Fiddling while healthcare burns

It has been a fascinating experience to spend 25 years – what am I saying? knocking on 30 years – working in healthcare information.

Throughout that whole time, the field has been marked by two powerful and constant trends. The first of these is a growing capacity to deal with more and more diseases. Whether it’s breakthroughs in pharmaceuticals, in surgical techniques, in equipment and consumables, or simply in approaches to care, the number of conditions that can be diagnosed, treated and cured has steadily increased.

And the second trend has been a reflection of the first: a steadily ageing in population, at least in the developed world. People are living longer and that is a tribute to the success of healthcare progress.

Unfortunately, the two trends come together to reinforce a third and much more worrying development: uninterrupted grown in health expenditure. When I started work in this area, healthcare expenditure in Britain represented around 6% of GDP, and in the United States, around 9%. The figures today are over 9% and, staggeringly, over 16% respectively.

Now nobody has ever worked out the maximum an economy can spend on healthcare. We know that on current trends, the US is heading towards 100% of GDP going on healthcare by the end of the century, which is obviously crasy. But what if costs were halted at 50%? That does seem a bit high.  What about 25%? Could a society stand that? Could it still spend enough on education? On roads? Or, given the tendency of both Britain and the US to intervene in other countries’ affairs, on the military?

What is clear is that somewhere there must be a limit. And it’s equally clear that the two great forces that have marked the whole of my career both push that limit: as populations age, they tend to require more healthcare, and they require it for longer; as technology improves, it allows more to be done, but generally at higher cost, at least when innovations first appear. So we have a conundrum.

However, it’s not all bad news. Because one of the effects of improving technology is that in the long run it makes it possible to reduce, rather than increasing, costs. By doing things more effectively, we can avoid certain forms of expenditure. And there tends to be a tipping point in all technology developments: there comes a point where things become cheaper because they become more efficient – we’ve seen it in cars, that have improved massively in efficiency and therefore in cost. And we’re seeing it in healthcare, where for example keyhole surgery techniques have reduced the cost of care substantially because patient recovery is so much quicker, without any great increase in the cost of the operation as surgeons have become more proficient and comfortable as the techniques become routine.

That’s why so many procedures that used to involve several days in hospital can now be performed on a day case basis. A striking example is cataract extractions. Even more serious surgery, such as open heart operations, have so evolved that an otherwise healthy individual may be ready for discharge within four days, where in the past it might have taken twelve.

These examples are a clear signpost of the way forward: use evolving technology to improve care delivery. In particular, use it to limit the time patients spend in hospital: hospitals are nasty, dangerous places, full of sick people and the longer you stay in one, the greater the chances of picking up a nasty infection and leaving in a worse state than you came in. They’re also about the most expensive places in which to receive treatment – anything we can do to get treatment carried out in a GP’s surgery, or even in a hospital on an outpatient basis rather than as an inpatient, is likely to be a benefit to the patient and a saving of money for society.

Vital when needed, but best avoided if you can. And very expensive...

Now all this has been known for decades. The trick is to start doing it. Start cutting out the unnecessary treatment, or at any rate the unnecessarily expensive treatment.

But that means taking clinical decisions, deciding what is the most intelligent and appropriate approach to delivering care.

So why instead of tackling those issues does government after government instead try to find economies in the area of healthcare management? The British National Health Service spends around 3% of its money on management. Just how much can you save from that?

And are the savings real anyway? If you take out the administrative support staff, the administrative work still has to be done. So who does it? Why, the front line staff themselves. The nurses and doctors. That diverts resource from healthcare, and is also far more expensive: most nurses and certainly most doctors cost a great deal more than most administrators.

But governments do worse than that. In my time, in Britain alone, I’ve watched the Griffiths reforms bringing in General Management. I’ve watched the idea of ‘Hospital Trusts’ being introduced, and later ‘Foundation Trusts’. I’ve seen the creation and abolition of Area Health Authorities, the setting up of Primary Care Groups and then their replacement by Primary Care Trusts, now just over a year from abolition themselves, if the latest legislation goes through.

In other words, I’ve watched government tinkering with the organisation, fiddling with the structure. Andrew Lansley’s proposed NHS reforms are probably going to cost about £1.2 billion – all in the name of seeking out economies. And all the time the real savings, which at the same time can generate real improvements in patient care, need clinical reform, not managerial change.

No wonder the controversy about the latest proposals is so intense. It deserves to be. The new initiative represents a huge expenditure to address completely the wrong issue. Not because trying to control healthcare expenditure is wrong, but precisely because it’s so badly needed: Lansley's legislation would waste money and fails to address the real problem.

When it comes to hare-brained government initiatives, it has to be right up there with the very best of them...