How would you cut the NHS budget?

The NHS budget is going to be cut. Recently the Today programme asked for money-saving ideas. Here are some suggestions.

1. Remember that health is a not a commodity and keep the market out of it. Professor Michael Sandel made the argument elegantly in the 2009 Reith lectures.
2. Do not let direct advertising of prescription medication into the UK. And stamp on pharmaceutical advertising aimed at ‘disease mongering’. See the BMJ article by Ray Moynihan, Iona Heath and David Henry.
3. Do not allow doctors a financial stake in businesses which give them an incentive to investigate and hospitalise patients. In his article in the New Yorker in June 2009 Atul Gawande illustrates how much this adds to costs and how it actually worsens health outcomes.
4. Educate the public to understand that investigations have a false positive rate, and in a healthy population this is likely to be far higher than the true positive rate. Health care professionals could do with a revision course too. Whoever does the testing, it is the NHS which pays for investigation of these false positives. This is not without risk, and we know that a positive test, even if subsequently negated,  permanently undermines people’s confidence in their health and increases health-seeking behaviour. Professor Charles Warlow’s describes his experience of commercial screening in a church in Edinburgh in his recent BMJ article.
5. In my experience of sitting on committees, the smaller the pot of money to be disbursed, the larger and lengthier the meetings called to decide on its fair distribution. Are we reaching the Jarndyce v Jarndyce point at which all the money is spent on making the decision, leaving none for distribution?
6. Fire the management consultants. I understand that a PCT spent £45,000 on management consultants whose advice led to a saving of £10,000. £35,000 could have financed quite a lot of patient care. Managers are paid high salaries to manage, so how come they have to pay large sums to consultants to tell them what to do? On the Today programme, Roy Lilley, terrier of the NHS, opined that many are incompetent. Many GPs would agree.
7. Put patient benefit at the top of every PCT agenda. Anything which directly improves patient care is difficult and seems to take second place to government must-dos and displacement activities like writing ‘latex policies’.
8. Most managers are very remote from patients. I would like to see every manager, including GP practice managers, obliged once a week to walk through a full waiting room and to talk to some of the patients. And to ask themselves every time they launch a policy what difference it will make to the patients they met last week. I recall meetings at a community mental health trust. The board room was near the wards for severely mentally disabled patients, who would wander in during meetings grinding their teeth and grabbing handfuls of sandwiches. They provided a powerful reminder of why we were meeting.
9. Whatever your view on the regime in Cuba, there can be no doubt that it is a poor country with a first world standard of health. Cuba’s expectation of life and infant mortality rates are at least as good as the UK’s and better than the USA’s — at a fraction of the cost. Yet when planners look around for models for improvement they have a blind spot: the Cuban experience is rarely if ever considered. It should be. Not everything in their health service would work or be acceptable in this country, for social and political reasons, but there may be lessons we can learn, and if we don’t look we won’t find out.
10. Educate the public to understand that good health is not a right but a matter of luck, self help and good sanitation. Doctors and medication play an important, sometimes vital, role, but there is not a pill for every ill, and pills are no substitute for personal effort and attitude. Nor are normal emotional states such as low mood, shyness and grief, illnesses. And it would help if more people realised that most illnesses are self-limiting and what is needed is time not tablets.
11. The NHS has a carbon reduction strategy. There are plenty of examples demonstrating that reducing the NHS’s huge carbon footprint can also save money and improve patient care and working lives.
12. Look hard at prescribing. Medication is large part of both the NHS budget and its carbon footprint, and much of it is wasted. I recall a patient who came up every month for his pills. When he died a five year supply was found untouched in his wardrobe. His prescription was a passport to a chat with the receptionists. Many of those who do open the packet take their medication incorrectly, so gain no benefit but risk adverse reactions. Patients accept prescriptions for all sorts of reasons, including over-optimism about the efficacy of pills and a wish not to say no to doctors who are ‘doing their best’. And doctors write them for all sorts of reasons with only a tangential relationship with therapeutic efficacy. Doctors need time to establish the sort of relationship with patients to say honestly what they feel about medication and why they don’t want to take it.
13. Walking is good for health, for the environment, and the NHS budget. That applies to staff and patients. Regular exercise improves health and may reduce the need for drug treatment of hypertension, cardiovascular disease, hyperlipidaemia, diabetes, COPD, obesity, depression, anxiety, agitation (in both the young and the demented), stress in all its psychological and physical manifestations, many rheumatological problems, constipation and no doubt other conditions I haven’t thought of.

What are your ideas?

Moynihan, R. (2002). Selling sickness: the pharmaceutical industry and disease mongering * Commentary: Medicalisation of risk factors BMJ, 324 (7342), 886-891 DOI: 10.1136/bmj.324.7342.886
Warlow, C. (2009). The new religion: screening at your parish church BMJ, 338 (may20 1) DOI: 10.1136/bmj.b1940