My colleague John Appleby's blog last week highlighted that the three main parties are all planning to fund the NHS at more or less current levels with little, if any, of the growth enjoyed over the last decade. But with rising demand from an aging population and new medical technologies driving up costs for the NHS what plans do they have for savings to constrain expenditure at current levels?
Labour say they 'will be tougher in ensuring value for money' and will 'deliver up to £20 billon of efficiencies', but other than a promise to scale down the Connecting for health IT programme and 'cutting red tape' they are silent on how this is to be achieved.
The Tories target 'expensive layers of bureaucracy' and plan to cut the cost of NHS administration by a third, but give no details of savings beyond this.
Helping the 'NHS work better with the money it has' by using the savings it has found to protect frontline services is a key focus for the Lib Dems. They are more specific than the other parties about where these savings will come from, including: cutting the size of the Department of Health by half; abolishing or slashing the budgets of health quangos; scraping strategic health authorities and limiting the pay of top NHS managers. They also refer to extending best practice on improving hospital discharge, maximising the number of day-case operations and reducing delays prior to operations.
What none of the three parties say is that a prime opportunity to improve NHS efficiency will come not from cutting the waste of managerial overheads but in reducing the waste from the variation in frontline clinical and operational practice.
Jack Wennberg at Dartmouth medical college said US patterns of healthcare practice were 'often idiosyncratic and unscientific, with local medical opinion and local supply of resources more important in determining how medical care is delivered'. The NHS Institute's Better care, better value indicators reveal very large, unjustified differences in practice across this country, including: length of hospital stay; referral rates; admission rates; prescribing practice and others, suggesting the same is true on this side of the Atlantic. The indicators also show that waste resulting from these areas alone amounts to billions of pounds each year.
The key to unlocking NHS efficiencies and therefore living with constrained resources is influencing the practice of frontline clinicians as they take decisions on a daily basis about patient care. It is at the frontline where the majority of NHS resources are committed and so the NHS leaders and managers' ability to engage frontline clinical staff in reducing variability in practice and improving care quality and efficiency is critical. Ironic then, considering this role, that all the parties see reducing NHS management as a priority.