"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Saturday, 19 February 2011

Efficiency and quality care

I posted this as a comment over at Liberal Conspiracy, but I thought I may as well put it here too.

Incidentally, does anyone know where the "£20 billion efficiency savings" comes from? I mean, it couldn’t just be made up, could it?

No. It comes from a report compiled by McKinsey. In this they list areas of the NHS where they think that money can be saved. (Selling off land appears to bring in a lot of money in their report – I wonder if they have any property developer clients? – but it is hardly an "efficiency saving" since it can only occur once.) McKinsey says that the NHS can save £15-£20bn over four years with their "efficiency" recommendations. The current government have decided that the NHS has to save £20bn, therefore, in the following, I have to use the maximum estimates from McKinsey.

McKinsey says that £9.2bn can be saved by efficiencies in providers (hospitals, community health services and GPs, p8). This can be achieved by £3bn from increasing productivity of acute providers and £1.9bn from productivity gains of non-acute providers (p10/13). Rather helpfully they say that acute providers have to spend 14% less than in 2008/09 and non-acute providers (GPs, community services) have to spend 12% less. These are big cuts efficiencies.

Since everyone is hysterical about nursing at the moment, let's have a look at what McKinsey says about that area of care. They recommend that acute providers can save £1.1bn on nursing out of a budget of £8.1bn, 14% (p14). Their rationale is that there is variation of productivity across the country and so if those providers at below the median increase their productivity by 80% of their variation from the median, then that will lead to the £1.1bn saving. Unfortunately, McKinsey does not say where the variation comes from. Could it be because there is a variation in the age of hospitals, so that clinicians are trying to provide 21st century care in 19th century buildings?

Increasing productivity means that the same number of nurses do more work for the same pay; or the same amount of work using fewer nurses. The RCN estimates that NHS providers intend to cut 17,932 nurses, so clearly providers are opting for the second case: fewer nurses. Whichever way you look at it (more work per nurse, or fewer nurses) the McKinsey recommendations will lead to the patient seeing less care from nurses.

Roy Lilley at nhsmanagers.net points out that from the McKinsey breakdown of the work that nurses do the 14% cut that is needed is equivalent to the time spent by nurses in "Psychosocial care of patients". This is exactly the sort of care that the Ombudsman was so critical about: she was complaining that there was not enough of this type of care. Yet the providers with the lower levels of productivity could dispense with this vital area of care so as to raise their productivity to the median.

What about community care? Well here McKinsey says that if district nurses saw more patients then there could be a saving by cutting staff by 15%. The report does not skirt around the issue, they specifically say that there should be 15% fewer frontline staff.

McKinsey give the following graph:

This, we are told, shows the variation of the productivity of district nurses. McKinsey does not say whether the survey compared like-with-like. So the nurses who see 11 or 12 patients each day, are they providing exactly the same treatments and travel the same distance to each patient as the nurses who see 1 or 2 patients a day? Could the variable be due to some nurses working in urban areas (less time travelling between patients) and some nurses working in rural areas (with much longer travel times)? Could it be that some nurses are performing complex, time consuming treatments and others provide more simple treatments? We do not know because McKinsey does not reference their research. If there are 15% fewer nurses, with each seeing more patients each day, then inevitably each nurse will have less time with each patient. I wonder what the Ombudsman will say about that?

The "£20bn efficiency savings" is not optional. It has to be done because the budget will be cut by £20bn - oh, sorry, to satisfy the pedants: there will be more work, equivalent to £20bn worth, but the NHS will not get the money to pay for it, they will have to find the money by having fewer nurses visiting more patients every day, and hospital nurses not having the time to talk to patients on the ward.

The McKinsey report is recommending that the NHS delivers worst care.

And now McKinsey are providing commissioning support for "dozens of consortia" according to Pulse.

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