David Nicholson, chief executive of the NHS, is said by those who meet him, to be fizzing with good ideas. It is Sir David’s thankless task to prepare the NHS for the age of austerity – a Parliament or more when, notwithstanding the mollycoddling of the NHS budget that is every politician’s priority, the unprecedented largesse of the last decade will become an ever more distant memory. Modest real terms increases in health spending, if that, are the order of the years, with the emphasis on modest.
Since last summer, Sir David (knighted in the new year’s honours) has been telling the NHS that it must deliver between £15 and £20 billion of “efficiency savings” over the next three years and has developed a reputation for thinking creatively about how this level of savings might be realised – for example by closer working with the private sector – rather than opting for obvious cuts. “We will have to do things we haven’t thought about before”, Sir David told the Health Select Committee on Thursday 21 January, during the Department of Health’s annual grilling by the Committee on its overall spending plans.
The questioning of Sir David and his team by the Committe proceeded along well-worn lines. The IT programme; the financial returns on PFI projects; the “Agenda for Change” non-revolution in pay; all had their outings. By the end, however, the impression created by Sir David and his colleagues was that when it comes to delivering the £15 to £20 billion, everything and nothing is under review.
No doubt this can partly be accounted for by the stage of the electoral cycle, with the NHS officials knowing full well that they could be serving different political masters in a few months time, but convention dictating that this is the war they must not mention. Perhaps it was because not a single Conservative member of the committee had shown up, but the election was hardly mentioned. It was left to a Labour member – the Dartford GP Howard Stoate - to push the witnesses on whether there were more savings to be found from further outsourcing of services and “contestability”, a topic from which, given its political sensitivity, they were glad to escape without giving any firm commitments.
The election was brought up on one occasion however, when the Liberal Democrat Sandra Gidley wondered about the potential impact of regime change on the Department’s predilection against ring-fencing of budgets for specific purposes.
Ms Gidley – a pharmacist – took the Department to task for pursuing the goal of more nurses with degrees – pandering, she called it, to the aspirations of the Royal College of Nursing and a bad case of “intellectual political correctness”. Ms Gidley’s main point seemed to be that the Department was encouraging the growth of more and more highly-qualified nurses, without making financial allowance to meet their higher pay expectations.
The difficulties shown by some of the NHS’ most senior officials trying to answer such charges stems from the fact that the NHS lacks a culture of rigorously measuring what it is trying to achieve. The PAC report on Agenda for Change, for example, pointed out that NHS trusts were never asked to measure the productivity improvements the policy delivered – a curious omission when that was the raison d’etre of the policy itself and the trusts the ones who were going to implement it.
This was apparent time and again at the Health Committee hearing. Committee chairman Kevin Barron MP asked the witnesses what they knew about the health benefits that have resulted from arguably the biggest success of Labour health policy in the last decade – the crushing of waiting lists. Nothing much was the answer. What evaluation had taken place of the cost-effectiveness of the copious government spending of recent years aimed at reducing health inequalities? None – though research is being carried out to look at “spearhead” PCTs. How will you evaluate the success of the CQUIN programme – the Government’s principal drive to improve quality standards through commissioning? We haven’t worked this out yet.
On one point, however, he does seem clear. Kevin Barron, again on the topic of waiting lists, asked whether savings could not be made by relaxing the targets – letting the numbers waiting, and the time people wait, drift up again. Indeed, they could, Sir David replied, but we don’t want to go there. And nor, one suspects, would Andrew Lansley. As Sherlock Holmes says, when you have eliminated the impossible whatever remains, however improbable, must be the truth.
Judging by the session, Sir David Nicholson and his colleagues have an uphill task delivering the NHS efficiency savings they are promising.
