25th January 2016

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Former Secretary of State for Health and now Chair of the Confed
Stephen Dorrell

Escaping from the old ones 
News and Comment from Roy Lilley
Davos, pronounced da'fo:s is a tiny canton in Switzerland with a permanent population of under 12,000.  It is the highest 'town' in Europe, very beautiful, very cold, -9, and under a blanket of snow.
It plays host to the annual World Economic Forum.  I was there a few years ago.  Not this time, so I missed Google boss Eric Schmidt telling us the internet will disappear; he means become so ubiquitous as to be invisible.
I missed Bill Gates, John Green, him from Downing Street and Kofi Annan.
I also missed our favourite air-mile-man Mark Britnell delivered the KPMG paper (must read) on 'which countries get the best and worst value in healthcare'.  We spend less than Finland, Iceland, Slovenia and just about everywhere worth going to for a holiday.  However, life expectancy outcomes on a par with average-to-best.
Mark's conclusions; strong primary care is essential and;
"... use of technology to contain cost is another feature of highly efficient health systems, as it speeds up activity, increases accuracy and allows for the kinds of big data analysis that can actually predict which patients are most likely to need follow-up care..."
Simon Stevens was also in Davos launching some tech-based initiatives that might, at last, drag the NHS into the 21st century!
For the NHS the only game in our town is efficiency and Lord Carter of Bog Rolls is soon to eventually announce his full review findings; revealing how he will save the NHS 5bn.  He has overcome a flaky start and some dodgy data and if not air-miles, he has certainly given his rail-card a bashing.
The Five Year Forward View, Tarzan's route to the future, is timed to sync with the general election, 7th May 2020, which means Carter has about 1,497 days to find 5bn.
Carter's pronouncements are getting more prescriptive.  It might be simpler to let him run the whole shebang from a big desk in Whitehall. 
He needs to understand...we won't find 5bn by worrying if your bog-rolls cost more than my bog rolls (or anything else), benchmarking, ticking boxes and palaver.  By the time you find out, it's too late to change the contract and another 250 days have slipped through your fingers.
The way to do it is to cap non-pay spend and ratchet it down, like Carter is proposing for management costs.  Why is he shy about taking on suppliers but not managers?  Easy target I guess but as only 1 in 100 is spent on NHS management you won't hear much money rattling in the tin.
National procurement takes ages to set up and the hidden 'on-costs' always work against you.  The regional hubs were a good solution.
To save 5bn Carter will have to get tough; offer suppliers 'austerity-partner' status, guaranteed speedy payment terms in return for 5% invoice discounts.  Sell licenses to access NHS electronic catalogues, the only way to trade.  Instant money rattling in the tin. 
Safe staffing; Carter must know it isn't doable.  His solution, calculating care-hours-per patient is complicated, bureaucratic, mired in exceptions, a fudge and won't mean safer wards.  By the time you find who and who isn't meeting this-or-that standard... another 200 days have evaporated. 
And, it wont work; once you have created the 'mean' what does it mean...  other than to create an emphasis on the numbers either side of it. We already know on average one nurse takes care of 7.8 patients. The range from 5 to 11.

Inpatient care is complex and not just 'time filled with tasks'.  This approach risks underestimating the effort required to deliver care and no way records work 'undone' and assumes the hours delivered are sufficient without any thought to the outcome.  A bunch of false assumptions.  

Nurse Directors; for goodness sake dump the idea.

All the evidence is; the higher the skills the safer the wards.  Computerised rostering, predictive demand algorithms, sickness monitoring software and a mouse click will always be cheaper, more accurate and instant than a tick in a box.  

Linda Aiken tells us; it is qualified nurses on the wards that makes the big difference. (Must watch
The ratio of nurses to HCAs is 56% so a trick, for a quick fix, we might learn from industry; reskilling.  Audit all the things Care Assistants can't do now and then consider which elements they could be fast-track trained to do, apprentice style; change the proficiency of the workforce in 60 days.  More care, for more people for no more money.
Do we really need more bureaucracy, more reports, more hassle... drawn from business text books of the 80's and 90's, to tell us what we already know?
Or, we could re-read Britnell; "...(the) use of technology to contain cost is another feature of highly efficient health systems."
Five key indicators on an organisation's dashboard, transparent for the ChEx, all staff, Whitehall and the world to see, would be a huge step forward.  The technology exists.  I fear the will doesn't.
Austerity-panic is taking us backwards.  The problem is not in developing new ideas... it is escaping from the old ones.
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