The call for efficiency in the NHS is hurting the ethos and values that embodies this national institution says Dr. Simon Poole, and suggests not everything could or should be measure by value for money.
There has been repeated criticism in recent years that those working in the NHS have failed to demonstrate an adequate understanding of cost. Yet the world of the NHS has changed: GPs now juggle huge budgets commissioning services on behalf of their patients, and the private sector is increasingly involved in service provision. Any lack of understanding is no longer so apparent.
There are ever more sophisticated ways of measuring how doctors handle patient care and finance departments across the NHS collect and scrutinise data to demonstrate “value for money”, constantly endeavouring to drive down costs. Meanwhile, private companies look for opportunities to bid for contracts in very specific areas of the NHS where a healthy profit is quickly discernible.
In primary care, the contracts offered to GPs are detailed on pricing, target delivery and efficiency. The emphasis is on cutting back on the use of hospital resources, especially through fewer patient referrals to see consultants. There is constant pressure to reduce the amount of money assigned to basic patient care in return for greater financial rewards for using things such as “Choose and Book” (an electronic system which is supposed to give patients the freedom to choose which hospital or clinic they are referred to), or for engaging in central IT strategies or reducing patient referrals.
The NHS procurement guidance for tendering General Practice services, which attracts competition and interest from the private sector, confirms that:
“The contract will be awarded on the basis of the most economically advantageous offer judged on price, delivery performance, risk and over all cost effectiveness. These factors are not listed in any particular order of importance.” There is no mention of quality, experience, reliability, commitment, education or training.
Yet the vast majority of patient consultations in primary care are entirely unrelated to issues of financial efficiency or the achievement of targets. Certainly there is a cost to this, but also there is value: value that is often difficult to clearly demonstrate.
There is no adequate measure to “justify” time taken to care for the dying. No price that can be attached to compassionate support and advocacy for a carer of a mentally ill relative. No defined “outcome” when providing reassurance and health education to a vulnerable single mother and child. An alcoholic who cannot or will not comply with treatment for the sake of their health and performance targets may still need help with pain and depression from a non-judgmental, sympathetic health professional who has perhaps developed a relationship with them over many years.
What demonstrable efficiency saving can be made through the holding of a hand?
When a health visitor attends a family in crisis, with childhood behavioural problems and conflict, how do we measure the preventative work that might make the difference between repair and learning or descent into breakdown and antisocial or even criminal activity?
This “softer” side of the cradle to grave care envisaged at the inception of the National Health Service is difficult to define, yet is the prime motivating influence for much of the workforce. The training and education of front line health service staff has great focus on the importance of communication, listening, intuition, consultation skills and empathic personal care. Yet health service management is today focused almost exclusively on cost efficiency and target delivery, and is performance managed with a ferocity that has been described by some who work in the system as poorly disguised bullying.
Government ministers and managers might do well to consider what patients value most of all, perhaps considering Einstein’s observation that “not everything that can be counted counts, and not everything that counts can be counted.”
There is a limit to the lessons that can be brought to the NHS from market systems. The concept of “value” in healthcare is one that needs far more research and understanding. As more evidence is gathered to attach price and cost to services, there is an urgency to acknowledge that our comprehension of value and outcome is considerably less sophisticated. Failure to recognise the importance of care to which we cannot attach a cost might ultimately destroy much of the humanity, commitment and compassion we experience every day in our Health Service, which would be a high price to pay indeed.
