When efficiency means health service cuts

Health minister Mike O'Brien has said he believes health bosses such as NHS London should keep a veil of secrecy over their discussions on how to impose wholesale changes to the service's operation. If information leaked out, he told MPs this week, opponents of the plans could "attack them over their lack of evidence." What a telling admission. Not only are paranoid levels of secrecy now official government policy, but ministers are actively encouraging health chiefs to hatch up plans for which there is no evidence - while opposing those of us who point out that these policies are potentially dangerous. The three remaining strategic health authorities that have so far kept a stony silence on their plans are expected to reveal how they intend to generate their share of a £20 billion financial "gap" in the service in the new financial year. Their policy changes, as called for by NHS boss Sir David Nicholson, are unlikely to contain many surprises. Across the country the same rhetoric is being wheeled out to justify proposals for astronomical increases in "efficiency" and "productivity" which will wind up as cuts. Buzz-words such as "reinventing care pathways" (dumping patients out of hospital A&Es onto untested, supposedly cheaper alternatives in primary care such as "polysystems" - see below) "working smarter" and "innovation" crop up again and again.

But so do more obvious, unambiguous phrases such as "affordability analysis," "decommissioning," "savings," and "tariff reductions" - in other words cutting the amount paid to NHS trusts for each episode of treatment.
Perhaps the most blunt statement about the real driving force behind the various new policies comes from NHS Southwark, which declares openly that its proposals are cash-driven. "Our financial modelling shows that the primary care trust's (PCT's) current profile of expenditure is unaffordable over the next five years. "The affordability analysis requires £18m of savings in 2010/2011. Our commissioning strategy is driven by the need to achieve a system of healthcare which is financially sustainable." (Strategic Plan 2010/11 to 2016/17)."  But this highlights a major question. Can the proposals outlined by health bosses actually work, delivering services to patients while saving a large amount of money? Central to the guidelines laid down by NHS London for cutting £5 billion from its PCTs' spending by 2017 is an assumption that 60 per cent of people who currently attend A&E units with relatively minor problems could be treated satisfactorily in primary care.

On this basis NHS London wants to divert around 2 million people annually away from hospitals and into a new, expensive network of "polysystems" - controversial centralised super-facilities which were originally designated "polyclinics" in Lord Darzi's 2007 suggestions for reform. Similar assumptions have also been made elsewhere and A&E has been a major focus for redesigning "pathways." I have consistently challenged these assumptions, which have become more and more extravagant since the early 1990s, and pointed to the failure of previous attempts to divert smaller numbers patients from A&E to "minor injury units." These turned out to treat mere handfuls of patients at high costs, while queues at A&Es were undiminished. But now we also know for a fact that NHS London's 60 per cent assumption is wrong. A recently released Primary Care Foundation report commissioned by the Department of Health found that less than half the A&E patients included in that figure were suitable for treatment only by GPs. Their figure showed that in some cases as few as 10 per cent, and a maximum of 30 per cent of people in A&E had no need of any form of hospital care. Since we now have fresh and reliable evidence that the 60 per cent figure was wrong, one obvious question is where such a false assumption came from.

It appears to flow from the top-secret document produced for NHS London by US-based management consultants McKinsey's. But where did McKinsey's get the number? Is it based on anything substantial, or just made up to drive forward the reorganisation of hospital care? Another question arises: would it save any money to deliver minor A&E services in polyclinics? Again the answer seems to be No. Lord Darzi's 2007 report on London, which argued A&E patients should be switched to polyclinics, estimated that the cost would be £66 per visit to a polyclinic compared with £81 at a hospital. However transferring the patients brings the added cost of building or renting the new polyclinic and running it day by day. Darzi-style health centres that are already running on a much smaller scale than the London plans are "jaw-droppingly" expensive compared with existing primary care services - with costs ranging from three to seven times more per patient. It seems most improbable that a new network of polyclinics in London will come in any cheaper, especially since private-sector providers such as Richard Branson's Virgin group now see them as an attractive future profit stream. Health chiefs have also been keen to switch a large volume of outpatient treatment - up to half, equivalent to 5 million appointments a year in London - away from hospitals and into polyclinics.

Yet even according to Lord Darzi's projections this would save no money at all. Instead it would massively inflate the costs of providing and running the polyclinic. It would also of course make running hospital services less efficient if consultants and staff have to spend hours at a time trekking round to small-scale clinics instead of working from a central base. The Audit Commission at the end of last year highlighted another reason to doubt the viability of these plans. Their report More For Less pointed out that while hospital unit costs were falling and productivity improving, there had been "no shift from hospitals to care closer to home in the community; either in terms of investment or activity." Nor, argues the Audit Commission, had PCTs succeeded in "dampening demand" for hospital care, despite years of promises. In fact the most recent figures show another substantial increase in numbers of patients referred to hospitals by GPs for inpatient care. These are not "inappropriate attenders" in A&E, but people whose condition requires treatment that primary care and community services cannot provide.



Flying in the face of all this hard evidence of rising demand, and offering no explanation on how it might be achieved, NHS London has said it wants to cut the number of hospital beds in the capital by a third. Even if they only focus on front-line acute beds that would mean a staggering 5,700 beds to go - equivalent to around 12 district general hospitals. This might save money - but only if the services are not replaced by any alternative. None of these proposals seems to have any basis in evidence in this country or elsewhere. Nor do they seem to fit with experience on the ground. Doctors are increasingly required to demonstrate the "evidence base" for the treatment they deliver.

But it appears that the most senior levels of NHS management feel no equivalent obligation to show that their plans are evidence-based, organisationally viable or likely to yield the promised cuts in costs. If the plans go wrong patients and NHS staff lose out either way. If they prove to save little or nothing, these policies will widen the gap they are supposed to help close and force another round of even bigger cuts. On the other hand short-sighted closures and excessive reduction in staff numbers can result in local collapse in service and the quality of care. Lurking in the background is the grim example of Mid Staffordshire hospitals, where the quest for just £10m of cuts resulted in the loss of 150 clinical posts and a total collapse in care, with dozens or hundreds losing their lives as a result. Managers who fail to learn from existing evidence could be doomed to repeat this type of failure.