Speculative Diversion: On Waste and Unnecessary Expenditure in the NHS (BBC News / Academy of Medical Royal Colleges / Department of Health / NAO / Carter Review / ILC-UK)

Summary

UK doctors and other NHS staff have been reminded there is an ethical duty to prevent waste in the NHS.

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Reference

Brimelow, A. (2014). UK doctors have ‘ethical duty’ to prevent waste. London: BBC Health News, November 6th 2014.

This relates to:

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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:

  1. 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).
  2. NHS Price Comparison Website: Improving Procurement in the NHS (BBC News).
  3. Medicines Optimisation: Helping Patients for Medication Best Usage (Royal Pharmaceutical Society).
  4. Shared Commitment Between NHS and Local Government Leaders to Integrate Care (BBC News).
  5. Adult Social Care Efficiency Tool (Department of Health).
  6.  NHS and Social Care Spending Estimation for Commissioners (Monitor).
  7.  Spend and Outcome Tool (SPOT) for Local Authorities (PHE).
  8. Speculative Diversion: Overdiagnosis and Overtreatment.
  9. Practical and Measurable Patient Safety Improvement Plans (BBC News).
  10. Jeremy Hunt Warns NHS Health Trusts Over Gagging Orders (BBC Health News).
  11. NHS Funding Shortage Forecast: Debate Proposed (BBC News / Times / House of Commons Health Select Committee / Nuffield Trust / Independent).
  12. 2015 Challenge Declaration (NHS Confederation).
  13. 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:

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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.

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Reference

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.

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Regulator sets up team to tackle billion pound agency black hole. London: Monitor, June 26th 2015.

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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…”

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Reference

Triggle, N. (2016). Chorley A&E closure: A cautionary tale? London: BBC Health News, April 14th 2016.

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.

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Reference

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.

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IT system for GP records criticised. London: BBC Health News, July 2nd 2015.

This relates to:

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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.

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Reference

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:

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Reference

Triggle, N. (2015). Simple steps ‘could save NHS £5bn’. London: BBC Health News, June 11th 2015.

This relates to:

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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

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Reference

Triggle, N. (2015). Hospitals in England to get individual savings targets. London: BBC Health News, October 21st 2015.

Further analysis:

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Pym, H. (2015). Lord Carter’s plans for saving the NHS £5bn a year. London: BBC Health News, October 21st 2015.

This relates to:

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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

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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.

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.

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Elderly ‘being trapped’ in hospital, says Age UK. London: BBC Health News, June 17th 2015.

See the Carter Review (above):

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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:

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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

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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.

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Medical legal costs ‘excessive and should be capped’. London: BBC Health News, June 28th 2015.

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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:

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Reference

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:

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Reference

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:

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Reference

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.

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Reference

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.

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Reference

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.

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Reference

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.

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Reference

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.

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Reference

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.

Fraud?

Independent estimates indicate that the cost of fraud to the NHS is probably between £3.73 to £5.74 billion per year.

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Reference

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:

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Reference

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:

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Reference

NHS health card fraud ‘only £700’. London: BBC Health News, September 11th 2015.

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.

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Reference

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.

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Reference

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).

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Reference

Doughty, S. (2016). Sickly immigrants add £1bn to NHS bill. [London, Online]: Daily Mail, [March 2016?].

Similarly:

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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:

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Reference

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”.

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Reference

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:

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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.

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Reference

NHS set to miss target on foreign patient costs. London: BBC Health News, October 28th 2016.

This relates to:

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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.

There is also a Press Release and an Executive Summary.

Chris Wormald says the NHS will go further in reclaiming money for treating foreign visitors:

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Reference

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:

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NHS overseas patient’s £330,000 unpaid bill. London: BBC Health News, February 1st 2017.

This relates to:

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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.

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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?

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Reference

MacIntyre, D. (2017). Who was the abandoned man with no memory? London: BBC Health News / BBC Panorama, January 30th 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:

  1. £501.7 million of potentially avoidable spending on people with dementia and depression.
  2. £377 million of potentially avoidable spending on people with dementia and diabetes.
  3. £115.7 million of potentially avoidable spending on people with dementia and urinary tract infections.

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Reference

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.

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Reference

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:

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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:

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NHS ‘overcharged’ by drug makers’ non-compete deal, says CMA. London: BBC Health News, March 3rd 2017.

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.

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Reference

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:

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Reference

Pym, H. (2017). Are NHS patients getting the best medicines? London: BBC Health News, April 28th 2017.

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