Allocative efficiency in the downturn: Is it possible to 'disinvest' in existing health services and programmes?

The last in the NHS Confederation’s strong 2009 policy salon series addressed whether health economic techniques of allocative efficiency, public engagement and the voluntary sector can give the NHS clues about how and where to make some disinvestment decisions. Coming before NICE’s recent publication on how to support world-class commissioning, the ideas explored could offer a QDOS (quick and dirty operating system) approach to world-class decommissioning.

The health economist
The first speaker, a professor of health economics, framed the discussion within the obvious financial context of approaching austerity. He noted that annual efficiencies were already mandatory following the Gershon Review, and added that the Toyota ‘lean’ methodology had already gained significant policy currency in parts of the NHS.

What does this mean for budgets, services and patients on the ground? The obvious general framework must be of rational disinvestment, looking for lean savings and service realignment but at no expense to personal and public health: a tall order.

The NHS must also look to eliminate unwarranted variations (noting that least use of services should not necessarily be deemed ‘best’).

Beyond those, the discussion has to be about cutting or stopping services on a ‘least harm’ basis: the conceptual, opposite of how the service has thought about spending new money where it will do most good.

That is, the speaker added, the logical and uncontended economic way of thinking about this. How to make it work on the ground in practice?

One issue is about education. Many NHS managers are still not trained in health economics and research outcomes, making it hard to agree how to measure health, how to know outcomes and when data are biased

It is also about leadership. All the system’s incentives remain still in favour of sucking more and more people into acute trusts. This is a ‘hearts and minds’ cultural issues.

Questions of rational disinvestment are ultimately ethical matters of doing least harm. The health economic approach provides a framework to be able to defend managers’ actions, which will be likely to be tested in courts of law.

The first speaker concluded that there will be challenges in the data requirements, but added that world-class commissioning is already pushing to get data fit to meet the needs. At the end of the coming stage, he hoped there will be a whole generation of NHS managers and clinicians re-educated on how to manage scarcity; skills which will go beyond austerity.

The opinion pollster
The second speaker, from an opinion surveying company, discussed how the public is engaged in rationing debates - or not. The DH is looking for 20% savings in health budgets. How can we engage the public in debate on that sort of saving?

His staring point was to recall his participation on health panels at the recent political party conferences, debating ‘can we sustain a free-at-point-of-use NHS funded from tax?’. He dubbed it “fascinating” that every other member of the panel gave a certain “yes we can sustain it free from tax” reply. In engaging the public to discuss disinvestment, he suggested, such certainty is a problem.

He noted the huge public commitment to and engagement in the NHS, which “it’s easy to see as a psychological contract with the NHS. Around 60% think it’s the best health service in the world, around 80% say it will be there for me when I need it, and around 73% think we should do anything to sustain it. Around half of us think there should be no limit on what the NHS does and pays for: about 75% think the NHS should fund new drugs no matter what their cost”

Huge expectations; how realistic are they? There is huge potential pubic disappointment if we do not manage expectations, that attachment sense to the NHS could be going, and the pessimism about the NHS of 10 years ago could return, undermined by failing to deliver on the psychological contract.

So we need to get the public on board about disinvestment: what where and why. Why should public engage in that debate, if there’s no need for any such conversation?

This is part of a bigger political lack of debate and leadership. Just a few months ago, the Prime Minister had been denying any need for any public spending cuts. Both main Westminster parties have been saying ‘whatever happens, the NHS will be protected’, so there’s been no engagement in starting a debate.

Which has left the public unready for this conversation: 82% think the NHS should be protected form any cuts. 75% think all necessary savings can be done through efficiency and management bureaucracy (reportedly, people always look for all savings to be in bureaucracy when asked such questions about any area of public spending).

The speaker’s polling firm had tracked the proportion of people saying we should cut services to pay off the national debt went down from 40% to 24% over the summer. Their work for the NHS Confederation recently on PCTs’ messages found (in a more qualitative piece of work) that people believed that the role of prioritisation was not an appropriate NHS function; the NHS should look after us and give us whatever we need.

So there is a problem with public opinion. However, the speaker cited clear evidence that the pubic can be brought in constructively, as shown in work with the Social Market Foundation on how to fund NHS budget shortfall - 59% of respondents said using prioritisation. They recognised choices had to be made, but were split between whether they should be made by government / political figures or NHS managers / clinicians

Opinion survey questions to the public reflect different views depending on the phrasing: whether asked as a general question or framed as a prioritisation issue. Unhealthy lifestyles send notional patients to back of the queue of public opinion once prioritisation is the framing issue. In general questions, the public are split between treating everybody equally according to clinical need and prioritising treatment away from people with unhealthy lifestyles; however, if asked about prioritisation for savings, more people favour putting the unhealthy to the back of the queue. An intriguing ethical dilemma.

He concluded that the NHS needs to engage the public, which can engage when invited. The fault has been a lack of political leadership on the issue.

The charity CE
The third speaker cited examples from cancer of what he termed “basic truths of work from patient organisations and networks: patients and patient organisations are not resistant to change and change can be about spending less, not more.

“The assumption that engaging with patients puts bill up is wrong, but they do want different sorts of spending once you ask them. Presently, different parts of the NHS system compete with each other to defend their patch, and patient benefit tends to come last”.

He added that the creation of foundation trusts also incentivises spending, as FTs protect their business and not customer gain.

The third speaker also suggested the debate may work worse if we talk of patients as customers, who have a sense of expectation and demand – “that language may not help us”.

He cited examples on how to engage users to cut costs, such as the breast cancer service pledge, which up to 30 NHS acute trusts are doing, and Scotland is leading, getting every breast clinic in NHS Lothian. This has been a bottom-up service reconfiguration, in which patients and front-line staff sit down together and discuss how to improve services. He said that most examples of changes developed this way are very low-cost or actually save money. Hev suggested that initial resistance by management stems from fear of higher costs and snobbery about people who run and use services.

Some of the changes are very simple: one service had no photos to show patients what a breast reconstruction looks like. Establishing a photo album dramatically improved patient service. In another outpatient clinic, patients were always running late as patients arriveand people tended not to have the right change – the clinic lost 20% of time through issued appointments, so the top of the appointment letters now says ‘you need £2 coins, bring them with you’. The clinic now run on time.

He suggested that the principles to underpin change should be:
- invest to save and get the saving timeline right
- awareness initiatives and education - stop Cindarella-ing public health, which could save 10,00 lives a year across all cancers.
- target investment investing in drugs and research on populations who can benefit as genetic and pther testing improves
- work with partners – the British Heart Foundation has found that the public respond better to information from effective voluntary sector organisations than to the NHS brand; use that brand value
- get rid of pointless appointments which often gve only false reassurance at enormous costs.
- avoid unplanned admissions – could save a million bed days a year in cancer by avoiding unplanned admissions, by having oncology expertise in A&E that could send patients home if that is safe – which would need more specialist clinicians in primary care who can manage chemotherapy

The NHS must stick to its guns, engage with patient organisations and redesign to make services work, he concluded: “we need world-class decommissioning to get things working more smoothly”.