In the good old days, when beer was warm and you could get drunk for a shilling; there used to be four golden rules of management;
- complications cost,
- complexity is a risk,
- variation is the enemy of quality
- and real costs are the costs-in-flow.
Somehow, don't ask me 'how', we've lost the plot.
Thanks to Lansley's madness, we have the most complicated healthcare system in the galaxy, outcomes can be the difference between chalk and cheese and I honesty don't think anyone knows what anything really costs.
The whole NHS has turned into a compost heap of complexity. Somebody, please, climb to the top and shout 'Stop'!
The whole system is wasteful. I'm not talking wasteful in the sense of; everyone working in the NHS, right now, could probably do something that would save a hundred quid.
Not that we shouldn't; 1.2 million people saving �100 is a shed load.
I'm not talking using both-sides of a piece of bog-roll, or turning out the lights, or pharma-waste, or any of that... though we should.
I'm talking about waste in the actual system.
Pick a long-term condition... anyone one you like. Let's do COPD. There's an argy-bargy over how many people have it. The DH have one figure the charities have another. Great starting point... no one knows.
Let's go for... 1.2m.
Stay with me on this. There are 200-odd CCGs commissioning services for people with COPD.
Do a simple and wholly inaccurate sum...
Divide 1.2m by 200 = 6,000. Let's overlook geography and demographics and pretend that figure represents the distribution, in CCGs, across the English NHS.
Each of those 6,000 people will have their LTC requirements commissioned in 200 places with goodness knows how many variations and as far as I know, no real rock-solid method of measuring success, nor out-comes, nor benchmarking, nor calculating a return on investment.
Start talking about the 'costs-in-flow'; overheads, depreciation, chairs to sit on, lavatories to clean, bog-rolls and floor polish, clinics to light and heat, appointments and all the rest, to make all that happen and you can see it starts to look like a big black hole.
That is without buying calibrating and cleaning a single peak-flow meter, employing a care assistant or training a nurse. Or, writing a prescription, or paying for it to be dispensed.
Two hundred commissioners, 200 administrators, pensions, car-parks and all the rest. Records, phone calls, +200 of just about everything that spends money on everything but the patient.
There is an NHS evidence web-site where you can idle away the afternoon browsing. If, by five o'clock you can answer the question, 'what does all this cost and did it work'... you are a better man than me... Gunga Din.
There are outcomes strategies aplenty and there's a DH guess that the spend might be around a �billion; always a good figure. I make that about �83 a patient per year.
What about we syndicate the whole costs in flow, reduce exacerbations (�1,200+ a time) and get the figure down to �50?
Can we? I dunno, my figures could be wrong. But, I do know 200x's anything is a lot.
Suppose we start with the patient and work backwards, instead of from behind the desk and working forward?
What would happen if we stopped 'commissioning' COPD services? Instead, suppose services were the result of a 'coalition' of local providers who put all their costs-in-flow in a hat and said how do we spend this more effectively.
I know; we'd have to tear up the tariff, strip-out commissioning and have a revolution of the sensible.
- Dump complications,
- avoid complexity,
- have a chance to reduce variations and
- know what it all cost.
Does anyone have a reason why not?
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