What would NHS managers dump on the hospital lawn ready for the crusher or eBay?

I love low-budget television. Perhaps it's the accountant in me. Not 'reality TV' - life's too short - but that class of honest-to-badness low-budget programme one can gawk at with a vacant expression, brain in neutral, when it has been a long, long hard day.

Especially sweet are sequences of vaguely low-life programmes. Shattered phew-what-a-week-that-was Friday nights at home are always more bearable when one can anticipate something like South Park followed by Eurotrash at the end of the evening. And in recent times there have been few TV pleasures to match the happy Thursday evening coupling - now sadly lost - of The Life Laundry with What Not To Wear.

You remember. Cheap psychology and ritual humiliation, always a winning combination. First the cheery Dawna Walter, who has been likened to colonic irrigation for the home, arrives to 'declutter' some poor sap's life. Twenty minutes later the large heap of surplus possessions is in the middle of the lawn and the futility of the victim's life to date has been cruelly exposed. The victim cries. As for the junk, the crusher and the car boot sale are ready and waiting (no green options here).

Time to put the kettle on in readiness for Trinny and Susannah working the same trick on some other poor sap's hoard of inappropriate clothing. (OK it's now Lisa and Mica in the hot seat, but let's not quibble.)

There are handy tips on disguising body bulges and a little vicarious retail therapy, but we really know that it's the all-important hair rethink (and sometimes the overdue pedicure) that will make the difference.

What has this got to do with managing a health service? Well, it is prompted partly by the sensitive issue of 'disinvestment', the NHS equivalent of the life laundry. At a recent Healthcare Financial Management Association conference I heard a delegate, presumably enthused by the prospect of reinvesting the freed-up money, ask a panel of 'experts' what they would actually disinvest from. The embarrassment was palpable.

And it is partly a growing fear of 2008-09, the year when the big annual financial growth percentages finally end and the seven lean years begin. NHS finance director Richard Douglas advised the Chartered Institute of Public Finance and Accountancy health conference earlier this month that to balance its books the NHS needs the equivalent of a diet.

So where might the NHS disinvest? What would NHS managers dump on the hospital lawn ready for the crusher or eBay? According to Dawna, 'most of us have 30 per cent of stuff that we just don't need' and it's 'important to acknowledge that we can change, have different interests and different people in our lives and can get rid of old things'. Well, the NHS certainly has different interests, and just lately it has plenty of different people. So what can go?

For me there are three big groups of clutter. One is redundant clinical activity. Years ago we learned that around 25 per cent of clinical procedures had no evidence base and offered patients little benefit. The trouble was, we didn't know which 25 per cent they were.

But an excellent recent publication from the NHS Institute helps enormously: if you haven't seen the snappily-titled Delivering Quality and Value: focus on productivity and efficiency, what are you waiting for? For example, its analysis of five common procedures (tonsillectomy, dilation and curettage, hysterectomy, lower back surgery and grommets), based on 2004-05 trust data, show wide variations between primary care trusts. Plenty there for Dawna's crusher.

Then there are inefficient ways of working. Think of the savings we could make if all NHS hospitals could get down to the average length of stay for high-volume, high-cost procedures. Or even to within 5 per cent of the average. (All right, yes, the average would then fall, but so what? It is the breadth of variation that's the point.)

Think of the savings that would come from everyone getting down to average rates of hospital-acquired infection that cost the NHS an estimated£1bn each year. Or the savings from standardising the duration of pre-admission processes. Not to mention the savings from matching operational policies and nurse staffing levels for the use of community hospital capacity.

And finally there are ineffective ways of working, including the residue of policies that once seemed important. Dawna again: 'We have so many failed dreams that we don't let go of that prevent us from moving forward.' Here's a challenge: if we were really going to focus on financial balance and the big six national priorities, what would you stop doing? Which important national initiatives could, let's say, drift a little? Or which bits of the healthcare bureaucracy could you cheerfully take a chainsaw to?

So, now we've decluttered, what can we learn from Trinny and Susannah? Here there's perhaps more of a problem. The tyrannical two never recommend actual weight loss. They steer towards better self-presentation, based on a more honest acceptance of the way we are. Typically this means older, fatter, and no longer capable of getting away with the stuff we wore back in the day.

Well, some of our hospital buildings could certainly do with a make-over. And word on the street is that there's plenty of NHS capital available this year, if only we can take the plunge and go shopping. But what to buy? How to prioritise? The Trinny and Susannah approach is, generally, to go for high quality. Go for something that will both impress and last more than one season. Go for class.

A bit of capital spending would not, of course, be a substitute for the diet Mr Douglas says we need, any more than a designer top and a fitted jacket is a remedy for a sagging belly. But it might boost self-esteem, for a while at least, and it might help us present a different image to the outside world. And, when it comes to reputation, that will do the NHS little harm.

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