Jeremy Hunt: Delivering high value health care

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In his ministerial keynote address at our conference, Delivering high value health care, Rt Hon Jeremy Hunt MP gives his response to OECD’s report Tackling Wasteful Spending on Health and discusses work being done to deliver better value in the NHS.

This presentation was recorded at our conference on Delivering high value health care on 10 January 2017.

Transcript

Thank you very much indeed, Chris, and I’m absolutely delighted to participate in this morning’s event because although the things that we’ve been discussing this morning aren’t the same things as you read about in the NHS on the front pages of the papers most days, unfortunately, but you do read stories. This is actually completely central to what I want and what I’m sure everyone here wants, which is for the NHS to offer the safest highest quality care available anywhere in the world.  That is my essential purpose.  And when you start to look at the challenges that we face, the fact that in five years time we’ll have a million more over 65s and that trend is going to continue, the change in consumer expectations and the desire to access things 24/7 in a way that wasn’t the case ten, twenty, thirty years ago.  Your Amazon Prime delivery arriving on a Sunday, all those kind of changes in behaviour, that creates extraordinary pressure and I think this OECD report highlights that, but it also makes the point that if we’re going to respond to that pressure we have to think much harder about our use of resources and I want to congratulate Mark and his team on a very, very thoughtful report.

I only saw it last week for the first time, but I think he has gone much, much further than many people would have expected in thoughtfully trying to understand this question of waste and understanding that, yes it’s the obvious things, paying too much money for the things that you procure, using branded medicines when generic medicines could be used instead. Although they’re obvious things, they’re things we have taken a woefully long time to address in this country, as in many other, but he also looks at the other areas, such as inappropriate treatment and indeed something that’s very close to my heart which is unsafe treatment.  And I think there is a very, very striking statistic in this report which I hadn’t come across before, but I think if there’s one thing that I’m going to remember from this whole report, it is this statistic that we give preventable, avoidable harm to 10% of all patients in major healthcare systems, and more than 10% of our costs are in putting that harm right.

And so, it is, I think, the insight here, and it’s something that Mike Durkin has been championing here in Britain, is so important that it isn’t a choice between better value lower cost and safer care, actually if you want safer care, the first thing you have to look as is avoiding unnecessary costs. If you want to reduce your cost the first thing you need to look at is doing what you can to improve safety and in the NHS one of the things that I’ve found most encouraging is the huge amount of support for the patients safety agenda and I know there are colleagues from around the world here, so allow me to make a parochial  comment for a moment, but I actually think that because of the founding values of the NHS, and because of the fact that we don’t, as the first thing we do when we send someone home, send them an invoice for their care, we actually have the opportunity to become the safest healthcare system in the world because of some of the things that we’re able to do in a national system and why is that? It’s because of you know, the central insight from Mark’s report, which is that if you’re going to tackle this, the first step is the sharing of data, and that is something that we actually are better at doing here and anywhere in the world.  What we’ve also learnt is that you then need to act on that data, it’s not just about sharing the data, but actually that first step, the sharing of data really matters.

So, I want to have a sort of a more open discussion but let me just tell you about some of the things we’re doing. I think many people here will know about the Carter programme which has a really inspirational leadership by Patrick Carter and has looked at this whole issue of where we’re spending money that we don’t need to spend, and his work has uncovered, I think, some really extraordinary things which have woken us up to the opportunity.  On the procurement side we’ve discovered that if you take a pair of surgical gloves, just standard surgical gloves, for exactly the same pair of surgical gloves, one NHS hospital in England will be paying £1.27 and another will be paying 50 pence.  If you take a box of 100 syringes, the same box by the same manufacturer, one hospital will be paying £12 and another hospital will be paying £4.

And then it’s not just about procurement, if you look at sickness rates; in our best hospitals 3.1% but the range goes up to 5%. Now you might say that 3.1 to 5 isn’t a big range, but what that’s actually saying is that sickness rates are nearly double in some hospitals what they are in other hospitals. If you look at the proportion of total space used for clinical purposes, in some parts of some hospitals it goes down to 12%, in other hospitals its 69%, so we have, just in terms of cost per square metre, we see that it varies from £100 a square metre to £1000 per square metre.  Now you obviously have much higher land values in the southeast of England but not by that factor and that’s why utilisation of resources is so significant.

So, we’ve looked at it from a procurement point of view, we’re looking at it now from a rostering point of view. We had a very, as everyone here knows, a very difficult and unfortunate junior doctors strike last year.  One of the things that that bought home to me, was that we are not as good as we should be at rostering staff, flexibly and efficiently and in a way that actually motivates people are often being asked to work very unsociable and challenging hours and at the moment very few of ours hospitals have the sort of e-rostering system that would be completely standard in the airline industry, that would allow for example, British Airways cabin crew, perhaps not the best of examples to use right now, but British Airways cabin crew to go onto their iPhone and request the weekends that they’d like to have off because they want to go to a wedding or perhaps work a bit more in the term time, a bit less in the school holidays, all those things have a very big impact on staff, not just in terms of quality of life, and there for people who have very challenging jobs, but also because they prevent staff that they want to become agency staff or locums which of course do offer the ultimate flexibility.  So I think we’ve made a big mistake in terms of not understanding the importance of flexible working and how important that is to staff and how that can control costs as well.

And then as you move further on, you’re then look at what can be done in the clinical area and there we’ve had some really ground breaking work by Professor Tim Briggs and Professor Tim Evans who I’ve seen here today, which is the Getting it Right First Time programme, and this has identified that for example in the NHS the cost of replacing hips varies between £800 and £1600, in the same country with the broadly the same input costs with standardised national pay rates for clinical staff and yet somehow some places are doing it at half the price of other places and so we are collecting that information and spreading that around.

So I’d just like to show you some examples of some of the information that we are collecting. So this is the purchase price index benchmarking tool which is part of the Carter programme, being run by NHS Improvement.  We now do this for the hundred most used products in the NHS and this is an example one product and if you look at the graph on the left, you can see the price paid and the quantity purchased and interestingly you can see that the lowest prices are not actually being paid by the people who purchase the highest quantities.  This information is now being shared by over a hundred hospitals for their hundred most purchased products and they can see it on a monthly basis and we’re already seeing examples of Trusts saving 40, 50, 60, hundred I think last month I think we had a Trust that saved £140,000 from using this tool, but on this particular product you can see the price paid varies between £2010 and £2820, which is a variation of 29%.

Now the NHS is actually collectively, the single biggest purchaser of healthcare products in the world so we should be getting the cheapest prices and this just shows how much we think we can save. We think there’s a saving there of around a billion pounds a year that we could be saving from better sharing of information and smarter procurement.

Let me show you what we’re doing when it comes to agency spending. I’ve taken out the names of the Trusts here, there’s an interesting debate about whether or not one publishes this data publicly.  Sometimes we do, sometimes we don’t, but for this work on the whole we are not publishing it publicly for the very simple reason that we want to be able to collect the data and we need people’s cooperation to do that, and as you can see, there is big variation in terms of the proportion of people’s agency spend ceiling that they’re hitting, they’re ranking across the country.  You can see in terms of the spend as a proportion of total staff on this graph, it ranges from 69% to 3% to there is huge variation in the use of agency staff and locum doctors, and this programme has bene going for about a year. Agency spend in the last financial year was £3.7 billion across the NHS.  We think that this year we are likely to get it to below £3 billion, it’s probably that small teams work has saved the NHS between 8 and 9 hundred million pounds in just one year and they still think there’s progress to be made.  The average price paid for agency nurses has fallen by 20% since this programme started for locum doctors by 13%, so that’s been extremely successful.

Then I just want to show you a dashboard from the Getting It Right First Time programme, which I was mentioning earlier and this again is showing clinical data, because it was started by Professor Tim Briggs who’s an orthopaedic surgeon that’s the area that he particularly focussed on and what he’s discovered is that if you look at orthopaedic surgery infection rates, they vary between 02% and 5%. So if I can put this another way, our best hospitals, we’re only seeing a postoperative infection in orthopaedic surgeons of 1 in 500 patients, compared to other hospitals where it’s 1 in 20 patients. Now, no-one here needs to be reminded of the human agony that can cause, potentially even death, but just in terms of cost, as we’re talking about cost, the cost of the NHS of putting this right, is around £100,000 a time.  So, this is a programme that we think is already saving in the hundreds of millions of pounds.

But I think there’s something even more exciting about this programme which is that there is nothing that any doctor wants to do more than do the best job for their patients, and by sharing information about things like infection rates, in a non-judgemental way, we’re actually helping people to improve the quality of care that they give to their own patients and I think that is actually something that’s handled correctly is an incredibly motivating thing for doctors and we are now collecting this information for, I think it’s nineteen specialties, Tim? And we’re going to be expanding that to thirty. We think there are ninety specialities in total in the NHS.  Some of them it might not be appropriate to do this for but we certainly think we’ll be able to do it for the majority of specialties, and we’re on track to cover more than 90% of the work done in hospitals in this programme, and that I think is something that is potentially extremely exiting.

I just want to finish by saying that there are lots of other things as well as the collecting of data that you can in terms of improving patient safety and therefore avoiding the costs that come with unsafe care. We’ve obviously had the whole Francis agenda, the duty of candor, the work on safe staffing in hospitals.  We have had the transparency agenda and I’ve shown you some examples but it’s worth saying that we are the only country in the world that publicly grades hospitals on the safety of their care with OFSTED style ratings.  Last year we extended that to areas of health provision that can span hospital and out of hospital so we now have OFSTED style rating for CCGs on areas like mental health, learning disabilities, cancer care and so on.  And I’m absolutely delighted we’ve got Professor Senik Blag here, many congratulations to Nick for his work on avoidable deaths and how you classify avoidable deaths.  Nick has brought to our attention the fact that 3.6% of deaths in the NHS are avoidable and this year we will become the first country in the world which on a quarterly basis publishes hospital by hospital what our estimates are on the basis of Senik’s methodology, the number of avoidable deaths and avoidable harm.

And it think it’s important to say that avoidable deaths is obviously the most tragic outcome that we’re trying the hardest to avoid but one of avoidable death is likely to mean a lot more avoidable harm to other patients where it didn’t lead to death, so this is completely the same agenda and I think we’re making pretty good progress in that respect.

So, I think if you take this together we’ve got a chance to tackle the two big things that any healthcare system is trying to think about which is how you create value and how you improve the quality and safety of care you deliver. I think the NHS does reasonably well actually in Mark’s report which is nice because we don’t always do well in these international reports but I think even in this country, too much of the debate has been about how much we’re putting in and no enough of it has been about how well we’re using the money that we do put in.  And the truth is, that however much any government puts into the NHS, the pressures on healthcare are so enormous that we are going to need to have this discussion about getting value for money for every pound that we put in and that’s why I think this is a very, very important report and a very important debate.

Thank you very much indeed.

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