Helen approached me at an NHS rally in Sheffield in 2018. She was a nurse working in social care and she asked me if the health activists knew of the desperate state of social care, owing especially to the lack of staff in the sector.
Letter to Helen
You were right. Social care residents suffering, and the impact of over a decade of government under-funding of health and social care is terrible. What happened to the promises made to increase staff levels and funding?
The Good Law Project provides some clues. We need to know how decisions are arrived at. We can see the adverse impact on patients, staff and funding. We can’t see why cutting costs has been the response to NHS challenges when there is evidence to show that better outcomes can be achieved at lower cost.
This is what health activists need to address. Appealing to the government about the human cost of under-funding is futile.
The pressure has been on the NHS to cut costs when what the management should be doing is reducing the demand for health and social care. Like any successful organisation, management must start by identifying and understanding where and how demand arises. This means working closely with Public Health, the community and, in particular, GPs through which 85% of demand is channelled. This is the basis of good planning: predicting the resources needed, acquiring and optimising them.
The NHS employs dedicated, smart, well-trained staff. All NHS management needs to do is provide the conditions and systems to enable them to do their best work. The problem is that the emphasis on cost cutting blinds management to the fundamental importance of improving service quality which improves patient care and reduces costs.
Some 70% of health costs are in acute care. However, around 85% of the demand for treatment and care is generated in social care. Consequently, NHS management should have identified where and why demand originated and designed delivery processes (known as pathways) to enhance patient care. Keeping people healthy is the essence of prevention, reducing demand and lowering cost across the whole system.
However, Jeremy Hunt and Simon Stevens did not do that. Instead, they created chaos with their constant reorganisations, targets and threats. It is not surprising that staff morale has hit rock bottom, and suspicion of creeping privatisation has reached epic proportions. Nor is it surprising that staff question the motives of the leadership. Are the conditions being created to make the NHS ‘fail’?
Understanding demand and improving performance
A good way to understand the nature of demand is to examine the excellent statistics provided by NHS England. These analyse key delivery process data such as the transfers of patients to and from social and acute care.
The key data are those called ‘bed delayed delays’ (DDs) also known as bed-blocking. A DD occurs when a patient ready to be transferred from acute care back to their home, or to a care or nursing home, can’t be. Each DD costs the NHS about £350 a day.
The data indicate the source of the delay, which is mainly in the hospital or the care/nursing home, or at home, and reasons for delay such as delayed assessments on leaving the hospital, lack of care packages, public funding, etc. How time-consuming it becomes is clear on the wards. Instead of delivering patient care, staff are diverted into finding a discharge bed or room somewhere, locating transport and ensuring medication is ready at the time the patient is to be discharged. All too often, the ensuing delays cause the more elderly patients to become unwell again.
Service transformation and cost cutting
In 2012, when the Health Act was passed, the number of DDs was 115,000/month, costing the NHS £41mn per month or £½bn a year. Back then, a team from the geriatric medicine department at Sheffield’s Royal Hallamshire Hospital studied the discharge process with multidisciplinary team assessors and decided to improve the discharge process of elderly and frail patients to their homes.
In just over two years, the time taken to discharge a patient fell from 5.2 days to 1.2 days. This was done by switching from assessing ready-for-discharge patients on the ward to doing discharge assessments (D2A) at home. This resulted in savings some £14mn processing 10,400 patients in 2015.
Good practice versus arbitrary targets
Now compare this quality improvement initiative with the cost-cutting efforts generated by David Nicholson’s invidious cost reduction drive formalised in the Quality Innovation Productivity and Prevention programme (QIPP). Its main aim has become setting cost reduction targets. A good example is the Sheffield CCG. The QIPP programme update report of February 2020 stated that they would only achieve a cost saving of about £13mn, 92% of the target of £15.2mn.
Where did this target figure come from?
There were no figures on patient care, pathway or transfer improvements – only cost savings, as the Royal College of Nursing (RCN) had feared. The RCN monitored the plans and were concerned that they generated “short term savings [cost cutting] at the expense of long-term service transformation to meet the challenges of an ageing population” (RCN Policy Briefing 13/12 June 2012).
The D2A geriatric project is exactly the kind of long-term service transformation needed. The QIPP programme was, and remains, a travesty, not least because all the evidence is that cutting costs leads to costs increasing.
Tampering, target setting and cost cutting
Between 2010 and 2017, DDs rose by 52%, and led to a £1bn overspend in the NHS. The level of care for users and the working conditions of beleaguered NHS and social care staff would have been improved if Sheffield’s approach to geriatric medicine improvement had been adopted in other departments. By achieving just half their level of discharge improvement, a 35% saving on the 2012 figures could have been made instead of the billion-pound cost increase. This would amount to £170mn. Add that to the overspend of a billion and the total savings would have been £1.17bn in running costs alone, achieved by collaboration and continual improvement.
Consequently, an opportunity to lower costs and instil a proven quality improvement project across the NHS has been ignored, by NHS leaders’ blinkered insistence on continuing with their simplistic policy of tampering, target setting and cost cutting.
So, Helen, I’m sorry I did not figure this all out earlier. I promise to try once again to get the health campaigners to address the economics of the leadership failure in the NHS, if only to shame the politicians into putting it right.