Friday, 9 October 2015

NHS is running out of money, again

NHS hospital finances are in deep deficit (again). But a lack of money isn't the primary problem. While more money is probably needed, the system will still be in trouble if it doesn't address the deep underlying problems it suffers from.

[Note: this is an extended version of a comment I made in response to Alastair McClellan's HSJ editorial on the current financial state of the NHS.]

Over history, the NHS is used to solving every problem with more money but it has little experience with redesigning the way it works to cope with less money. or to do a better job with the same money. Over its life it has, on average, had a budget that increases significantly faster than the economy as a whole. During the Blair years its budget doubled in real terms in less than a decade.

The NHS needs to do better both in quality and efficiency. But every time budgets are tight, the wrong things get cut and the problems get blamed on the budget cuts not the chronic failures to modernise operational practice. 

The trouble is the sort of investments that might lead to significant operational improvements are neither sexy nor popular.

Much more IT, for example, could lead to the automation of data collection and administration, freeing medics from tedious admin and form filling and thereby leading to better decision making when they treat. Much more usable IT could reduce the burden of fragmented and user-hostile current systems again freeing up useful time for the benefit of patients.

Better management quality especially at the operational level might lead to better performance and a better workplace for nurses and doctors (better matching of capacity and demand is good for patients and better roster design is good for staff). But the naive slogan "more staff to the front line" make better newspaper headlines than better management of the staff on the front line (see my comments here).

Better understanding of costing could lead to improved focus for improvement efforts (if you don't know where the money goes–and many trusts don't according to costing audits–how can you know what needs to improve?) Or how come so many trusts argue they are not being paid enough to operate a service when they have such a poor grasp of how much that service costs?

Sadly none of the key things that are obviously broken in the NHS are things that generate good newspaper headlines for politicians who choose to invest in fixing them. And the internal lobby that calls for more staff and more money to solve the current problems don't have the wit to grasp that more staff in a badly managed system doesn't improve things much.

It is far too tempting, for example, to cut the capital budget for short term gain and far too headline-pleasing to focus on front-line staff numbers than on improving the way staff are organised. 

It is also too tempting to focus on big top-down structural changes rather than the much more effective bottom-up operational changes that actually drive long term improvement (see my comments here).

So the response to a short term crisis makes the long term problems underlying that crisis worse. And the medical lobby that argues that more money fixes everything reinforces the underlying problem by offering a naive analysis of what the problem is.

So, even if the NHS gets a short term injection of money, it will likely be spent on the wrong stuff.

The NHS probably does need a significant injection of cash. But it needs a serious dose of sense about bottom-up productivity and quality improvement even more and we shouldn't let the current debate distract from that.

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