Dr Lansley's Brave New World?

We are now well into the convulsions caused by Andrew Lansley's radical reorganisation of the NHS in England. Already, the NHS senior management establishment is undermining much of what he set out to achieve. We were told that it was expected that there would be about 550 consortia formed. Clearly this is far too anarchic for the bureaucrats and they have fought back with dogged determination to ensure that the "new" NHS structures retains as much as is possible of the "old" NHS structures (that got us where we are today).

Now, the NHS hierarchy seem determined to create much bigger consortia than was originally envisaged. They are suggesting that in East London, the minimum size they see as sufficient to create the necessary economies of scale is about half a million patients. That is roughly the combined populations of the London Boroughs of Newham, Tower Hamlets, Hackney and The city of London. Amazingly enough (or not), that is precisely the description of the existing "cluster" formed by the amalgamation of the three PCTs last year. If you divide the poulation of England by half-a-million, that would mean about one hundred consortia for the instead of the 550 suggested by Dr A and his merry men. This is all a far cry from the original plans as they were explained to us.

Meanwhile, the PCT/Cluster seems determined to fashion things as it thinks they ought to be rather than what the commissioning groups think or want. Since it is these same PCT managers that got primary care where it is today, they’re mostly the people I would rather were NOT designing their replacement. However,  turkeys rarely vote for Christmas and here in East London, the turkeys still reign.

I now longer have either the energy or the enthusiasm to try and change things.

At a personal level, I am saddened by how little of the energy that is being expended is making any difference to patient care. Things are being rearranged, usually at some considerable cost, but rarely to make things better. We have been tricked into doing the government’s dirty work for them presiding over significant cuts in funding despite all the rubbish that ministers spout about “spending in real terms”. Primary care is 90% of the care and 10% of the funding. Giving us amateurs the budget for the other 90% whilst slashing it can only be poor value for taxpayers and poor value for patients. The answer to the problem of NHS managers that clearly can’t manage is to find managers that can, not give it to GPs who have no training or experience.

I am glad I will have retired by the time that our local general hospital announces firstly that it will have to close its A&E service (probably done in stages by first reducing opening hours), and then that it is closing most of the rest of the hospital too. For consortia, they should realise that the politicians will be quick to point out that this will be a commissioning decision so it will be their fault.

Let's think the unthinkable - smoking

In the 1970s, I spent a great couple of weeks in Bristol learning about "Operational Research". This was the original name of what is now called "Applied Statistics" - using statistics to solve a specific "here and now" problem. The course lecturer had formerly worked on the great technological white elephant that was Concorde.He explained that he watched the Concorde project abandon financial commonsense as delays, overruns, modifications all added to the bill. That's the trouble with big numbers. They start to reach a size where we loose our grip on reality. Once you start talking "billions", then £0.05 billion seems like petty cash.

But it isn't. It's fifty million quid!

Our lecturer explained that he kept his sanity by converting all these overspends into Mars Bars. He knew the volume of a Mars Bar and how much it cost. It was fairly simple arithmetic to represent the "latest cost overrun on the Concorde undercarriage system" into enough Mars Bars to fill three aircraft hangars - floor to ceiling .. wall to wall! You may think he was potty but it kept his cost accounting feet firmly rooted on the ground instead of in project-financial fairyland. I have taken advantage of his wisdom ever since. It helps me to ensure that cost projections, financial forecasts, etc. can all stand up to real world scrutiny.

Which leads me to the NHS expenditure on helping people to stop smoking. Why are we forking out MILLIONS of pounds for smoking cessation treatments? People smoking a packet of fags a day are spending £42 a week on the habit. They could afford to buy any of the various OTC patches and potions for a fraction of that. I've checked on Amazon and patches vary in price from £1.05 each up to £1.75 or in cigarette terms that's between six and eight ciggies a day. If they do give up, then they will reap the financial benefit for the rest of their lives.

By this point, any "health professional" reading this will have marshalled the forces of righteous indignation to attach me as an inhumane and illogical idiot (which may be true but that's not the point). Helping people to stop smoking saves the taxpayer money. You've all see the headlines. Smoking costs the NHS £1.5bn, £3bn, £5bn a year (what's a few billion matter here?). Don't believe me? Just click on this link to Google and see what numbers pop up for "smoking costs NHS". Read the headlines for yourself.

Increased likelihood of coronary heart disease, lung, throat and mouth cancers, respiratory disease, etc.etc. are all consquences of smoking. However, there are also savings to the NHS and the taxpayer.

• The excise duty on cigarettes is vast: excise duty in 2010 is estimated at £8.8bn and VAT is a further £1,7bn. (Tobacco Manufacturers' Association). That's ten percent of the total NHS budget of £103.8bn
• The biggest cost to the NHS is in treating the effects of getting old. If smokers (on average) die sooner, then whilst they still incur the costs of their chronic conditions but save on the costs of elderly care.

If the NHS wants to have a financial debate about smoking, then perhaps it should consider encouraging us to smoke. It looks as though there's a net gain in terms of revenue and expenditure here! Even if I'm wrong, about the big picture, I still don't see why we should be subsidising people who want to stop smoking any more than we should subsidise people who want to stop biting their nails or sucking their teeth.

The NHS is running out of cash. We have more important things to do than this.

(for the record: I use to smoke - sixty-a-day in fact. So did my son. He now runs marathons and I get my exercise watching him occasionally).

Alice in Budgetland

The NHS year runs from April to the following March. Over the past couple of years, we have been encouraged to take a greater interest in the cost of the medicines we prescribe for our patients. You might think that such interest would be a "given" but it is not so. The NHS relies on doctors to "do the right thing" when choosing which drug to prescribe. At the same time, these same doctors are the targets of the intense promotional activity by the drug companies. Busy doctors have little time to take a calm, measured look as the latest drugs on offer.

One positive move was the allocation of prescribing budgets to GP practices. The carrot has been the offer of allowing practices to keep a proportion of any savings they make providing these savings are reinvested in improving care for patients. At the moment, there is no "stick"; there are no sanctions for exceeding budgets but it is hard to believe that won't come in due course. Last year we saved £70k from our budget. We look forward to using these savings to add to our services. An in-house physiotherapist; an acupuncture clinic, and the like. Our budget this year is £1.33m. That's our share of a total budget of £32m for the PCT as a whole. We have worked hard to make further savings and at about the half-way point (the latest figures available) we have increased our savings to an annualised £130k. Great! We can continue to offer these extra services and add to them.

This week I received a letter from our PCT. They have finally incorporated the changes in payments to community pharmacies. These changes will have to be funded from this year's budget. It means that £1.8m additional funding has to be found. Thats about 5% of the total budget and it will have to come out of all our budgets.

Let me see. Five per cent of our budget is £66k. Gone! Half the savings we have worked hard to achieve. It is the end of month nine of our financial year. What is the point?