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Why you won’t get much change out of £20bn


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Thursday, 12 April 2012

Why you won’t get much change out of £20bn

The NHS has a bizarre view of money. Here’s the evidence. Last week’s quick poll asked what effect a 20% budget increase might have. There were three possible responses: a) outcomes would improve by 20%, b) they would improve but by less than 20% or c) nothing much would change.

Polls like this usually have predictable results – that’s why we like them – and the risk with this one was that everybody would go with the obvious option a).  If resources increase by X%, outcomes would improve by a similar degree, right?

Apparently not.

Only one in ten believes that you get a like for like improvement for a bigger investment in the health service. A sceptical 51% think the money will make some difference, but that what came out would be less than what went in.  

If we were talking about famine relief going to a war-torn and corrupt dictatorship, that answer would make sense. The money would be siphoned off and used to build a new golf course and spa complex in the palace of the mad despot, and to buy cocaine and Kalashnikovs for his bloodthirsty rabble. 

However dim a view you take of NHS bureaucracy, you’d expect all of the investment to get through to the front line. Well, wouldn’t you? 

Even if we allow for the view that waste cannot be completely eradicated from the system, the biggest surprise is that 38% believe that increasing investment by 20% would result in no change. Really? 

The belief that a sudden windfall of £20bn plus would produce no benefit is shocking and inexplicable. Perhaps morale is now so low that some people have given up hope or maybe they believe that the NHS reforms will be a huge drain on resources. The former is too depressing to contemplate and the latter is illogical: even by the most pessimistic estimate, the reforms won’t cost billions to implement.

Two years ago we ran a poll asking if the aims of the QIPP programme were realistic. It found people broadly optimistic that the NHS could save money without damaging care. 

Apparently we have faith in our ability to tighten belts and knuckle down in a period of austerity, but rather less faith in our ability to invest wisely when money is no object. 

Or in other words, the NHS can do more with less but not more with more. That’s pretty scary if you think about it.

Have you got an alternative theory? Share it by commenting on this blog. And before anyone points out that the poll is not statistically valid (someone always does and it never is), vote yourself. Simply go to the NHS Networks home page and scroll down for the poll. 25,000 of you get this newsletter, so we ought to be able to clock up a few hundred more votes. We’ll keep the poll running for another week and let you know how it turns out. 

PS The following objections are inadmissible: scenario not credible, question hypothetical, terms of reference not qualified, "outcomes" not defined. 


Hendricks says:
Apr 12, 2012 09:42 PM
I don't quite understand the link between 20bn and 20%, even mathematically it would only apply if the basic budget is 100bn at present.

However this is not the point here. 20bn could lead to more or less the 20% or nothing depending on what you do with it and how you measure it.

The reason why I do not like such simplified questions is that the answer can be anything as the system is far too complex.

If you invest 1 million pound in setting up a national staff bank system with automatic registration of any permanent or fixed term NHS employee including their availability to do additional work hours, their CRB check details and confirmation of mandatory and statutory training and give trusts access to recruit from this bank at rates that are slightly higher then normal rate, but much less then locum rates you actually get massive savings.
You even get better care if you include a rating system for hospitals to rate the person and the person to rate the hospital.

You invest, save money and improve care.
Give me the million to set it up and I proof it.
Improve our IT systems and massive improvements will follow. E.g. invest in an electronic prescribing and bedsmanagement system in all hospital trusts. You will see massive improvements followed by savings.

More ideas can follow.

Any objections????
trevorjenkins says:
Apr 13, 2012 08:31 AM
Let's get some sense and sensibility into the question firstly. What are the "outcomes" and do we measure the correct ones from a) patient b) financial c) professional d) social e) other ? Yes ? yes ? yes ? Go ahead and make my day and show the model for how we demonstrate the 20% increase in "outcomes". Walk before you can run?
Karen.Michael-Cox@briscomhealth.nhs.uk says:
Apr 13, 2012 09:22 AM
"If we were talking about famine relief going to a war-torn and corrupt dictatorship, that answer would make sense. The money would be siphoned off and used to build a new golf course and spa complex in the palace of the mad despot, and to buy cocaine and Kalashnikovs for his bloodthirsty rabble. "
mjones3 says:
Apr 13, 2012 09:22 AM
The obvious answer to this question is: "yes, outcomes would improve by 20%."

Now give us the money. We can sort out the detail later.


Dr. Ashton Leighton
Softhead Clinical Commissioning Group
StephenMasters says:
Apr 13, 2012 09:42 AM
With a bit more money, my PCT will hopefully allow my wife's consultant to prescribe the 80mg of Humira she needs instead of the 40mg they say she can have. This will then save her life, which would be a really improved outcome compared to the currently expected outcome. Is there anyone out there
capable of initiating this?
swarmington says:
Apr 13, 2012 09:52 AM
If we can't say for sure what time of day/night real human beings are discharged from hospital, what chance have we got of working out if cash injections make any difference?
lyndon.johnson@nhs.net says:
Apr 13, 2012 10:27 AM
How often do I see PCT's suddenly get told to spend some cash on 'x' project. Has to be delivered/spent in two months - no baseline and no sensible system of measurement in place.
Back of a fag packet calculation happens - pointless project ensues, people wonder why there is no improvement....if there was how would they know?

Can you imagine Google spending vast sums of money negotiating between its departments on how they are funded? Why are providers not simply given a pot of money per capita rather than the dysfunctional child parent relationship between commisioner and providers?
jo.verrall@eastcoastkent.nhs.uk says:
Apr 13, 2012 11:02 AM
As someone else has pointed out, there is no connection between £20bn and a 20% improvement in outcomes. What units are outcomes measured in? Oh that's right, all different depending on the intervention. Even with a specific intervention, outcomes are often complex and interlinked, so how would you decide what percentage increase you had achieved? It seems that the people voting are better at maths than the original poster, but I hope the OP comes back and apologises for scaremongering and writing such a doom-and-gloom article! And I don't think I've had to use any of the "inadmissable" objections...
jo.verrall@eastcoastkent.nhs.uk says:
Apr 13, 2012 11:08 AM
Well OK, re-reading properly, it did orignally say a 20% increase in budget, not £20bn. But I still think it's not valid question. If you asked "If the NHS budget is increased by 20% will the NHS be 20% better?" more people might respond positively - I think a lot of us have problems with the complexity of outcomes and their measurability.
philton says:
Apr 13, 2012 01:13 PM
A reason why outcomes would not match expectations is that suppliers would salivate over £20Bn likely a hungry pack of wolves parked outside McDonald's. Their grossly inflated prices and over-infflated assessmenst of the value and utility of their products is a key factor for me. Oh and the apparent inability of Government (by no means just the NHS) to rule them in.
SJBurnell says:
Apr 13, 2012 02:52 PM
Past performance is often a good indicator of likely future performance. Are we convinced that a 50% increase during past government delivered 50% more / greater outcomes?
swisbauer says:
Apr 13, 2012 02:53 PM
With less than 2% spent on prevention and many of the expensive diseases being preventable, spending some more money to curb the increasing rates of obesity, diabetes etc. would seem a wise investment if made on evidence-based interventions. One cheap change would be to introduce ways that actually create an incentive to play ball, e.g. our vascular screening programme has poor participation rates. Abu Dhabi's has 99%+, if you don't show up you don't get your national health insurance card... the mantra that education alone will curb the public health trends is clearly not working...
janrock@tiscali.co.uk says:
Apr 13, 2012 03:02 PM
My background has been in public sector regeneration programmes and I suggest the following:

Sebastian - your suggestion - a waste of public money - work with Job Centre Plus and private sector providers to deliver this. Why waste money re-inventing the wheel?

Jo + Trevor - outcomes are measured in 'distance travelled from the original baseline'. It has nothing to do with money spent - other than demonstrate the 'return on investment' in services. Past projects + increased budgets delivered 0% ROI.

Lyndon - You're dead right. In my experience PCT's can't develop or implement 'effective' projects or commission services properly. They do not appear to understand the role and purpose of 'commissioning'. Within the NHS there appears to be no culture of learning or continuous improvement through which to transform service delivery. Also no strong leadership through which to deliver the necessary change.

Martin - 22 years of regeneration experience has demonstrated that more money = no change. Learn from the mistakes of other public sectors. Your suggestion to 'give us now/worry about it later' - is a typical 'old school' public sector response to money. The outcome is predictable - no change - because in order to find the right solution to the problem (i.e. deliver a valid project) - you need to understand what the problem is in the first place. This then provides the valid business case through which to deliver change.

Step aside NHS managers and let public sector regeneration staff show you the way! Over the past 20-25 years - we've seen it, done it; and got the T-shirt!
lyndon.johnson@nhs.net says:
Apr 13, 2012 05:31 PM
I agree with you Jan apart from thier are pockets of resistance....i mean good practice in the NHS. We just need to move all NHS managers to a place where they would be comfortable presenting thier project proposal in a dragons den environment. IE its well thought out organised and set up for measurement success or fail.
I think a lot of big NHS projects would get laughed out of the room in a functional commercial environment and that is the level we need to be operating at.
phil.lucas@live.co.uk says:
Apr 13, 2012 10:55 PM
The proposition here was very simple, but most of the posts here deride the question for being simplistic, which is not the same thing at all.
Why is there so much huffing and puffing about the need to define terms? Whatever people think they are being asked or however they define an outcome, the fact remains that most people think that however much you put into the NHS rather less comes out of the other end.
You can argue about how you measure it until you're blue in the face.
What the poll shows is that most people think that for every pound you invest in the NHS, you'll get less than a pound of value back.
It might not add much to our knowledge of health economics, but it's a fascinating insight into the psychology of the NHS.
Any industry would expect to get a proportionate gain from investment. It might be a dividend for shareholders or, in the case of the NHS, a dividend for patients.
So why is it different in this case? It's not a difficult question. Perhaps it's just a difficult pill for some people to swallow!
phil.lucas@live.co.uk says:
Apr 14, 2012 06:24 PM
Think Jan said what I was trying to say, plus she's got a T-shirt. My vote is that we leave it to her.