Wednesday 4 June 2014

Some thoughts on a £364m question.


The front page of Bradford's Telegraph & Argus was splashed with the terrible truth about health spending - a £364m 'spending gap':

Bradford’s health and social care services face a funding shortfall of a staggering £364 million over the next five years, health bosses have warned.

And one health board member has said the district faces some “really hard” decisions, including possible hospital restructures, as it tries to balance the books. 

Now that 'one health board member' was me - pointing out that something should be done now to address the problem. Indeed the longer we leave the hard decisions the more painful those decisions and the greater the prospect (as neighbouring Calderdale is discovering) of those decisions being imposed rather than agreed locally.

The instinct of observers is to start talking about 'austerity' or 'cuts' and to calling down opprobrium on the evil government for not protecting health services. And this instinct is wrong - however much Labour may pretend with their jobs tax to fund the NHS. The problem isn't maintaining levels of funding but increasing demand for health services. An increasing demand driven by two factors - the wonderful truth that we're all living longer (around three-quarters of NHS spending is on the over-65s) and the equally wonderful fact that clever scientists, doctors and surgeons are discovering ever more creative ways to improve medicine.

In the article where I'm quoted the issues raised are whether we need to review hospital provision in the District (we have three general hospitals) and whether there is the need for reform in primary care (there are still a lot of single-handed GP practices especially in the inner-city). But there are some other issues to explore including the application of technology to reduce the cost of healthcare - this could be telemedicine such as that pioneered at Airedale Hospital in partnership with the Prison Service. In the emerging model remote consultation removes the cost of transporting patients to hospitals for consultation and can be extended to supporting nursing homes and even the management of treatment for people in remote locations (Airedale's catchment includes the Yorkshire Dales).

We also need to consider that the funding gap in question is not a cut but rather an estimation of the shortfall in cash resource if nothing changes - there is no prospect of the roughly £1.2bn spent currently on health in Bradford getting smaller. Indeed the £364m estimated shortfall assumes that this figure will rise. This means that we need to find ways to increase productivity - getting more treatments than we currently get from a given budget, for example. This again makes for tough choices - for routine elective surgery do you commission private sector provision? And do you continue to improve the speed at which patients are released from very expensive hospital beds?

The other aspect of this productivity lies with self-care - or rather people being healthy enough not to need expensive medical support. Most of the population do not place much burden on health services (and, despite what the nannying fussbuckets say, this includes most smokers, drinkers and consumers of hamburgers). It is only as we age that this burden increases. If the age at which we become regulars at the doctor's surgery rose then this would represent a significant improvement (even though the long-term cost is unchanged as we will live longer).

We also need to direct investment towards things that really will reduce the health bill - chiefly by reducing or eliminating things that result in expensive hospital treatment. At present the public health budget is dominated by two things - treating people with drug and alcohol problems and running public health campaigns such as smoking cessation, weight management and alcohol awareness. We perhaps need to rethink some of this focus and to switch attention to environmental factors that contribute to those long hospital stays (typically by the elderly).

These factors where a sensible public health approach would concentrate would include:

  • Reducing trips and falls especially in the home
  • Programmes to reduce damp and cold conditions for the elderly
  • Initiatives aimed at improving air quality in urban environments
  • Actions to improve road safety

Alongside new technology, greater productivity and further private sector involvement, these sort of actions will help close the terrible spending gap - there may still be some tough decisions but we will have bought ourselves some time to make those decisions and implement them with care. I fear, however, that the producer interests dominating the health economy (most notably the medical profession itself) will act as a brake on many initiatives meaning we could end up closing hospitals, clinics and services rather than facing up to the challenges of improving the system's productivity.


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