Delivering better value in the NHS

2014/15 looks like being a watershed year in which the NHS moves decisively into deficit. Although the political parties have begun to debate the level of funding that will be needed, it is not clear by how much the NHS budget will increase. The impact of continuing financial constraints on patient care is also uncertain.

What is obvious is that the NHS is currently run on the basis that money follows targets. The government’s very public commitments on access have resulted in money being channelled to these areas – for example, the additional funding provided in 2014/15 to help hard-pressed providers deal with lengthening waiting times for elective care and treatment in A&E.

Services lacking high-profile targets – like mental health and primary care – have not benefited in the same way, and there is growing evidence that patient care is suffering.

It follows that new areas of political priority, such as safe staffing levels and seven-day working, may also attract additional funding to enable aspirations to be turned into practice. The difficulty this presents is that with around two-thirds of hospitals’ budgets going on staff, the costs of these commitments is likely to be considerable. If the next government does not provide sufficient additional funding, it may not be possible to deliver on them.

Future funding levels will also determine whether NHS providers will be able to maintain current staffing levels, which in many cases have grown as a result of the Francis effect. Providers will be understandably reluctant to put safety at risk but, faced with the challenge of balancing budgets when workloads and deficits are both growing, they may not feel they have a choice. Much will depend on how regulators weigh these risks in their dealings with providers.

Much will also depend on the ability of NHS providers to extract further improvements in productivity to bridge the £30 billion funding gap identified by NHS England. The Fund’s analysis shows that the Nicholson challenge has been delivered mainly though controls over pay and prices and cuts in management costs.

Looking ahead, the main opportunities lie in reducing variations in clinical practice by tackling inappropriate use of services and inefficiencies in the delivery of care. There are also opportunities to reduce harm to patients and the waste involved in not providing care right the first time.

It will be much harder to realise these opportunities than it was to deliver the Nicholson challenge because it requires staff throughout the NHS to be engaged in improving productivity rather than relying on national leaders to exercise crude controls over pay and prices. And as our work on high-performing organisations has shown, engaging staff in quality improvement takes time, and often exceptional leadership, to deliver results.

Given the state of the public finances, it is unlikely that the next government will find all the resources needed to fill the funding gap. We are therefore starting a new project to illustrate the scale of the opportunities available to the NHS and to highlight examples of improvements in care that have delivered better value.

The project, reporting in early 2015, will illustrate how extra investment needs to be linked to continuing innovation in how clinical services are delivered if the NHS is to deliver financial balance and maintain acceptable standards of patient care. We would welcome contributions and suggestions on ways of delivering better value in the NHS as well as ideas on how the current barriers to innovation might be removed.

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#85618 Sue

The simple fact is there are too many chiefs and not enough indians. Too many people sitting in offices, when there should be more out on the clinical floor. Not a single Government though is willing to take this on and start at the top. Until that happens the NHS will continue to decline.

#85876 James Bunt
Gordian Management Ltd

In this environment stopping waste and rapid sharing of best practice through specifying it in commissioning is needed. Providers will then respond. The Kings Fund exercise will contribute to that. One client, Gables Medical Group, I have in the NE has some excellent primary care solutions tested and developed in offender health that may work in community. How can we share these? Please email me and let me know.

#90505 Tony
public health

I totally agree with Sue! There are too many highly paid people telling others ( the lower paid) what they should do. The NHS has always reorganised on the basis of structure. What should happen is that the function should be clearly be defined - eg how to provided personalised care 24/7 for vulnerable people. If this was undertaken I am sure you would find the unmet need for many more lower paid professional staff.

#98166 Terry
Member of the public

How reassuring to read that at least a few people have grasped the nub of the problem in their answers (too many chiefs etc) and may I add, too many of them not up to the mark and allowed to be so..
You could ask why haven't this still not been grasped by those that manage and decide on policy? There are some real gems but could it be that overall, despite promises and cut backs, 'pips are still not really squeaking' in this area and until they do, there will be no real management change as most continue to feel safe in the knowledge that the service remains the Governments electioneering friend and new money still keeps coming in. Why therefore put your name on the line when you can get away with the 'heads down approach'?

#98182 Allison
Health and Social Care

I would disagree with the comments made about senior staff in the NHS, particularly in NHS Foundation Trusts. Many senior posts have been stripped back to allow for services to be commisioned at local level needs. There is a great deal of change going on in the NHS at present and any good change management theorist will tell you that leadership is key to affecting a change. In modern NHS frameworks the senior management teams are much more hands on and many 'model' the way for other staff members ensuring that they are sufficiently supported to deal with the changes and challenges that many NHS workers face on a day to day basis. Large organisations need people with strong leadership skills to effectively plan and negotiate innovative and dynamic new services to meet local peoples needs - many clinical staff have not been trained in this area and some do not see this as their role. A change in trainng for nurses, OT's and social workers is required if this is the route we wish to take. Many Foundation Trusts recognise that their staff are their biggest asset and as such provide training and support to help staff deal with the many transitions that they face. The future of the NHS is a worry for everyone and funding has to be carfully considered in line with local needs.

#98214 Anon
NHS Manager
N West Health Care

The predictable kicking of NHS managers from some is depressing reading. In the past 5 years I have seen the management layer continually stripped back in commissioning and provider organisations. The toll this has on individuals health and family life is significant. Increasingly management posts are down graded also through restructuring with additional responsibilities added. More from less equals increased productivity i guess but numerous colleagues have been made ill through the stress of implimentation of numerous political policies. See CSUs as an example, created by Nicholson and constant changes in direction from the centre.
Heroic leadership not required but a massive resiliance is a key competency for all NHS managers. See Nuffield reports on impact on staff.

#98754 Vince Molloy
Former PCT Lay Rep

I use and depend the NHS extensively. I am also ex RAF and long time retired. I have managed in the RAF, Industry and Local Government and these observations are based on that experience.

The proliferation of paper work that I have seen in the NHS and all Care Systems in response to fears of Litigation damages Patient Care and must cost multi millions in Professional Medical Time. My formal complaints on the subject have had the response that 5 year plans to computerise everything will solve the problem.

The NHS record on computers is poor. Many sharp end staff lack computer skills and that currently slows jobs down in many areas.

The RAF deployed their first sharp end Computer in 1964, designed by experts and not fit for purpose. We replaced it in 1971 AFTER a Working Party that included ALL ranks and duties specified exactly what the job needed in detail and ensured that the programmes delivered were fit for purpose. That approach WORKS.

The cost of what happening now is massive in financial and Patient Care terms. How much litigation money has been saved?

The whole needs costing and review. NHS I love you but please learn from the experience of others on many fronts.

#217103 HSB
Nurse/Project Lead/Manager

I agree that we still have to many (very) senior managers and not enough senior, experienced clinicans. My organisation are restructuring yet again. Each restructure brings more directors or deputy directors - as is this one, yet we lost all our matrons and clinical nurse specialists two years ago leaving a huge gap where the clinical leadership should be.

Senior clinicans have no where to go except senior management or some kind of project/transformation role - which takes them away from clinical care.

As a result, our services are being run on the front line by the most junior staff while whole gangs of directors run around wondering about why we can't improve quality and safety.

I think it's probably quite obvious!

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