Ten-Year Plan – we need to move from what to do, to how to do it
When there is so much low-value care in the NHS, it is tempting to wonder if the extra injection of funds into the NHS might mean that a precious opportunity is being missed. Teresa May’s cash promise is being turned into a wish-list by pundits and pressure groups attempting to influence the Ten-Year Plan. There is a lot of advice about what to do, and most of it is about doing more. But no-one is pausing to think how we might do things differently and deliver better value for the people and populations receiving care from the NHS.
At best, the NHS’s record on delivering personal value is patchy. Professor Al Mulley from Dartmouth College, a long-time friend and close observer of the NHS, reminds us that the NHS Plan of 2000, which led to a major injection of resources, also led to an enormous increase in unwanted and unnecessary procedures. People were given, and continue to be given, treatments, such as hip replacement, stents, chemotherapy, and cataract surgery, that do them more harm than good, not because of quality or safety issues – those have been successfully addressed – but because “wrong patient surgery” (people receiving care with no benefit, and the potential for harm) runs at over 20%.
Moreover, the NHS, tasked with providing universal healthcare, still has depressingly high levels of inequity. The results of most studies suggest that someone living in the most-deprived ward of England is only one-third as likely to have a hip or knee replacement as someone living in the least-deprived ward. Although a focus on the broader determinants of health inequalities is important, it seems that one of the major causes of inequality, inequity, has been ignored.
The degree to which the NHS has addressed population value is no better. In some parts of England, the NHS appears to deliver high value, achieving better outcomes for people with conditions such as diabetes despite investing less resources than geographies with demographically comparable populations. In other areas, the opposite is true.
Overall, the spread of higher and lower levels of investment, and better and worse outcomes for different population groups across the country, is so scattered as to be random. The English NHS does not focus on value, nor on learning to improve value. Furthermore, the NHS does not make conscious decisions about where it is best to invest resources.
If, in the Ten-Year Plan, there is a policy decision to increase funds for mental health, it will be important to pause and determine in which parts of England, and on what mental health interventions, the increased investment should be made. Before receiving extra funds, geographical areas with pre-existing high levels of investment need to learn from those areas achieving the highest value. Areas in which there are poorer outcomes for people receiving care and low levels of investment need funding, but only to help them replicate the success of areas with demonstrably higher-value mental health systems. Extra funds should be spent on increasing value, not on increasing capacity.
This months issue of the month was brought to you by Dr Tim Wilson, 3V Managing Director.