care might be delivered outlines a wide range of opportunities to provide care more appropriately in future and in so doing to reduce waste and inefficiency.

Realising these opportunities requires action at all levels of the NHS, with a particular emphasis on changes in clinical practice. 

Clinical leaders throughout the NHS are already demonstrating how these opportunities can be delivered in practice.

‘Clinicians alone will not be able to deliver the Stevens challenge’

Examples include Sheffield, where work to improve patient flow for older people has reduced delays and enabled more and better care to be provided within available resources.

In Plymouth, the care pathway for stroke patients was redesigned, and in Walsall prescribing in general practice has been reviewed to improve care and reduce waste.

Service delivery

Clinicians alone will not be able to deliver the Stevens challenge.

They will need time and support to improve care and release resource, and their efforts will need to be complemented by system-wide changes in how services are delivered at a city and county-wide level.

‘Resources must be saved before they can be reinvested’

All of these efforts in turn will need to be supported by political leaders and national bodies, particularly where difficult and unpopular decisions need to be made about where services are provided.

Recognising these truths, we make no apology for placing the emphasis on clinical practice because the opportunities in these areas have been relatively neglected in the response to the Nicholson challenge.

We also make no apology for framing the challenge as how to improve value rather than make cuts because only in this way will it be possible to engage clinicians and other staff in the work that needs to be done.

Of course, resources must be saved before they can be reinvested, but to borrow John Kay’s insights from successful businesses, this is often best done obliquely instead of head on.

Living examples

Evidence gathered by the King’s Fund shows that high performing healthcare systems around the world have succeeded in becoming more productive in the course of improving value.

These systems are living examples of how it is possible to deliver better outcomes at lower cost by reducing unwarranted variations in care and cutting waste.

Virginia Mason Medical Center and Intermountain Healthcare in the US exemplify what this means through a relentless focus on providing safe, high quality care.

‘US systems have appealed to clinicians’ intrinsic motivation to improve outcomes by setting ambitious goals’

Both systems have adopted explicit methodologies for quality improvement and have invested in training clinicians to apply these methods to clinical care.

They have appealed to the intrinsic motivation of clinicians to improve outcomes by setting ambitious goals for improvement and measuring progress towards them.

They have also developed an impressive cadre of clinical leaders with the skills to use data to challenge their peers and deliver better value.

Patient partnership

Clinicians will need to work in partnership with patients in taking forward this work.

Previous research at the King’s Fund with international experts such as Al Mulley and Judy Hibbard has made the case for patients to share in decision making with clinicians to avoid the silent misdiagnosis, and to play an active part where appropriate in promoting health and wellbeing.

Related initiatives such as Choosing Wisely are giving practical expression to this thinking.

‘The biggest challenge is the time needed to bring about improvements’

The biggest challenge in acting on the experience and evidence summarised here is the time needed to bring about improvements in clinical practice and release resources for reinvestment.

A recurring message of our report is that it is the accumulation of many small improvements over time that matter rather than the futile quest for a giant leap forward.

Only a sustained focus on delivering better value in the ways we outline will enable to get close to the £22bn the NHS has been challenged to deliver.

Professor Chris Ham is chief executive of the King’s Fund