Author: Rebecca Rosen
Date: 14/04/2010
Organisation: BMJ
Extract:
We face a tough financial climate. We don’t know exactly how much we’ll need to save across the NHS, although the amount will be substantial. But it is not inevitable that cost cutting will reduce quality for two reasons.
Firstly, much activity has no value in the NHS so it can be cut without detriment to clinical outcomes or patient experience. NHS "better care better value" metrics highlight opportunities for this. Up to £0.5m (€0.56; $0.76) of savings are still available in most hospitals by reducing preoperative bed days. Potential to save millions of pounds exists, and more than 10% of bed days could be saved by reducing length of stay by 25% towards the mean value for matched patients.
Crump estimates that up to £3bn can be saved by tackling this kind of variation in the delivery of care. So, doing what we currently do, but doing it better, will make a good start towards the savings needed in the NHS, but it won’t be enough. The cuts we need will require a transformation of the way we work. We must look to the best health systems in the world for ideas.
Former chief executive of the Mayo Clinic, Denis Cortese, was surprised when he discovered, on the basis of an evaluation of performance, that Mayo delivers excellent clinical care at lower cost than many other health systems. (Cortese D, personal communication, 2010.)
He attributes Mayo’s success to its focus on the best interests of patients through integration and coordination of care. Integration ensures they connect the whole organisation so everybody knows everything about each patient and receives evidence based prompts about best practice. Coordination of services around patients and their carers—particularly when they leave hospital—is achieved through team work and by allocating a coordinating doctor and nurse. This improves communication, makes it easier for patients, and reduces duplication and waste.
The techniques that underpin integration and coordination are not rocket science. Mayo has used system engineers to design efficient processes of care since 1901. The NHS Institute’s "Productive" programmes aim to introduce similar techniques in the NHS. Mayo also excels at data integration, linking all clinicians through a single electronic record. We’re not there yet, but some primary care trusts have developed data systems linking GPs, community services, and hospitals, so we know data integration is possible in the NHS (Burke C, personal communication, 2009.)
Mayo also makes selective use of financial microincentives to change and improve clinical practice for selected conditions—as we do with the GP quality and outcomes framework. Finally, it minimises incentives to over treat. Cortese concluded that using this combination of methods, Mayo Clinic utilisation rates are 30-35% lower than other systems, and they are not an exception. The Commonwealth Fund Commission on high performance health systems describes other high performing health organisations using similar techniques, many of which are used in the NHS.
These institutions evolve over years and we have little time before the financial axe falls, so we need to move fast to get some ingredients in place. Firstly, we need medical leadership, which is a key feature of all these organisations. Their boards typically include 30-50% doctors, who are highly trained and fully engaged in the pursuit of high performance. Secondly, to improve quality and continuity of care and reduce duplication and waste we need rapid development of data linkage systems. Thirdly, we need novel governance and accountability arrangements that can blend professional and patient expectations to set reasonable goals for the turbulent near term future. This will require effort and innovation, but high performance health systems show us the rewards available if we get it right.
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