Comment / Walking the walk

The focus needs to be on service redesign, not merely cutting input costs, if demanding productivity targets are to be met.

I was discussing the content of colleagues’ cost improvement programme plans for the coming year recently. I was alarmed at the proportion of schemes that are still focused on reducing input costs. We have all talked the talk about the need to redesign services and develop new pathways, but it seems to me that we now have to start walking the walk.

Of course we will always need to keep pressure on input costs – optimising rostering to reduce reliance on agency nursing, ensuring efficiency in back office services, maximising generic prescribing, getting better value from procurement – but we surely need a broader outlook if we are to deliver the productivity improvement that is needed across all four UK health services.

The £20bn Nicholson challenge may have provided a handy quantification of the size of the challenge in England – but all the UK nations face the same pressures. In fact, there are those that argue that the Celtic nations face even greater challenges given levels of deprivation/need (see page 4) and the workings of the Barnett formula.

We must take every opportunity we can  to learn from each other. Northern Ireland’s experience of combined health and social care, for example, and the different approaches to health economy integration in Scotland and Wales.

But if we truly aspire to maintaining or even improving quality over the coming years while delivering the financial agenda, we have increasingly got to shift the emphasis into redesigning services.

New services to support patients out of hospital or to enable rehabilitation in the community will pay back in better services for patients and reduced length of stay.

The financial agenda means that – and perhaps this is where we have failed before – we need to turn this reduced length of stay into reduced acute capacity and that might mean reduced input costs, relating to capital charges and staff, falling out as a consequence. But this surely has to be the right approach rather than starting with the focus on input costs.

The starting point has to be to initiate a debate about how we can radically deliver different services. It is a debate that needs to involve all the local stakeholders in service delivery – including GPs and commissioners, social services and other providers.

The debate has to be quality driven – improving patient safety, outcomes and experience has to be the priority, but doing it in the most cost-effective way possible. We know the quality and productivity agendas are intertwined. There is clear evidence that getting the service right first time not only improves services for patients, but also improves value for money.

Some of the changes will require even broader solutions. Some services in future may be better delivered from a smaller number of centres of excellence. These kinds of changes are not easy – the response to last month’s proposals on children’s cardiac surgery centres demonstrates this.

But if this sort of specialisation is clinically driven, we have a duty to investigate and ensure the financial implications of different approaches are also factored in. We need to take the public with us and politicians need to provide us with the backing for exploring these options, but we shouldn’t shy away from the issues just because they appear too difficult.