Hello. I've had a day off - it was great.

Firstly, may I draw your attention to some good things. You will find another instalment of Maynard Doctrine for your edification and entertainment. The good professor discusses the theory about why bigger hospitals should have higher costs.

You should also look at the National Patient Safety Agency's 10 for 2010 campaign. Their list of attention areas is a sound one:
deterioration, falls, insulin dosage, anticoagulation, pressure ulcers, 'five steps to safer surgery', reducing avoidable harm in childbirth, suicide prevention, 'matching Mitchigan' on central venous catheter bloodstream infection reduction, and healthcare for people with learning difficulties.

It's a good and sensible safety programme. How do you think your local hospital would score on these?

The not-so-good
Oh dear. I'd like to be able to say something positive about Dr Mark Porter's speech to the 2010 BMA consultants' conference, but it isn't easy.

Porter joins the BMA in welcoming another year's delay to the implementation of revalidation for doctors. He also notes disapprovingly that "NHS commissioners are drawing up lists of health interventions that must be decommissioned. Cut. Stopped. Not done any more.

"This is wrong."

Which seems confused, to put it mildly. Healthcare interventions will always have some benefit to somebody, even if it is only to the bank balance of the provider of the intervention. Thomas mentions but does not engage with the fact that the NHS is going to have less money.

Nor does it embrace the reality that if medics want to lead the NHS, which is often stated but far from proven, they will have to get their hands dirty with rationing decisions. That is commissioning - and decommissioning.

Porter's pay-off line paraphrases David Steel to the Liberal SDP Alliance in the 1980s - "go back to your hospitals and prepare to protect patient services". He is likely to have similar effect on the NHS political landscape as Steel did on Westminster's.

And the interesting - McKinsey, at last
Health Secretary Andrew Lansley CBE MP has bowed to the inevitable and published the infamous McKinsey Report into the fiscal future of the NHS.

You will remember that HSJ had a leak of this some time back.

Once again,the report, Achieving World Class Productivity In The NHS 2009/10 – 2013/14: Detailing The Size Of The Opportunity - is just slides.

Its summary findings are worth reproducing here:
▪ The next spending review may well result in significantly lower rates of growth in NHS spending than has been the case for the last 8 years, resulting in a possible funding gap of £10-15bn in 2013/14 or ~ 10% of spend.
▪ The NHS in England could potentially capture efficiencies in health and healthcare services by between 15 and 22% of current spend, or £13–20bn, over the next 3-5 years.
▪ This reduction could come from
– technical efficiency savings of £6.0 - 9.2bn found from provider costs
– allocative efficiency savings of £4.7 - 6.6bn due to no longer commissioning low value added healthcare interventions and ensuring compliance with commissioners’ standards
– savings of £2.7 - 4.1bn from a shift in the management of care away from hospitals towards more cost effective out-of-hospital alternatives.
▪ Further savings could come from a greater focus on prevention resulting in lower demand for healthcare services but this would likely not be realised within the next 3-5 years.
▪ Achieving a step change in spend on health and healthcare services will require a compelling case for change; the use of formal mechanisms to drive through efficiency gains; deployment of WCC structures and processes; removal of national barriers to change; introduction of incentives schemes; and an increase in skills and capabilities to drive out costs.
▪ We recommend a nationally-enabled programme delivered through the SHAs and PCTs to drive through efficiency savings. The DH should take direct actions to capture some opportunities e.g. lowering tariffs. And should enable delivery by creating a compelling story, removing barriers, developing frameworks/tools and embedding the drive for efficiency gains within existing mechanisms e.g. WCC.

Mmm. Interesting. The tiny text at the side of each page reveals that this was a "working draft".

There are some useful slides on the Monday-Friday NHS (20 - I'm using the numbering on the McKinsey document; the download PDF has 2 introduction slides), under-use of day surgery (21) and regional and sectoral variations in sickness absence (22).

It also assumes that annual recurring productivity gains in the acute sector of £1.9-3 billion and the non-acute sector of £1.3-1.9 billion could be possible by 2013-14. Its ward observation-based time and motion study suggests that nurses in the acute sector spend only 41% of their time on direct patient care (17).

The report also suggests that based on interviews with PCT and practices and McKinsey analysis (30), a low-performing GP can spend less than 30% of their contracted hours actually seeing patients.

Supply chain is thought to still contain savings worth between £1.3 and £1.9 billion (36).

Slides 46 and 47 point out what we have been saying for some time: that PFI renegotiations could reduce financing cost by £0.1–0.2 billion (HM Treasury and Bank of England data). It also reveals the stunning figure that the unitary charge is running at 14% over the PFI book value. In anybody's terms other than the PFI banking and building consortia, that is bad value for money.

50 and 51 suggest potential savings of £0.8–1.5 billion through enforcing compliance with commissioners’ standards, and of 0.3-0.7 billion from decommissioning procedures with limited clinical benefit.

It all adds up to quite a sum. The variation slides (53-60) will have Alan Maynard laughing into his pint. £1.9 – 2.5 billion savings could be achieved through enhanced chronic disease management programmes.

Where the 'how to do it' section disappoints gravely is in its simple incomprehension of the cultural and organisational challenges facing people who want to change things in the NHS. It is much, much harder to change culture than the report seems to suggest.

Moreover, far too many of the references contain the line 'McKinsey analysis' for comfort.