Will 2015 be yet another year of crisis for the NHS, or can we find a more positive note? I described why so-called “protected NHS funding” felt like cuts in my last blog. I still think that’s the number one challenge facing the NHS over the next five years. But given that neither of the two UK parties of government are willing to address that, what else can we do to protect healthcare provision in the UK?

Let’s assume we want to keep universal healthcare, and that we are not willing to sacrifice quality. In fact, we probably want quality to increase. The key is to increase productivity (defined as the ratio of outputs per input). If we can produce the same output for less input, or more output for the same input then we’ve increased productivity. However, this can be challenging in the service sector, because of the need for one to one attention from staff to patient, which is not readily automated: also known as Baumol’s cost disease (discussed in a previous blog). In other words, we have to prove Baumol wrong. Others have been recognising this productivity challenge for some time: several publications from the Kings Fund, McKinsey and the NHS England QIPP programme, for example.

The big question is how do we improve healthcare productivity? Below are six possible solutions:

1. Decrease staff inputs

There are a variety of ways to do this, but not all represent genuine increases in productivity. Paying staff less (an approach used over the last few years) will reduce the input, but is not a genuine increase in productivity. In the long run those staff will be harder to recruit as other more lucrative employment competes. In the short run it is likely to be de-motivating.

Downskilling is a widely used approach, where staff with lower levels of training or qualification are used to perform tasks. For example, phlebotomy is now mostly done by low paid staff (~£8/hr), but was previously done by junior doctors (£11/hr), giving an apparent 27% productivity improvement. However, one of the predictable consequences is that junior doctors now request more blood tests, as they no longer have to take the sample themselves: so in reality the productivity gain will be less than at first sight. Endoscopy is another area to which this has been applied. This is one of the most high volume procedures performed, with 69,000 upper and 75,000 lower gastrointestinal endoscopies performed in Scotland in 2013-14. Traditionally performed by consultant gastroenterologists and surgeons, now substantial numbers are done by nurses. Again, the apparent productivity gain is large, with a consultant earning £37-62/hr compared to an endoscopy nurse’s £16-21/hr. However, this does not take into account the flexibility provided by the greater training of the consultant who may be able to do interventions at the first scope, rather than bring the patient back for a second procedure; or who can redirect time to the assessment unit when necessary. There is more scope for downskilling, but it requires careful assessment to decide if efficiency is genuinely improved. A simple hourly rate comparison is not sufficient.

An alternative approach is to shift work to the patient and carers: approaches such as co-creating health and increased self-management. This increases productivity, mainly because it values the patient’s time at zero. If a patient administers their own intravenous antibiotics, they are taking on work which would normally be paid for. This burden on the patient may be offset by benefits to the patient, e.g. not having to wait around for a district nurse to arrive to administer the antibiotic.

2. Quality improvement

It’s not unreasonable to believe that improvement in the quality of care might also save money, and increase productivity: stripping out unnecessary process steps, or reducing complication rates, for example. But is there any evidence that it works? The Health Foundation commissioned a review of this topic, “Does improving quality save money?“, and the answers were a little disappointing. There was a reasonable body of evidence to suggest that poor quality care was associated with higher costs. However, the evidence that the cost of improvement initiatives were lower than the improvement they delivered, was much weaker. Showing that improvements delivered by one method in one institution would be effective in another institution is also a major challenge.

3. Technological improvement

IT has been heralded as a way to improve productivity. Interestingly, the world economy has not seen a great increase in productivity as a consequence of the information revolution, unlike the previous industrial revolution (Solow’s computer paradox: “you can see the computer age everywhere but in the productivity statistics“). My personal experience of IT in healthcare confirms this. In the main, it increases the quality of what I can achieve, but it takes more of my time. Previously, I took a drug history by asking the patient. Now, we ask the patient, check the Emergency Care Summary, look at the electronic discharge letter from the previous admission and look at the GP prescription sheet, and then try to reconcile all of that. However, it’s not all doom and gloom – we are in the early phases of learning to work with IT: we still try to use IT in processes that were developed in the nineteenth century (e.g. the ward round; the history and physical examination), rather than developing new approaches; communication from primary to secondary care remains far from seamless, with social care even further behind; and the potential to use analytics to improve care are grossly underused.

New medications and procedures also represent technological advances, and are one of the main drivers of increasing cost in healthcare. For medication, we at least have processes in place to assess cost-effectiveness, but much less so for non-pharmaceutical interventions. However, this will only improve productivity, if displaced interventions are less cost-effective. Typically, interventions are recommended for use if they cost £20-30k per QALY, but this may rise to £90k per QALY for end of life interventions. However, the NHS spends around £18k per QALY across all of its activities. So interventions authorised at or above the £20k threshold, are actually displacing more productive activity. So telehealth for example, which costs about £90k/QALY would displace significantly more efficient interventions. Disinvesting from less cost-effective activities would require significant investment in economic analysis, and would also be politically challenging to implement.

4. Stop doing useless stuff

Stopping doing things for which there is limited evidence of benefit, should be the easiest way of increasing productivity. Patients would not be subjected to unnecessary interventions, and money would be saved. NICE continue to expand their do not do database, which is worth examining. It feels like this is an area that has only had the surface scratched. How many stress tests for ischaemic heart disease could be avoided if patients were seen by a cardiologist rather than a generalist? How many patients genuinely need to be on proton pump inhibitors long term? How many CT scans were actually helpful and necessary? But how do we make it easy for clinicians to actually reduce these activities?

5. Integration and moving care to the community

A lot of hopes are resting on the benefits to be achieved from better integration between primary, secondary and social care, and by implication on moving more care from hospital to community. Better integration seems like a good idea. If perception is true, and the pressures on our inpatient wards are due to inadequate funding and coordination of social care, then perhaps redistributing funds will be more cost-effective. For example, the delayed discharge data published by ISD shows that in NHS Ayrshire & Arran, approximately 75 beds are occupied each day by patients who could be discharged with social care input. Of those, however, 22 beds are due to complex patients who require highly specialised input (so-called code 9s). So if funds were redistributed, then potentially 54 beds could be freed up. Although clearly the right thing to do, that would free very little actual money, as it would simply take occupancy down to the level at which it should be.

What about increasing care in the community? Hospital at home approaches may actually improve patient outcomes, although the evidence remains weak. Again this is something we should probably pursue because it provides better care in the environment that patients would like. However, the evidence that it saves money, and improves productivity is unconvincing.

6. Prevention

Prevention is obviously a good thing in itself, but it is often assumed to be cost-saving which may not be true. One key reason, is that we do not prevent death – rather we postpone it, and perhaps alter the cause. For example, if we give people statins to delay cardiovascular events, then they may die later, but of cancer, which might be more costly to manage. The total lifetime costs will then be higher. This then requires complex calculations to see whether the output (increased longevity) exceeds the increased inputs (statins and cancer costs, minus the cardiovascular event costs). More worryingly, preventative care can often lead to over-diagnosis and over-medicalisation, which are highly likely to increase costs, with limited benefits.

Where to put our efforts in 2015?

Quality improvement – despite the lack of evidence, this has to be the main focus. Stripping out unnecessary steps in processes, only doing what adds value, and doing things right first time (avoiding failure demand). We know how to do this, we just need to allocate more time to it. Stop doing useless stuff – it feels like there is more to gain here, but the challenge is how. It has to be driven from our clinical teams or it will fail. Technology – investment in IT is a must for the long game, but we need to spend more time on understanding how to redesign our processes in the information age. I would love to see more invested in health economics and optimising allocation of resources. Given the politics involved, I’m not holding my breath for that one though. Integration – I’d be surprised if this delivers much productivity gain in the medium term. Ten years after primary and secondary care were integrated, few would feel that its potential has been delivered yet. Prevention – prevention is important, but I don’t believe it will deliver much in the way of productivity gain, from a lifetime healthcare costs perspective. Decrease staff inputs – there may still be some oil in the well of downskilling, but it doesn’t feel like a big winner to me.

If you have better ideas, then do share. Have I missed any major categories to improve productivity?

Have a great 2015!