With more money coming to the NHS do we need to rethink how it’s spent?

While some of the major health think tanks such as The King’s Fund say the announced 3.4% increase in annual NHS spending is not enough – and I would agree with that – can we at least use the additional NHS funding more efficiently? I would say it might be worth looking at changing some long-established patterns of patient care.

Let’s start by looking at primary care. Currently it is estimated that around half of all GP appointments are for just two kinds of conditions – musculoskeletal (MSK) problems (accounting for a fifth of all GP appointments) and mental health problems (accounting for a third of appointments). Imagine if all these patients were directed straight to appropriate healthcare professionals for their treatment, rather than having to see their GP first: MSK patients being seen by an NHS physiotherapist (who could also refer them on to a specialist if required), and patients with mental health problems being seen by an NHS psychologist or counsellor for ongoing support.

In some areas, patients can already self-refer to physiotherapy services, the benefits of which have of been well set out by the physiotherapy profession, but this model is not available across the board. If up to 50% of GP appointments could be diverted straight to such specialised NHS services, affected patients would get the urgent care they need more quickly. This model could potentially also be extended to a number of other conditions, such as chronic pain management – after all people don’t need a referral to go to the dentist! This approach was touched on in the 2015 report Making Time in General Practice, but changing patient pathways could go even further.

Such a change would also leave GPs with more time to see other patients. If patient appointments could be extended to say 15 minutes (currently the average appointment time is 10 minutes), GPs could assess patients more thoroughly – especially valuable for those with long-term conditions or presenting with more complex symptoms. At an event on improving cancer outcomes I was involved with last year, one of the speakers talked of a patient with pain who went to her GP seven times before being diagnosed with cancer. Longer appointment times might mean serious health conditions would be picked up more quickly – or ruled out earlier; outcomes could be improved; and overall costs even potentially reduced, as diseases caught early usually need less drastic and costly treatment. This approach would also help to facilitate the NHS’s new Get it Right First Time Programme.

The simple heart of the new approach therefore, would be to get patients through the system as quickly as possible with speedier access to specialist care if required, rather than the current situation where GPs are required to act as ‘gatekeepers’, with access to specialist care being restricted. In rare cases, clinical commissioning groups have even incentivised GPs not to make referrals.

The average cost of a GP appointment is around £40 and an outpatient appointment £120, so accessing secondary care is more expensive, but money would be saved in the long run with less ‘false starts’ and unnecessary repeat visits to the surgery (although primary care would, of course, have an important ongoing patient management role). Streamlining patient pathways would make better use of the available healthcare workforce and scarce financial resources. However, patients would also have to commit to acting responsibly and using NHS services appropriately – and should potentially be charged if they fail to turn up for appointments. Last year missed appointments cost the NHS £1b – that is also completely unacceptable.

Finally, some of the increase in funding also needs to go on prevention – we absolutely need to do more to keep people healthy.

* Judy Abel has worked in the health information and policy sector for more than ten years, including managing the All-Party Parliamentary Health Group for three years until April 2018.

* Until recently, Judy Abel was Head of Health Policy at Policy Connect.

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35 Comments

  • Phil Beesley 25th Jun '18 - 2:38pm

    I agree with Judy Abel that it is essential for the NHS to create cheaper and better ways of working. I am not sufficiently informed to comment much — that is down to practitioners and nurses and other observers.

    It is essential that we all understand that “efficiency” is insufficient; efficient organisations don’t have any pounds left to save by pursuing existing practice; they have to do something different.

    I read a Daily Mail-style story the other day about inefficient purchasing of toilet rolls. Most likely, a ward ran out of bog roll (none immediately available) and sent an SOS call to a bog roll provider, charged at 16 rolls of the finest plus bike delivery. If you want to buy bog roll at the cheapest price, there’s a UK gov framework price for toilet paper.

  • @Phil – thanks. I think national procurement for essential supplies is an obvious way to go rather than local purchasing. I know Lord Carter conducted a review saying the NHS could make £5b in savings. I think reform need to go further though. Delays in treatment are known to affect outcomes, especially when it comes to things like cancer. I know there is not a cure for all ills, but just like a broken machine in a factory, the sooner you get it fixed the sooner it is up and running again. No one would wait months to get their car fixed but we seem to think people are less important.

  • @Thanks Phil. National procurement of essential supplies makes much more sense than local purchasing arrangements. Lord Carter identified $5b in savings the NHS could make through efficiencies but I think reform should go further than that. We need to improve outcomes and patients getting into the system more quickly for treatment where they need it. Cancer outcomes are particularly dependent on patients being seen as soon as possible.

  • Peter Martin 25th Jun '18 - 4:39pm

    “National procurement of essential supplies makes much more sense than local purchasing arrangements.”

    Yep. Agree 100%. The National government has much more political clout and the buying power to be able to stand up to the Pharmaceutical companies for example. But this goes against the grain of Lib Dem thought that devolving power away from the centre is always the best option.

    Sometimes (often?) it isn’t!

  • John Barrett 25th Jun '18 - 4:49pm

    It is time for a radical rethink to make the NHS deliver a better service, and for the general public to accept that playing their part in the care of the NHS is not only a matter of paying tax, or agreeing to pay extra tax to increase NHS funds, they could also play a key part in reducing the demand for a multitude of services which are at breaking point.

    The evidence is clear that NHS provision and care to deal with a range of “lifestyle choice” problems including drinking too much alcohol, smoking, taking little or no exercise, eating too much junk food and sugary drinks, all combine to cost millions in care costs and endless appointments at GP’s surgeries.

    While all political parties are happy to say more funding is required, few if any ever (including our own) make any concerted effort to say that reducing the demand for a wide variety of services could save millions and be easily delivered – if people were more responsible with a range of actions which could improve their own health.

    Having attended A & E facilities at the weekends, when the place is full of drunks who are attacking each other and the doctors and nurses, it made me realise that providing more funding is not the answer and only part of the problem in overstretched A & E facilities and that while many like to blame the politicians for failing in the NHS, there are others who abuse the first class service provided by many dedicated staff.

    The question of missed GP appointments is also more complicated that appears at first sight. when I mentioned to my local GP surgery that my dentist had all but eradicated missed appointments by sending text reminders, I was told that GPs enjoyed using the time provided by missed appointments; to catch up with other work or appointments, to do paperwork, or have a coffee.

    The average cost of GP and outpatient appointments quoted above should also be taken with a pinch of salt, as most of the costs involved do not vary much if the patient turns up or not, so providing an average cost is an art, rather than a science.

  • Sorry for the repeat – seemed to be a glitch first time so rewrote my comment! I think all the health think tanks say that the increased funding allocated is not sufficient to make up for reduced funding increases over the past five years or so, so I generally trust them on that. The figures on appointment costs were taken from NHS sources but I agree they must be estimates only. I absolutely believe that NHS services should still be provided free of charge, but public health action must be taken to reduce alcohol-related attendances (maybe an extra tax on alcohol)

    When something is free it is easy to abuse it so new ‘rules of engagement’ need to be set out for use of NHS services, but ultimately my article was more about how genuinely sick people can get the help they need more quickly.

  • @David Same with the trains. But nonetheless we need to make care cheaper by getting the most out of the specialised skills in the health workforce. The UK’s lung cancer outcome are worse than Mexico’s – we need to some reform in the system

  • Many other countries have paediatric GPs and most have more GPs per head of population. Mental health provision is woeful. It is really hard to access technology for some lifelong conditions. Some positions dont pay enough and stay unfilled for very long periods. Massive sums are wasted on agencies- the NHS should offer a wider range of contracts – some that reward flexibility.

  • Good topic.

    Judy points out one (enhancing self-referral) of dozens and dozens of possible reforms to the NHS that could make it better and more efficient. I emphasise ‘could’ here because I would be doubtful if reforms enabling more self referral at the moment would actually make things better and more efficient overall. Just to pick apart the scenario of MSK and mental health being half of GP appointments. I’d guess half if not more of MSK presentations at GP are actually rooted in mental health issues, either depression manifesting as pain (aka somatisation) or mental health problems having the knock on effect of less physical activity leading to lower back problems (lower back pain being the bulk of GP MSK presentations). Self referring to a physiotherapist is actually not necessarily a good thing to do here. Likewise not all mental health problems need specialist care and can be managed well be a GP (they are a ‘healer’ as well as gatekeeper to other ‘healers’). Though I’d caveat that too many mental health cases that should be managed by mental health specialists are managed by a GP (mostly because there just isn’t enough specialist mental health resource available). Generally though, the extensive gatekeeper role of GPs is actually working reasonably well at the moment, and from an efficiency point of view, is extremely cost effective when compared to countries with extensive self-referral (Germany, Switzerland and the US).

    Pouring more money into the NHS isn’t a solution. I think without (some pretty major) structural reforms, it’s actually an irresponsible misuse of taxpayers’ money

  • In my opinion the top policy areas where new initiatives and changes to existing structures could make the most impact are;
    -Health informatics. Researching, developing, and deploying new automated systems and AI to improve the efficiency of diagnostics and healthcare organisation from the supply side, as well patient empowerment from the demand side (so that they can reliabley self-refer for example) .
    -Healthcare in the last year of life; an extremely high proportion of healthcare spending occurs in the last year of a person’s life, often with extremely limited benefit. I don’t know for the UK, but in many countries this spend approaches or even exceeds half the budget of secondary and tertiary care (which is already the bulk of spending because of humans’ psychological obsession with hospitals and their perceived importance to health; they are an extremely minor component). Getting patients to think about and plan the terminal part of their life is useful here, as well as avoiding prolonged hospital stays for last year of life patients whose only needs are social and or nursing (social care reform being a big thing here), empowering doctors to make sensible decisions as opposed to prolonging the inevitable, and generally being more judicious with resources
    -Redistribution of roles. Far too many activities are carried out (often by law, or by statute from professional bodies) by “expensive” personnel (doctors, nurses, allied health professionals), when they could be carried out by “cheaper” personnel who have received targeted training. From diagnostics, to procedures, to prescribing, it’s a huge area
    -Mental health. Massive under investment here, which has a huge knock onto all parts of the healthcare system (and education, work etc etc)

    The current policy offerings from all political parties in the UK is abysmal and generally lacks any sense of ambition. For what its worth at least the Lib Dems lead on mental health (though get very little recognition for it)Good topic.

  • Nonconformistradical 26th Jun '18 - 7:55am

    @Judy Abel
    “In Germany people can ring a specialist directly without having to go via their GP. I am certainly not suggesting we go that far but think we could extend this model to a limited number of conditions.”

    So if someone who has started having chest pains self-refers (wihtout having see GP or practice nurse) to a heart consultant on the assumption that it must be some form of heart trouble – and it turns out that they have strained some chest muscles or something like that – how is that going to save money?

  • Judy Abel 25th Jun ’18 – 9:26pm……………In Germany people can ring a specialist directly without having to go via their GP. I am certainly not suggesting we go that far but think we could extend this model to a limited number of conditions…………..

    I’m not familiar with German systems but, in France, after an initial reference from a GP, one can make further appointments directly with the specialist. My wife had a heart irregularity and, on recurrence of the symptoms, telephoned, and saw, the specialist without recourse to a GP…
    Such actions are possible because copies of test results, X-Rays, etc. are given to the patient after every visit and you take them with you to whoever you see next.

    I won’t go into details but I found the French system far more efficient, effective and responsive than our NHS…

  • Innocent Bystander 26th Jun '18 - 9:04am

    The problem is mainly the sense of entitlement that the NHS has engendered in the British. We are 1% of the world’s population who have come to believe that we can have unlimited free health care to keep us alive as long as possible, whatever the cost. The other 99% are more realistic and can easily see that this British method will lead to bankruptcy (as it is).
    The NHS is on an unsustainable trajectory. People live longer because of more expensive health care but they need ever more expensive procedures and eventually 24\7 care, ad infinitum.
    Taxes are going to go up but why would a nice acceptable 1% fix it? There isn’t a convenient plateau where just the amount we can afford gives us all the health and social care we want. The costs are ever diverging and the situation gets worse and worse. I know this is heresy now but just wait. Soon it will be mainstream.

  • Nonconformistradical 26th Jun '18 - 9:17am

    @Judy Abel
    “That system does not apply to emergency medicine but things such as back pain.”
    Which doesn’t mean the patient is going to make the right decision on who to see.

  • Peter Martin 26th Jun '18 - 10:11am

    We spend more on health than some but less than others. About 2/3 of what Americans spend as a % of GDP.

    http://www.who.int/gho/health_financing/health_expenditure/en/

  • Innocent Bystander 26th Jun ’18 – 9:04am……The problem is mainly the sense of entitlement that the NHS has engendered in the British. We are 1% of the world’s population who have come to believe that we can have unlimited free health care to keep us alive as long as possible, whatever the cost. The other 99% are more realistic and can easily see that this British method will lead to bankruptcy (as it is).
    The NHS is on an unsustainable trajectory. People live longer because of more expensive health care but they need ever more expensive procedures and eventually 24\7 care, ad infinitum……………………

    Point a) it isn’t’ FREE’..

    Point b) We are well into the bottom half of the EU-15 as a % of GDP spending on healthcare.

    Point c) Thank goodness you are not my GP or specialist. Money is important but should not be the major factor; after all, if a child is trapped in a sinkhole, how much should be spent on getting him/her out?
    Money, spent wisely on health, can save vastly more in the long run.

  • Phil Boothroyd 26th Jun '18 - 11:15am

    If you aren’t interested in this, but haven’t yet done so, I suggest you read the actual report. It’s not particularly long as these things go – and even if all you read is the conclusions section (which is only a couple of pages) it gives much better insight than the related articles and comments (no offence intended) that I have seen. See:

    https://www.nuffieldtrust.org.uk/files/2018-06/the-nhs-at-70-how-good-is-the-nhs.pdf

    Based on those conclusions, if I were to respond to the question above ‘is it time to spend differently’ – the only significant change I’d like to see is a serious plan to train enough staff and have a comparable number of drs and nurses per head of population to our peers, as well as building the infrastructure/resources to match. Preferably something agreed across the parties to ensure adequate provision, and with the required funding ring-fenced – so it can’t subsequently be filched by one party or other based on a cost/benefit analysis that looks no further than the next election. It’s not quick or easy, but would be right for the long term sustainability of the service in my view.

  • Innocent Bystander 26th Jun '18 - 11:28am

    Judy and expats,
    Having spent two days recently in close proximity to the NHS I testify that it is staffed by truly loving and dedicated people and also horrifically inefficient in every regard. It seems antiquely hierarchical and ponderous. The simple processes now universal in business and commerce have passed it by and what it does with more funds is to add more pointless bureaucracy.
    So I agree, the life of the NHS can be prolonged by improvements but not at the superficial level discussed here but at the fundamental process level with a list of other obvious changes too many to cover here.
    However, my point remains. The NHS is a broken dream. All I read here is the ostrich defence. Money, expats says, shouldn’t be a factor. Well it isn’t while we are still bankrupting our grandchildren to maintain our comfort levels. It’s going to be the only factor as we join the rest of the third world and experience what level of health care the majority of the world has to put up with.

  • Innocent Bystander 26th Jun '18 - 11:44am

    David,
    I don’t accept any political label. I would regard myself as a very extreme moderate. The closest party would be LibDem as they are the nearest to non-ideologically driven thinking. However, dreams and ideals have to be connected to achievable reality, or they mislead the trusting. I only offer non political opinions but specialise in reality, and make uncomfortable points. No society has managed unlimited free health care so one day we will confront the issue as to how we limit it (funding, rationing??) whether we want to face it or not.
    That’s not right or any other wing. It’s just what, sooner or later, will have to be confronted either by us or by the next generation.

  • Innocent Bystander 26th Jun ’18 – 11:28am……………… Money, expats says, shouldn’t be a factor…………………….

    If you comment on my post at least do me the courtesy of quoting, or even paraphrasing, me correctly…
    Wot I rote …”Money is important but should not be the major factor” is rather different than your ‘Money shouldn’t be a factor’.

  • If we are going to spend the increases promised on the NHS we need to look at streamlining care and reducing errors. If my car breaks down I take it to the garage and it’s fixed in two days – we need to take a more functional aporoach to healthcare and direct people to where they can get the care they need quickly.

    I spoke with an academic recently who said a comsultant he knew wasn’t popular because he got through his surgical lists too quickly.

    I know people who have had to pay privately to see a specialist to get to the root of their health problem. One friend told me I really had to push my GP to see a specialist – what about people who lack the ability to be pushy?

    Some conditions are complex and the NHS does a fantastic job on treating these cases but change is needed.

  • Innocent Bystander 26th Jun '18 - 3:02pm

    Expats,
    Please accept my apologies. For the vast majority of the world money is the sole determinant of their standard of health care. Us, too, sooner rather than later.

  • @Judy

    Yes I don’t doubt there are delays in referral and GPs holding onto patients longer than they should. I don’t know about studies, but I’d guess on balance the current GP gatekeeping system provides for a more efficient service overall. There will be winners and losers. But this could change with advanced health informatics where people could partially self-diagnose at home and self refer with greater accuracy.

    There is a huge national shortage of qualified clinical psychologists. This is madness, because there are plenty of high calibre individuals graduating with degrees in psychology, and then working in fields unrelated to psychology. Many want to work as clinical psychologists, but the number of training programmes is utterly inadequate. Most patients with mental health problems would actually benefit much more from seeing a clinical psychologist (where they can receive psychotherpies) than a psychiatrist (who just prescribes drugs). But the lack of clinical psychologists means they end up getting treated with drugs (either by a psychiatrist or a GP)

    Anyway, health policy is a huge area. So many possibilities and I totally agree with you that we should be looking at ways to imprint the structure of the NHS before throwing more money into it

  • Edit

    improve not imprint

  • @David Raw

    “”””For myself, I happen to believe in a mutually supportive society part of which, for all its failings, is the brilliant concept of a universal National Health Service. I take it that you don’t – though you do appear to believe in a right wing penny pinching bromide as a remedy for all ills..””””

    A fact that many people fail to appreciate is that resources are finite. Spending on one thing means not spending on another.

    One can spend £60,000 pounds on a course of chemotherapy that will prolong the life of someone with metastatic cancer by 6 months. Or you could use to pay for a specialist Child and Adolescent clinical psychologist who over the course of a year could have a caseload of 40 children and young adolescents intensively helping them through the early stages of mental health issues (eating disorders, early onset psychosis, severe depression), and setting them up for the possibility for a normal adult life unplagued by their troubles as children.

    Currently we fund the former but rarely the latter. It’s only with a mindset of “penny-pinching” can we readjust health spending priorities so that we use the scare resources to maximise the benefit. Approaching with the mindset of giving everybody everything sets us up to fail.

  • Richard Underhill 27th Jun '18 - 11:23pm

    The Kings Fund was a contributor to a TV programme broadcast tonight about PREP. The Open University also.
    Senior figures in the NHS have refused funding, lost in court and lost again on appeal. Why do they want to spend large amounts of public money in paying lawyers? The case for this medicine is overwhelming. The NHS refused to be interviewed. Perhaps a parliamentary committee will take an interest.
    This is an excellent example of campaigning for a cause and winning, so far.

  • Interesting item in media today saying health outcomes are better when patient sees the same GP or specialist for their care – reinforces point made in article that if some patients can be seen straight away by, for example, a physio or mental health professional – rather than needing a GP referral – those with complex long-term conditions will stand a a better chance of seeing the same GP for a longer consultation.

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