Noel Plumridge on cutting the NHS cost base

Displacement behaviour usually occurs when an animal is torn between two conflicting drives, such as fear and aggression. Displacement activities often consist of comfort movements, such as grooming, scratching, drinking, or eating.”

Taking perhaps 5 per cent out of the NHS cost base each year for the foreseeable future is the devil’s own challenge

Naturally, the NHS rarely limits itself to one pair of conflicting aspirations at a time. Productivity and quality are potentially reconcilable, but competitive tendering and job security are probably less so. Anyone care to square the rumoured 2010-11 cap on fully funded payment by results activity with sustaining a maximum 18 week wait for treatment? Improvement and efficiency tsar Jim Easton’s main result area - save £15bn or so without anyone really noticing - appears, well, tough. And as for the requirement for PCT chief executives to balance the books yet avoid being “named and shamed” by the minister…

One definition of stress is the tension between fear and aggression. NHS management has stress in shed loads at present, and there’s more than a little aggression and fear as well. So, when it comes to addressing that £15bn question, it’s not surprising there’s a fair amount of displacement activity. Not grooming and scratching but in the classic human behaviours of denial, evasion and euphemism - and perhaps some drinking.

Taking perhaps 5 per cent out of the NHS cost base each year for the foreseeable future is the devil’s own challenge. Here are some measures that will not achieve it:

• Tinkering with the payment by results uplift. Debating whether the 2010-11 uplift should be inflation or flat cash will not in itself save a penny.
• Basing funding on a “best practice” payment by results tariff. The NHS will have four from April. They are an excellent innovation, but will not release a red cent.
• Identifying variations from “best practice” and calculating how much capacity might be released if the trust could perform at upper quartile level.
• Setting up a new primary care led service, or putting a service out to competition, and “decommissioning” arrangements with the local acute hospital.

The only way to save money is to spend less of it. That means fewer (or cheaper) staff, premises, drugs and supplies. It requires the will to eliminate budgets that are no longer needed, costs that are redundant.

The NHS is coy about converting productivity gain into hard cash, especially if it involves reduced numbers of clinicians. Laparoscopy, for instance, has revolutionised the treatment of many conditions, but has hardly decimated the surgical professions. Even the excellent NHS Institute publication on Productive Community Services - the one that identifies how much district nurse time is spent driving - maintains the comfortable notion that “improvement” leads to “improved staff morale.”

In commerce things are different. Banks have switched en masse to ATM technology and the move hasn’t resulted in improved bank clerk morale and more quality time spent with customers. The banks have pocketed the savings. And by and large we, as consumers, don’t mind.

Scientific advance is the great lever for radical pathway redesign, and its spread often comes with ready quantified scope for savings. Here are two examples.

Besides offering huge potential for the centralisation of hospital support functions, such as pathology and radiology, telemedicine offers efficient ways of monitoring patients in their own homes, reducing the need for hospital visits. Patients with cardiac defibrillator implants (ICDs) need high quality follow-up care, at intervals of between one and six months. The technology now exists to perform most follow-ups remotely and brings both efficiency gain and immediate savings.

Another example is joint replacement. We can review orthopaedic surgeon productivity, we can haggle over the price of implants, but the real potential for gain lies in a reduced length of stay. For knee replacement surgery, one company has pioneered a model, known as “rapid recovery”, that integrates the choice of prosthesis with techniques for pain management, early mobilisation and planned discharge. Oh, and no small emphasis on data collection and analysis. It’s off-the-shelf integrated pathway redesign, if you like, and with ready quantified anticipated savings.

How much? In Denmark (Hvidovre Hospital, Copenhagen) the reported whole system saving in 2008 was 30 per cent.

Much of the hard work identifying opportunities for productivity gain has been done. All NHS management needs to do is implement them. According to the recent Heart Rhythm Congress in Cannes - no, this columnist didn’t get invited - around 5,000 heart patients in the UK are using remote ICD monitoring. So what about the rest? And those district nurses still waiting at traffic lights?

Take the costs out. Move from displacement activity to action, without upsetting anyone. That still sounds like a challenge and a half for 2010.