Wednesday 30 June 2010
by John Lister
One bizarre side-effect of the Con-Dem coalition government has been the belated publication of two documents which the new Labour government stubbornly refused to allow into the public domain.
Both are the result of work by US management consultants McKinsey’s. Both address the issue of the drive for “efficiency savings” (aka cuts) in the NHS to bridge a predicted £20 billion gap between a frozen budget and rising pressures by 2016-17.
The first, smaller document is a national survey. Elements of it leaked into the public domain last summer, but it was publicly disavowed by Labour ministers, who insisted that it was not government policy and would not be implemented.
Nevertheless it soon became clear that despite the government’s view a number of strategic health authorities were seeking to adopt a number of the proposals, not least in the rapid reduction of the NHS workforce by as much as 10 per cent as a way to save money.
The second document was shrouded in even more secrecy. Commissioned by NHS London, it was a special version of the original with more detailed facts and figures on the London context.
Some of the content of this second document was leaked by the Health Service Journal last September. For the following six months or more campaigners and health unions attempted to use the Freedom of Information Act to force NHS London’s secretive bureaucracy to allow proper public scrutiny of plans which were quite obviously controversial.
When all 159 pages of this second document were finally published the reason for NHS London’s reluctance to release it became obvious.
Contrary to expectations, the “document” is not so much a “report” as a ramshackle collection of sometimes quite smart-looking Powerpoint-style slides containing a series of statistics and assertions, but with little if any connecting explanation, evaluation or discussion of the proposal.
If this type of report were presented as an undergraduate research project at a university it would be rejected for inadequate use of supporting evidence and references, the lack of any clear structure or approach and the lack of any coherent or collected conclusions.
McKinsey’s itself appears to have removed any trace of its name from the NHS London pages and the document also begins with a public disclaimer that the list of ideas “in no case” reflects a “set of imposed directions/actions which the SHA is ‘telling you to take’.”
Nonetheless this document contains many of the seed ideas around which primary care trusts across London, grouped into five secretive “sectors,” have been meeting behind closed doors to plan the cutbacks.
Here are the proposals for “levers to reduce costs of care,” including “reduced double running costs through a single point of access to urgent care.” In other words, the rundown and closure of A&E units in London.
The document goes on to claim that more savings could also be had from “increasing scale, efficiency and quality from centralisation” of other hospital services (more closures).
Other “levers” to cut costs include reducing costs of clinical staff, using nurses and health professionals to replace doctors, and reduced costs of overheads. The latter suggests that the roll-out of polyclinics could bring an 80 per cent cut in clerical and admin staff working for GPs.
The report also discusses at some length the “decommissioning of some services” – effectively imposing a system of rationing access to treatment for conditions such as varicose veins, hernia and even joint replacements, leaving patients in pain with the “choice” of going private or going without.
The McKinsey’s document is also confirmed as the central inspiration for those NHS managers who want to switch up to 60 per cent of A&E patients and half of outpatients away from hospital facilities and into “polyclinics” or other as yet non-existent facilities in primary care.
However the document also reveals how strange this obsession with running down A&E services has become. Total London spending on existing A&E units is just 5 per cent of the hospital budget and 2.65 per cent of the total cost of London’s NHS. This means that even a big proportional saving would not amount to much.
But there are no big savings to be made. In 2007-8 London’s A&E units treated almost four million patients at an average cost of just £79 each. It is hard to see how switching services to new premises could save very much from this. On top of this new research evidence has shown that it would not be safe to shunt anything like 60 per cent of A&E cases into primary care.
Time and again the ideas proposed in the McKinsey’s document are simply thrown in without any serious analysis of possible downsides and problems, and without any discussion of the systems changes that would be needed to achieve the desired result.
In almost none of the examples is there even a costing of the likely investment required to make the change happen, let alone a balance sheet to show how any significant savings could be brought about.
Instead savings are sought in all kinds of unhelpful and unlikely areas. We are told that there should be a reduction in numbers of patients referred for outpatient care. This is despite the fact that 18 out of 31 London primary care trusts are already referring fewer than the national average. Nowhere is there a discussion of the possible impact on patient care of being denied specialist outpatient treatment.
Sickness rates in London’s hospital staff are the second lowest in England and below the national average, but McKinsey’s claims that more money could be saved if fewer staff got sick. It doesn’t tell us how and appears to have no detailed analysis of the causes of sickness absence.
The London document argues for “possible but challenging” targets to save £2.4 billion through acute sector productivity, but this turns out to require a massive 21 to 37 per cent increase in productivity by nurses, a 9 to 43 per cent increase in doctors’ productivity and a massive 34 to 42 per cent saving on overhead costs. However it offers no practical ways in which these savings might be made.
McKinsey’s appears to regard all paperwork, all admin and even discussion with other nurses as outside a nurse’s proper role, but it does not suggest who else should perform these roles if it isn’t nurses.
McKinsey’s also proves to be the source of the suggestion that very large sums of money could be saved in primary care by slashing the average time allocated to patient appointments with GPs by a third, from 12 minutes per patient to just eight. The consultancy firm claims that this could “save” a massive £570m, but it offers no discussion of the possible impact on patient care or patient satisfaction, let alone the job satisfaction of GPs. The Royal College of General Practitioners is currently campaigning for longer consultation times.
The document also claims that the same level of community services could be delivered by 11 to 15 per cent fewer staff if district nurse productivity could just be increased. Once again we are given no clues on how this should be done.
There are more examples – a long and shapeless list – but time and again the same gaps and evasions recur.
It seems clear that a lot of money has been wasted on these reports. Any money spent on them was wasted, because the total silence on exactly how any of the proposals are to be implemented means that they are as useful as a chocolate fireguard.
Maybe we should not be so surprised that McKinsey’s can’t offer any concrete guidance on which of its proposals are more likely than others to deliver or which have the least damaging implications for patients. They are management consultants, not clinicians, and they clearly know little and appear to care less about the systems in which NHS staff work.
But what is more worrying is that NHS London paid out good money for their report, attempted as best it could to suppress it from public view and has used it as a basis for its own and primary care trusts’ irresponsible proposals for cuts and “efficiencies.”
And as the Con-Dem coalition cranks up the heat, demanding the same level of NHS cutbacks or more, these proposals are the only ones on the table.
So publishing the documents by no means amounts to dismissing their content. And just because the ideas are ill-judged, inconsistent and impractical does not mean that they will necessarily be discarded.
Campaigners and health unions will need to pile on the pressure to demand these plans are dumped publicly and unceremoniously in the bin, and demand that any quest for economies in the NHS begins with sacking any and every management consultant who has been picking up fat fees for peddling such nonsense.
John Lister is information director of Health Emergency.
From the Morning Star