UK doctors and other NHS staff have been reminded there is an ethical duty to prevent waste in the NHS.
Brimelow, A. (2014). UK doctors have ‘ethical duty’ to prevent waste. London: BBC Health News, November 6th 2014.
This relates to:
Maughan, D. [and] Ansell, J. (2014). Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care. London: Academy of Medical Royal Colleges, November 6th 2014.
Possibly of related interest:
- The Financial and Human Costs of Mistakes (BBC News / Frontier Economics / CQC / NHS England / NHS IQ / BMJ Quality and Safety / Department of Health / BMC Family Practice).
- NHS Price Comparison Website: Improving Procurement in the NHS (BBC News).
- Medicines Optimisation: Helping Patients for Medication Best Usage (Royal Pharmaceutical Society).
- Shared Commitment Between NHS and Local Government Leaders to Integrate Care (BBC News).
- Adult Social Care Efficiency Tool (Department of Health).
- NHS and Social Care Spending Estimation for Commissioners (Monitor).
- Spend and Outcome Tool (SPOT) for Local Authorities (PHE).
- Speculative Diversion: Overdiagnosis and Overtreatment.
- Practical and Measurable Patient Safety Improvement Plans (BBC News).
- Jeremy Hunt Warns NHS Health Trusts Over Gagging Orders (BBC Health News).
- NHS Funding Shortage Forecast: Debate Proposed (BBC News / Times / House of Commons Health Select Committee / Nuffield Trust / Independent).
- 2015 Challenge Declaration (NHS Confederation).
- Text Messaging Improves Adherence to Cardiovascular Preventive Treatment: the INTERACT Trial (BBC News / Plos ONE).
Speculations on the Wastefulness of Misaligned Incentives and Poor Integration / Coordination
A brief “think piece” on the perverse incentives, short-sightedness and hidden wastefulness of silo-based thinking in commissioning; this opens a fresh perspective on willful blindness in the NHS:
Patterson, J. (2014). We must be blind. London [Online]: NHSNetworks, November 28th 2014.
Agency Staff, Private Finance Initiative (PFI) Schemes and Other Alleged Drains on NHS Finances
The House of Commons Public Accounts Committee (PAC) recommended radical improvements to make the NHS more financially sustainable.
Brimelow, A. (2015). MPs call for radical change to make NHS sustainable. London: BBC Health News, February 3rd 2015.
Monitor has reported that NHS spending on temporary staff increased by 29% to £2.4 billion in 2013-14. A team is working to identify weaknesses in staffing management and potential savings.
Regulator sets up team to tackle billion pound agency black hole. London: Monitor, June 26th 2015.
NHS England cap on agency payments comes into effect. London: BBC Health News, November 23rd 2015.
“ …some hospitals are [suspected to be] playing fast and loose with the cap regulations to make themselves more attractive…”
Triggle, N. (2016). Chorley A&E closure: A cautionary tale? London: BBC Health News, April 14th 2016.
Possibly of Northern Ireland interest:
Agency nurses ‘can cost Northern Trust £100K a year’. London: BBC Health News / BBC Northern Ireland News, October 6th 2017.
Midwifery Not Exempt?
The Royal College of Midwives estimates an annual bill of £100 million (2016 figures) for UK maternity units, arising from money mis-spent on three types of expensive temporary staffing arrangements:
- Agency staff.
- NHS bank.
This money could have funded between 2,700 and 4,300 full-time NHS midwives.
“ …the average hourly spend on agency staff was £43.65, compared with £18.20 for a staff midwife with 10 years’ experience in England and Wales”.
Triggle, N. (2017). The £97m bill for ‘midwife shortage’. London: BBC Health News, October 31st 2017.
The Private Finance Initiative (PFI) Arrangements Legacy
The Centre for Health and the Public Interest (CHPI) has discovered that Private Finance Initiative (PFI) companies take around 3% of the NHS budget (which has generated pre-tax profits of £831 million over the past six years for the companies concerned).
NHS ‘leaking millions’ in PFI contracts. London: BBC Health News, August 30th 2017.
Well-Intentioned Top-Down Re-Structuring at National Level
The Coalition Government’s reforms and re-organisation of the NHS are said by some to have resulted in distracting, damaging, over-complex and confusing new systems.
“Not only were there costs associated with making the changes (including redundancy costs to long-serving and often highly paid managers) but there were also costs in establishing many new organisations. Additional costs that are difficult to quantify resulted from marketisation of health services, as in negotiations between commissioners and providers, tendering and procurement exercises, and mergers and acquisitions. The opportunity costs of the reforms were as important as these direct costs, especially the way in which NHS leaders at all levels were distracted as they were required to rearrange the deckchairs…”. (p.23-4)
On the plus side, there is closer involvement of GPs in the commissioning of services, the responsibility for public health given to local authorities and the establishment of health and wellbeing boards.
Ham, C. Baird, B. Gregory, S. [et al] (2015). The NHS under the coalition government. Part one: NHS reform. London: The King’s Fund, February 2015.
Ill-Considered Procurement and Contract Management in Large Scale NHS IT Projects
The General Practice Extraction Service (GPES) cost £40 million to develop, instead of the predicted £14 million. It became only partially operational years later than expected.
IT system for GP records criticised. London: BBC Health News, July 2nd 2015.
This relates to:
General Practice Extraction Service – Investigation. Report by the Comptroller and Auditor General. Ordered by the House of Commons to be printed on 30 June 2015. HC 265. Session 2015-16. London: National Audit Office, July 2nd 2015.
There is also an Executive Summary.
New Drugs: Price Matters
Research from the University of York indicates that the price paid by the NHS in England for new medicines may be too high, diverting funds from alternative more effective treatments.
Mundasad, S. (2015). NICE ‘sets price too high for NHS medicines’. London: BBC Health News, February 19th 2015.
Carter Review: June 2015
Lord Carter on efficiency savings:
Triggle, N. (2015). Simple steps ‘could save NHS £5bn’. London: BBC Health News, June 11th 2015.
This relates to:
Review of operational productivity in NHS providers: an independent report for the Department of Health by Lord Carter of Coles. Interim report; June 2015. London: Department of Health, June 11th 2015.
Carter Review: October 2015 Recommendations
Triggle, N. (2015). Hospitals in England to get individual savings targets. London: BBC Health News, October 21st 2015.
Pym, H. (2015). Lord Carter’s plans for saving the NHS £5bn a year. London: BBC Health News, October 21st 2015.
This relates to:
Lord Carter: reducing variation in care could save NHS £5 billion. London: Department of Health, October 21st 2015.
February 2016 Update: The Carter Review Report
Operational productivity and performance in English NHS acute hospitals: unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles. February 2016. London: Department of Health, February 5th 2016.
Collaborative Purchasing Across Hospitals
A collaborative purchasing scheme across seven hospitals – involving agreed evaluation of the best products by clinicians, followed by bulk purchasing – generated savings of £2 million when tested on eleven products in Sheffield.
Clinician-led scheme in Sheffield frees up millions of pounds to fund frontline care through pioneering ‘price match’ scheme. London: NHS England, April 4th 2018.
Operational Productivity in Mental Health and Community Health Services
Potential savings of around £1 billion in efficiencies could be made, by 2020/21, across mental health and community health services.
Lord Carter of Coles (2018). NHS operational productivity: unwarranted variations – mental health services and community health services. London: Department of Health and Social Care, NHS England and NHS Improvement [Unbadged report; An independent report for the Department of Health by Lord Carter of Coles], May 24th 2018.
There is also an Executive Summary.
Delayed Transfers of Care
Age UK has pointed out that delays in hospital discharge are generally harmful for patients’ health, a waste of NHS resources and a potentially avoidable cost for taxpayers.
Elderly ‘being trapped’ in hospital, says Age UK. London: BBC Health News, June 17th 2015.
See the Carter Review (above):
Hospital bed-blocking ‘costs’ NHS England £900m a year. London: BBC Health News, February 5th 2016.
Professor Jane Cummings, Chief Nursing Officer (CNO) for England, recommended greater investment in social care, as NHS England spends an estimated £820 million per year treating older patients in hospital; people who could be treated more effectively and cheaply in the community:
Chief nurse: ‘Cut hospital beds to increase care at home’. London: BBC Health News, December 27th 2016.
N0n-Emergency Operations Cancelled Due to Bed Shortages
Surgeons ‘kicking their heels’ as bed shortage delays operations. London: BBC Health News, February 12th 2017.
Excessive Legal Costs for Medical Negligence Claims
The NHS was charged £259 million on legal fees for negligence claims in 2013-14. The Department of Health has plans to cap such charges by introducing a defined limit on legal costs in those cases where claims are valued below £100,000.
Medical legal costs ‘excessive and should be capped’. London: BBC Health News, June 28th 2015.
NHS negligence claims bill tops £1bn. London: BBC Health News, July 17th 2015.
The NHS Litigation Authority (NHSLA) is attempting to reduce the escalating medical negligence claims bill, which has grown to £1.4 billion per year:
Morris, J. (2016). NHS negligence claims hit £1.4bn. London: BBC Health News / BBC News, September 29th 2016.
Bungs From Personal Injury Lawyers?
Hundreds of NHS hospitals may have been hosting adverts for personal injury lawyers in return for payments / donations:
Kretchmer, H. (2016). No win, no fee adverts ‘common on NHS advice cards”. London: BBC Health News / BBC Radio 4’s You and Yours, November 28th 2016.
The government has re-asserted that it is against lawyers providing personal injury advice on NHS hospital wards, although it has been trying to prevent these conflicts of interest since at least 2012:
Kretchmer, H. (2016). NHS claims lawyers ‘unacceptable’. London: BBC Health News / BBC Radio 4’s You and Yours, December 23rd 2016.
Personal / Citizen Responsibility (1): Prescription Medication Funded by UK Taxpayers Awareness Messages
Approximately 30% – 50% of patients don’t use their medicines as intended. It is estimated that avoidable waste of medicines costs around £150 million per year. Packets of prescription medication costing more than £20 are to display how much their contents cost. The actual cost and the reminder “funded by the UK taxpayer” are expected to appear on packs in England, to increase general awareness of wasted medicines. It may be possible to reduce £300 million on wasted – prescribed but unused – medications.
Prescriptions to display drug cost. London: BBC Health News, July 1st 2015.
Personal / Citizen Responsibility (2): Cost of Missed Appointments Awareness Messages
Over 12 million doctors’ appointments are missed per year in the NHS, costing taxpayers roughly £160 million annually. Patients missing appointments are to be informed how much their appointment(s) actually cost the NHS.
NHS to reveal cost of missed appointments to patients. London: BBC Health News, July 3rd 2015.
Personal / Citizen Responsibility (3): Cost of Unhealthy Lifestyles
Public Health England (PHE) estimates that health problems arising from unhealthy lifestyles – including poor diet, obesity, physical inactivity, drinking and smoking – cost the NHS in England approximately £11 billion per year.
Hughes, D. (2016). Illnesses associated with lifestyle cost the NHS £11bn. London: BBC Health News, September 26th 2016.
York Health Economics Consortium estimates that the NHS spends 10% of its entire budget across the UK on diabetic care; this could rise to 17% by 2035 if rates of Type 2 diabetes continue to grow.
Hughes, D. (2016). Diabetes: Tenth of adults at risk of disease by 2035. London: BBC Health News, October 24th 2016.
Awareness: The BMJ’s Too Much Medicine Campaign
“The BMJ’s Too Much Medicine campaign aims to highlight the threat to human health posed by overdiagnosis and the waste of resources on unnecessary care”.
Click here to view recent articles relating to the BMJ’s “Too Much Medicine” campaign.
King’s Fund: Better Value in the NHS
The King’s Fund “Better value in the NHS: the role of changes in clinical practice” report presents examples of overuse and misuse. The authors suggest there are significant opportunities to achieve better value from the NHS budget.
Alderwick, H. Robertson, R. [and] Appleby, J. (2015). Better value in the NHS: the role of changes in clinical practice. London: King’s Fund, July 8th 2015.
There is also an Executive Summary.
Independent estimates indicate that the cost of fraud to the NHS is probably between £3.73 to £5.74 billion per year.
Triggle, N. (2015). Fraud could be costing NHS in England £5.7bn a year, says report. London: BBC Health News, September 24th 2015.
The NHS has been vulnerable potentially to fraud arising from loopholes in the issuing of European Health Insurance (EHIC) cards:
NHS vulnerable to EHIC card fraud loopholes, government admits. London: BBC Health News, August 10th 2015.
Suspiciously low numbers… Complacency, cover-up or merely a genuine storm in a teacup? Hard to judge:
NHS health card fraud ‘only £700’. London: BBC Health News, September 11th 2015.
The NHS Counter Fraud Authority (November 2017) reduced estimate may be incorrect, as fraud is – by definition – largely undetected.
Triggle, N. (2017). ‘Despicable’ fraud costs NHS in England £1bn a year. London: BBC Health News, November 1st 2017.
Antimicrobial Stewardship and the Challenge of Antimicrobial Resistance
It is estimated that 10 million prescriptions for antibiotics in the UK per year may be inappropriate.
NHS Staff Sickness and Absence Rates
It is estimated that the cost to the NHS of staff absence, due to poor health, is £2.4 billion per year; accounting for roughly £1 in every £40 of the total NHS budget.
NHS England has devised financial incentives to improve the health and wellbeing of NHS staff in England, with schemes covering mental health, physical activity, physiotherapy, improvement to flu vaccination uptake rates and action against junk food. This guidance involves the new Health and Wellbeing CQUIN, based on commitments made in the NHS Five Year Forward View.
NHS staff health & wellbeing: CQUIN Supplementary guidance. Leeds: NHS England, June 3rd 2016.
Ill-Conceived Hospital Mergers?
Analysis of 20 mergers between 2010 and mid-2015 found significant expenditure on mergers (£2 billion for 12 mergers) was based largely on faulty arguments and a lack of evidence.
Collins, B. (2015). Foundation trust and NHS trust mergers: 2010 to 2015. London: King’s Fund, September 23rd 2015.
The Costs of Sickly Immigrants and Health Tourism: an Oft-Ducked Issue
Questions have arisen as to whether the NHS is being subverted from a “national” health service into a global health service at the beck and call of all-comers (who typically will have not contributed to the taxation which pays for the increasingly expensive treatments on offer within this system).
Doughty, S. (2016). Sickly immigrants add £1bn to NHS bill. [London, Online]: Daily Mail, [March 2016?].
Dalgleish, A. (2016). Hospital spent £181,000 treating illegal immigrant: Taxpayers foot huge bill racked up by foreign patients using the NHS amid warnings high costs are ‘absolutely unsustainable’. [London, Online]: Daily Mail, March 2016.
“ …the NHS is wide open to people who have no right to use it and make no contribution towards its costs. Britain paid more than £674 million last year to EU governments for the care of UK citizens abroad, yet NHS hospitals received only £49.7 million for foreigners treated here. The amount recouped by the NHS was down on the previous year’s £50.3 million”. Lord Green: MigrationWatch UK Chairman.
More equivocal, but worryingly inconclusive:
What do we know about the impact of immigration on the NHS? London: King’s Fund, April 9th 2015.
Questions concerning the EU Referendum Debate are handled elsewhere. Official data shows:
“Reality Check verdict: There are no figures to show the exact cost to the NHS”.
Kovacevic, T. (2016). BBC Reality Check: How much pressure do EU migrants put on NHS? London: BBC Politics News / BBC Health News, April 15th 2016.
This relates to:
Visitor and migrants NHS cost recovery programme: Impact assessment, No: DH 3130. London: Department of Health, July 14th 2014.
Ensuring the National Health Service (NHS) Does Not Become the World Health Service
The Department of Health is expected to miss the target of recovering £500 million per year from overseas visitors treated by NHS hospitals in England. There are wide variations in cost recovery across Trusts, yet health professionals (ever bemoaning under-funding and lack of resources in the NHS) insist that helping to act as gate-keepers for the NHS is none of their responsibility. The National Audit Office estimates £289 million was recovered in 2015-16 and £73 million was recovered in 2012-13.
NHS set to miss target on foreign patient costs. London: BBC Health News, October 28th 2016.
This relates to:
The Comptroller and Auditor General of the National Audit Office: Morse, A. (2016). Recovering the cost of NHS treatment for overseas visitors. National Audit Office Report (HC 728). Session 2016-17. London: The Stationery Office [Department of Health / National Audit Office (NAO)], October 28th 2016.
Chris Wormald says the NHS will go further in reclaiming money for treating foreign visitors:
Proof of ID may be needed for NHS care, says health chief. London: BBC Health News, November 22nd 2016.
The Public Accounts Committee produced a report highlighting how the system(s) for recouping costs from overseas patients is shambolic / chaotic:
NHS overseas patient’s £330,000 unpaid bill. London: BBC Health News, February 1st 2017.
This relates to:
House of Commons Committee of Public Accounts (2017). NHS treatment for overseas patients. Thirty-seventh Report of Session 2016–17. Report, together with formal minutes relating to the report, ordered by the House of Commons to be printed 25 January 2017. London: The Stationery Office Limited (House of Commons Committee of Public Accounts), February 1st 2017. HC 771.
Health Secretary Jeremy Hunt has announced that NHS hospitals in England will be legally obliged to charge overseas patients for non-urgent care, upfront. Foreign visitors needing urgent care will be treated immediately and invoiced later, where they are ineligible for free treatment. The aim is to recover up to £500 million per year for the NHS.
Upfront charges for NHS foreign patients in England. London: BBC Health News, February 6th 2017.
International parasitism can impact on social care just as it can be a drain on the NHS. Health tourism by proxy?
MacIntyre, D. (2017). Who was the abandoned man with no memory? London: BBC Health News / BBC Panorama, January 30th 2017.
Patients of NHS providers are now asked for documentation showing they are entitled to free NHS care, such as a non-UK European Health Insurance Card. Access to A&E, maternity, general practice and infectious disease treatments all remain free of charge however; although maternity tourism alone is thought to be widespread.
Silver, K. (2017). Health tourism charges come into force in England. London: BBC Health News, October 23rd 2017.
Opinions differ as to the scale and significance of the amounts recoverable in practice (possibly reflecting different levels of motivation to change practice):
Reality Check: How much could NHS recover from foreign patients? London: BBC Health News, October 23rd 2017.
Inadequate Care of Co-Morbidities in People with Dementia
Disjointed substandard care is currently estimated to cost the UK’s health and social care system nearly £1 billion per year. Broad cost estimates include:
- £501.7 million of potentially avoidable spending on people with dementia and depression.
- £377 million of potentially avoidable spending on people with dementia and diabetes.
- £115.7 million of potentially avoidable spending on people with dementia and urinary tract infections.
Scrutton, J. [and] Brancati, CU. (2016). Dementia and comorbidities: ensuring parity of care. April 2016. London: International Longevity Centre (ILC-UK), April 5th 2016.
Anti-Competitive Monopolies in the Supply of Some Generic Prescription Drugs
The Association of the British Pharmaceutical Industry (ABPI) has condemned price rises potentially costing the NHS over £250 million in unnecessary expenditure per year. Some businesses make excessive profits hiking their prices for generic prescription drugs, according to the Times newspaper.
Pym, H. (2016). Generic prescription drugs: are prices excessive? London: BBC Health News, June 3rd 2016.
Research by the European Cancer Congress indicates that UK prices for generic cancer drugs have risen excessively over the past five years. Price increases for generic drugs, and super-normal profits for the drug industry arising from anti-competitive practices, could be costing the NHS in England £380 million a year:
Cancer drugs price rise ‘costing NHS millions’. London: BBC Health News, January 29th 2017.
Further Anti-Competitive Price-Fixing Agreements
The Competition and Markets Authority (CMA) believes Actavis and Concordia may have fixed the market for at least one drug; yet this may be the tip of the iceberg concerning over-charging across the industry:
NHS ‘overcharged’ by drug makers’ non-compete deal, says CMA. London: BBC Health News, March 3rd 2017.
Public funding of drugs development research, but private pocketing of the profits?
Cohen, D. [and] Clifton, H. (2017). Taxpayer-funded drugs ‘too expensive for patients’. London: BBC Health News (BBC 5 Live), October 22nd 2017.
NHS Oversight Asleep at Wheel? Other Explanations Invited
Concordia appears to have abused market dominance and made super-normal profits by overcharging the NHS millions for the thyroid treatment liothyronine. The NHS spent over £34 million on liothyronine in 2016, compared to £600,000 in 2006.
“The amount the NHS paid per pack rose from around £4.46 in 2007 to £258.19 by July 2017, an increase of almost 6,000%”.
NHS overcharged by millions for key drug, says watchdog. London: BBC Health News, November 21st 2017.
This relates to:
Drug company accused of abusing its position to overcharge the NHS. London: Competition and Markets Authority (CMA), November 21st 2017.
Possibly also of interest:
Boots owner denies overcharging NHS for cancer mouthwash. London: BBC Health News, May 26th 2018.
The Cancer Drugs Fund in England: Well-Intentioned Policy on the Hoof?
The final assessment of Cancer Drugs Fund is that it may have been an uncontrolled waste of money, and in most cases (with some exceptions) may not have delivered significant benefit to patients.
“When it was launched it was not monitored properly. It was politically and intellectually lazy”. Professor Richard Sullivan: King’s College London.
Triggle, N. (2017). Cancer Drugs Fund ‘huge waste of money’. London: BBC Health News, April 28th 2017.
Big pharma’s trade body, the Association of the British Pharmaceutical Industry (ABPI), disagrees and submitted a public-relations revenge rebuttal early:
Pym, H. (2017). Are NHS patients getting the best medicines? London: BBC Health News, April 28th 2017.
Getting It Right First Time (GIRFT)
The Getting It Right First Time (GIRFT) report on general surgery identifies potential efficiency savings which could save the NHS an estimated £268 million every year.
Abercrombie, J. [et al] (2017). General Surgery: GIRFT Programme National Specialty Report. London: NHS Improvement, Royal College of Surgeons and Royal National Orthopaedic Hospital, August 2017.
Low-Value General Surgical Interventions?
A systematic review identified 71 low-value general surgical procedures. Discontinuing five high-volume, high-cost general surgical procedures (“inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis”) could save the NHS €153 million per year.
Malik, HT. Marti, J. [and] Darzi, A. [et al] (2018). Savings from reducing low-value general surgical interventions. British Journal of Surgery. January 2018; 105(1): pp.13-25.
Under-Utilisation of NHS Resources?
NHS Improvement estimates that NHS hospitals could perform 280,000 more non-emergency operations per year by organising operating theatre schedules optimally.
Pym, H. (2017). How operating theatres are wasting two hours a day. London: BBC Health News, October 24th 2017.
Pym, H. (2017). Do NHS operating theatres really have ‘wasted time’? London: BBC Health News, October 31st 2017.
Bailouts and Short-termism in NHS Funding / Planning
The National Audit Office reported that sustainability and transformation funding had been misdirected into handling short-term financial pressures and local deficits. There is a need to re-consider how to stop the (unintentional) misuse of sustainability and transformation funding.
Therrien, A (2018). NHS bail-outs could become new normal, National Audit Office says. London: BBC Health News, January 18th 2018.
This relates to:
The Comptroller and Auditor General of the National Audit Office: Morse, A. (2018). Sustainability and transformation in the NHS. National Audit Office Report (HC 719). Session 2017–2019. London: The Stationery Office [Department of Health and Social Care / National Audit Office (NAO)], January 19th 2018.
“ …a wide range of estimates for costs range from €67.93 per intercepted error for inhaler medication to €6,927,078.96 for litigation claims associated with anaesthetic error”. p.4.
Triggle, N. (2018). Drug errors cause appalling harm and deaths, says Hunt. London: BBC Health News, February 23rd 2018.
This relates to:
Elliott, RA. Camacho, E. [and] Campbell, F. [et al] (2018). Prevalence and economic burden of medication errors in the NHS in England. London: Policy Research Unit in Economic Evaluation of Health & Care Interventions (EEPRU), February 22nd 2017.