In a previous blog (“Prioritisation in NHS Scotland” – November 2015), I opined that ‘we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.’ In other words we really need ‘to start debating and defining the essentials of health-care and what can we pull back from’. I had numerous comments and emails from colleagues; the majority supportive of my view. Since then there have been several blogs, including Chris Isles (“Time to Prepare for our new Hospital” – December 2015), Catherine Calderwood (“A Message from the CMO” – February 2016) and Anne Marshall (“Rights without Responsibility – Where are we Going?” – August 2016). These, in some way, have all informed that debate.
Chris believes ‘that the 5th largest economy in the world could afford to provide high quality emergency care as well as batteries for hearing aids and palliative chemotherapy for the frail elderly (if that is what they really want), but if I am wrong then surely the batteries and the chemo must go’.
I think he is wrong and here’s why. Year on year from 1997 to 2013, the UK has spent more and more on healthcare. Below is the most up-to-date data I could find from the Office of National Statistics.
Currently (2016-17) the UK spends approximately 18% of its overall budget on healthcare – about £143 billion (total UK expenditure is £784 billion). If our answer to the increasing demand on our current health service is to keep increasing the amount of money that we spend on it by the same factor (x2.97) every 16 years, then by 2033 we’ll be spending approximately 52% of our country’s overall budget on the NHS, squeezing out spending on education, pensions, social security and defence. Now I know that Economists will laugh at the simplicity of this argument (fair cop I say) as I haven’t taken into account rising GDP (if it does post-Brexit), but my point is that there is never going to be enough financial resource in the NHS to meet an ever increasing demand (and nor has there ever been).
The recent Chief Medical Officer’s Annual report ‘Realistic Medicine’ and the National Clinical Strategy (NCS) 2016 raise several fundamental questions, which include:
How can we further reduce the burden and harm that patient’s experience from over-investigation and over-treatment?
How can we reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients?
How can we ensure value for public money and prevent waste?
The context to these questions is described in the NCS:
“Value-based healthcare is an established approach to improving healthcare systems across the world – the central argument is that higher value healthcare is not necessarily provided by higher inputs. What matters more is that care is provided early in disease to prevent progression (avoiding the added patient burden of more intensive interventions), it is provided safely to avoid harm, it is proportionate to the patient’s needs (avoiding the waste of providing outcomes that are not relevant to the patient), it is provided consistently and reliably (avoiding unwarranted variation).”
“Over-treatment, wasteful treatment and variation is a broad subject, and an important one. It is important that it is addressed in Scotland so that we can be more confident that the use of resources is targeted to producing outcomes that matter to patients.”
So the national conversation has started. How do we ensure value for public money? And how can we be more confident that the use of resources is targeted to producing outcomes that matter to patients?
Do we systematically, and with rigour, evaluate and rank the clinical value of new drugs, new devices, new clinical guidelines or new procedures? No we don’t, but we should and if we are going to invest in a new intervention with significant clinical value, how are we going to afford it?
Part of the solution might be for each of us to start looking at our own clinical practice in terms of over-treatment, wasteful treatment and variation. Does our rate of intervention vary significantly with the national mean, and if so, is this variation warranted or unwarranted? Is there any part of our clinical practice that we do, because it’s always been done this way, but actually it really doesn’t benefit the patient?
There is already a lot of good work going on in Dumfries and Galloway looking at waste and variation. The Surgical team, led by JK Apollos and Stuart Whitelaw have recently been looking at the clinical value (there’s very little) of routinely sending sebaceous cysts and lipomas to Pathology. What about gall bladders? Heather Currie, Ranjit Thomas and Kim Heathcote and other clinicians meet regularly (the lab demand-optimisation group) to put in place measures to reduce wasteful and thoughtless laboratory requesting (do you know that the blood sciences lab processed 40,000 thyroid function tests last year)? This is not just about money. Over-requesting of lab tests can often result in the clinical pursuit of minor, insignificant abnormalities, which can lead to over-investigation of patients and on occasions harm.
There are lots of opportunities here to improve patient care and start to tackle some of the issues raised by the CMO and NCS. I have been asked to start looking at waste and unwarranted variation here in Dumfries and Galloway and hope that you will help by considering the real clinical value of all that you do and identifying clinical waste.
Ewan Bell is a Consultant Biochemist and is AMD for Clinical Efficiency