We asked readers what behaviour and process changes do they believe are needed for the NHS to deliver consistent, financially sustainable 24/7 working. These are the most popular answers regarding procurement and commisisoning

Change the GP contract

GPs should be salaried rather than be independent practitioners. The ability of the system to change pathways is hampered by them being outside rules that apply to the rest of the system. We need to create the conditions for everyone across the health system to work on the shared vision rather than to be hampered by the constant response of payment for every change.

Stop the NHS being overcharged for services and equipment

Having worked in the NHS for more than 25 years I never cease to be amazed at the exorbitant prices we are charged for goods and equipment and I firmly believe that this should be tackled to help save money which can be channeled back into care.

I once had to order a new medicine trolley at a cost of £500, the item was just a chipboard box on wheels with a lock. How can this cost be justified? Suppliers need to bring their prices down.

Integrated care without an internal market – maximising population outcomes

Simple. Take the best bits of the various current (and proposed) UK systems to arrive at an integrated health and social care system (one funding pot, based on “Total Place” principles). Burnham makes this proposal well, except in his version of the model local politics will stifle care provision if the “NHS” responsibility is handed to local authorities – stop short of this and create accountable health and wellbeing bodies similar to the Welsh health boards.

Remove the English internal market - PbR and “commissioning” via tariffs and rules creates bureaucracy and costs £billions. Clinical commissioning can be much more sophisticated when the organisational and transactional boundaries are removed. This will save £millions overnight and put the focus back on cost vs. outcomes as opposed to the current cost shifting principles we see played out.

Now, this really would be a change that we could see from outer space. The difference being, this has longevity and reality built in to it in a world where we all want to see a continued NHS offer but equally cannot ignore the relentless economic pressures that the current system (health and social care) are facing.

The greatest risk for patient and service users in the receipt of care happens at the hand offs and hand overs between bodies. Only by removing the barrier between health and social care, and removing the internal market that will otherwise self destruct, will be really achieve the best population outcomes (health and social care) to justify ongoing current investment.

Stop responding to political whim

Politicians’ ill-informed half-baked ideas disrupt any form of sensible long term planning: NHS managers seem to line up to demonstrate how ruthless they are in grabbing hold of a new directive and forcing people to follow it, at the cost of ignoring the many areas which need attenton and nurturing.

It is possible that long term condition management might stop admissions and call outs, but most studies show that interventions increase call outs A+E attendances and hospitalisations when more and more is done to achieve less and less. Many elderly people are in physiological status quo; attempts at normalisation put all the other body sytems out of kilter causing destabilisation and leading to the need for acute intervention.

This may sound defeatist but it is in fact common sense.

The recent cry to detect all our patients with dementia is another ill advised intervention. Why? There are no drugs that make a significant difference nor any social care to provide the demand which will be created. Lets be clear: dementia is an issue for social care and not for medicine. Doctors have little to contribute here.

So whoever is at the top of the tree needs to vet what politicians say before the words leave their mouths, and that high ranking person must be a clinician who has the ability to see the overall picture.

Stop reviewing everything ad nauseum and just deliver useful incremental improvement

Too often in the NHS time is spent discussing an endless stream of ideas – all of which have some merits, but none of which is perfect… and so another round of ideas gets created, discussed and rejected… rather than galvanising effort behind one clear deliverable and focussing the energy on making it happen.

By way of example, just recently I have seen three acute trusts take a business case to their respective boards, get approval, and then at the first hint of disagreement between the trusts on this shared initiative, they have suspended the project to re-examine the case. If it was a good enough idea two months ago for three trust boards, why is it that as soon as the difficult bit comes along (ie making change) the management crumble and take the easy option of another review?

Break down siloed budgets and the focus on reduicng acquisition costs, which prevent long-term planning and design

The seemingly perpetual focus on reducing costs in the short term prevents any service redesign or roll-out of new technologies if they come with a price tag, even though in the longer term they may clearly be able to reduce costs. The NHS should be freed to balance the books over the longer period, albeit with clear clinical and financial performance milestones along the way.

One of the factors compounding this short-termism is siloed budgeting. One department won’t invest in any change or technology that increases their spending if the benefits are realised by another department, even though there may be a significant overall benefit to the Trust, and the patients, as whole. I’ve run up against this problem a number times - anaesthesia not using new tech as surgery is credited with the performance benefits; spend on prophylaxis being cut to reduce meds budgets, at the cost of increased admissions and readmissions.

Many Trusts have leadership teams who are skilful and knowledgeable enough to look across departments and combine clinical insight with financial strategy, but many others don’t.

Disband market structure

Completely disband the market structure and business management philosophy of the English NHS. Instead, have a singler joined up system without the myriad of structures and staffing invovled in construction and running an artificial market. Massive savings would accrue. Let clinical staff deliver heathcare, oversight and standards being set by professional bodies rather than by agencies set up by government, which have hardly covered themselves in glory.