The leaked McKinsey report on the NHS, which endeavoured to provide a review of areas where efficiencies can be achieved in the face of declining public finances does not really offer anything we don’t or at least shouldn’t already know.
NOTE: This post does endorse the McKinsey’s report findings — only to express some surprise that it was not more insightful. Of course, I have only read the leaked documents, and cannot comment more fully, but then if the Department of Health did want a proper (adult) debate, they would put it in the public domain for all to see. Perhaps McKinsey would, as supposedly insightful strategy consultants, suggest to the Department the value of a wider social debate on the NHS priorities — but this isn’t their style. The wisdom of crowds, or the madness of experts?
So on with the commentary.
As if at least 20 years of NHS reform meant nothing, OECD countries together are grappling with rising healthcare expenditure coupled with demand that seems insatiable. The recession and its consequences has for many offered a useful policy window through which to drive changes that under more benign economic circumstances would be untenable. Health, as always, is the last to face the music.
What actually is the NHS? In the UK, it is 4 devolved publicly (tax) funded universal health systems (England, Scotland, Wales, Northern Ireland run their own show); McKinsey is writing about the English NHS. The “NHS” is often described as one of the largest employers in the world, but then healthcare systems are generally large employers, usually about 5% of a country’s workforce, consuming around 9% of GDP. The whole health industry is usually about 15% of GDP, employing perhaps 7-8% of the workforce. So they are all big. What characterises the UK’s fascination with the NHS is the tendency to speak of the NHS as though it were ‘one thing’, whereas it is more likened, perhaps more accurately, to a confederation. Regretfully, policy makers have failed to really make sense of the role of private and non-profit providers so there is really only weak integration of services across all providers. This constrains policy and service delivery somewhat in England as there is always the fears of privatisation and so on. It is worth keeping in mind though that general practitioners are private sub-contractors, while the acute sector is increasingly run by autonomous arm’s length hospital ‘foundations’ (a weak attempt at copying a hospital arrangement from Spain).
So the NHS is an acute service provider, a contractor for primary care from service providers, and a buyer of services from acute providers. That it is characterised by a purchaser/provider split is helpful in understanding the constraints under which the system works, as the purchasers (primary care trusts) are in the main general practitioners commissioning (English jargon for buying) care from acute providers. This engenders some confusion in the public domain between who is responsible for the planning and problems that get thrown up. The McKinsey report can be seen either as a message to acute providers to reduce their overheads, or a message to purchasing organisations to set contracts with tighter cost controls for the value received (i.e. for the care provided at what level of quality to their patients).
The politicians are indeed running around in a bit of a frenzy because the NHS is seen as a sacrosanct public sector organisation, and that cutting the budget would be equivalent to committing treason. Of course, this adds to the problem and increases the denial. This strengthens the hands of those who oppose reforming healthcare, and makes the case for increasing efficiency and productivity, and in general ensuring that the public receives good value for the tax money spent on healthcare more difficult.
Yes, healthcare is a hands-on activity, and yes we need hospitals (at least for now). But it is hubris to suggest that the acute hospitals are as productive and efficient as they could be, or that the distribution of clinical work across the health professions is a well done as it might be. Hospitals by and large still draw on industrial age models of organisation — they are little different from commercial conglomerates. Efficiencies in McKinsey’s report comes from things such as:
- vertical integration (hospitals into community care, for instance)
- integrated care pathways (something healthcare has been up to for at least 20 years)
- reduction of waste and duplication (no surprise there)
- role clarification of clinical work (yes, professional cartels called Royal Colleges)
- elimination of clinically ineffective or doubtful work (the tough call but is a natural consequence of evidence-based medicine).
Criticisms of the report are right to the extent that McKinsey has done what they are generally good at: stating the obvious. Any of these items should be on any hospital CEO’s to-do list, and subject of Board level discussions. Unfortunately, where McKinsey is less good is in looking at the NHS and assessing the underlying logic and meaning of its organisational structure, its clinical care paradigm, and how it can evolve, as a dynamic entity, into a better care system (they would surely argue that that wasn’t their brief, but good consultants work with, not just for, their clients).
But salaries and infrastructure (buildings) are the costs to look at: perhaps 80% of a hospital’s budget. Choices here require a different logic, and include:
- using e-health, telehealth technologies to replace both staff and infrastructure (home telecare monitoring, for instance)
- use of supportive clinical decision-support technologies (from robotic vision systems to work with radiologists to scan mammograms, thus doubling the number of radiologists, to artificial intelligence systems to data-mine health records to identify patients are risk of A/E readmission to a COPD exacerbation)
- using medicines to replace hospital stays, surgical interventions
- using best-imaging-technology first to diagnose (the best technology to diagnose a problem is not generally used in initial diagnosis, an x-ray might be used, then CT, then MRI. Just use the best first.)
- and so on.
These all address the possibility of labour (clinical work) substitution, (which might improve the quality of the jobs clinical and support staff actually do), greater patient empowerment (as they take greater control of their healthcare, direct resources to achieve their own healthcare goals), and a real use, slowly being addressed by the Connecting for Health initiative, for information for clinical and patient decision-making. This emerging information value-chain will produce improved measurement of clinical outcomes, and thus inform better in-hospital decision-making and resource allocation.
Of course this ignores the actual physical unbundling of hospitals themselves. The organisational logic that requires the aggregation of clinical skills in the modern hospital is dated under many service scenarios.
So where are we? We are at the point of knowing that much can be done to improve the patient’s experience of healthcare, by driving out dated clinical and organisational practices, adopting new practices and technologies, procedures and methods. It should not be inconceivable for any healthcare system to achieve 20% savings. Fear of alienating clinicians is less the issue than engaging them in service improvement, to which they should be committed. This will in the end ensure the high-touch requirements of healthcare where it is needed, without protecting sacred cows and vested interest groups. In the end, it will come down to political will, managerial commitment, and clinical professionalism to ensure, in a publicly funded healthcare system, that the public gets what it thinks it is already paying for. Otherwise, resistance looks a lot like protectionism.