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It’s still possible to be wise before the event


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Tuesday, 6 April 2010

It’s still possible to be wise before the event

At the onset of any crisis there are always plenty of people ready to point out that something should have been done sooner.

While this is almost always true it is also unhelpful, annoying and illogical. If we had done everything possible to avert the crisis we probably wouldn’t be having one.

The past decade of record investment in the NHS is part of the reason we find it difficult to change now. If you know you are going to get a pay rise next year whether you work harder or not, you don’t have much of an incentive to worry about your performance. That’s not an argument against adequate funding but about the habit-forming complacency that can set in during long periods of growth.

The truth we are beginning to face is that we don’t know what enough is. The assumption has been that spending will increase year on year in line with inflation, increases in population, people living longer, long term conditions and all the other well communicated pressures.

We understand the impact of spending in particular areas but we do not understand the impact of the sum of investments across the whole system. We don’t know, for example, when spending less in one area actually pushes higher costs to another. We also don’t know when investment is working or how well. But we do know that continued spending alone does not solve the problem:

As a recent paper put it: ‘Pouring money into the NHS has not delivered value for money.’ We also know that a period of record expenditure has coincided with a period of falling productivity and that health inequalities continue.

Investment in unscheduled care is largely predicated on reducing A&E attendance and improving access to services. In some cases we know that where there are walk-in centres, GP led health centres and other facilities designed to reduce the pressure on secondary services, A&E attendance is rising. Could it be that the designers of health services, like the developers of the M25 are forgetting the first rule of planning? New roads create new reasons to travel.

Most of the information about NHS investment exists somewhere. The trouble is that data is fragmented, there is a lack of whole-system accounts and a shortage of analytical capacity.

But there are encouraging signs of change. In the past year or two there has been a marked increase in emphasis on and development of analytical tools. The most recent example is provided by the Health Investment Network, part of the World Class Commissioning support and development website hosted by NHS Networks.

Among other things, the network provides a set of resources including a programme budgeting tool to help PCTs understand how they spend their allocation over 23 disease groups; a spend and outcome tool to help them analyse the relationship between expenditure and health outcomes; programme budgeting atlases, which help map expenditure against activity data; and NHS Comparators, which allows different data to be compared in the same format.

These tools will not solve the problems of the NHS but they will improve the basis on which decisions are made. They won’t suggest solutions, but they might draw the attention of managers to areas that might benefit from close attention. They won’t make it any easier to make hard and sometimes unpopular decisions about investment strategy but they should make it easier to justify why these decisions are made and to monitor the impact of resulting changes.

To those who mutter that this is too little, too late, what are the alternatives? A better informed NHS will be better equipped to tackle the challenges ahead. It will also be better placed to work with government on effective strategies rather than wait for policy to be imposed.

Of course it would have been better if the sense of urgency had set in sooner, but with NHS funding protected for another year there is still time to be wise before the event.