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Doctors must lead efforts to reduce waste and variation in practice

BMJ 2013; 346 doi: (Published 06 June 2013) Cite this as: BMJ 2013;346:f3668
  1. Chris Ham, chief executive, King’s Fund, London W1G 0AN, UK
  1. C.Ham{at}

US healthcare organisations show that leadership by doctors is essential in tackling the pressure of further financial cuts and to halt the decline in performance if the NHS model is to survive, says the King’s Fund chief, Chris Ham

The King’s Fund’s latest survey of NHS performance in England paints a picture of a service struggling to cope with increasing demands at a time of unprecedented resource constraint.1 2 The pressures on the NHS are greatest at the front doors of hospitals, with waiting times in emergency departments the longest they have been in a decade. The prime minister’s pledge to maintain the commitment to treat 95% of patients within four hours in emergency departments was broken in the first quarter of 2013, a clear and worrying signal of what lies ahead.

With public spending under renewed scrutiny as the chancellor concludes the spending review for 2015-6, there is little prospect that more money can be found to deal with these pressures. Indeed, with press reports suggesting that some of the supposedly ring fenced NHS budget may be taken to support hard pressed social care services, health service leaders will have to redouble their efforts to squeeze more out of existing budgets.3 The challenge they face is how to do so when about two thirds of these budgets go on staff, and when recruiting and retaining sufficient nurses and other front line staff are critical to the delivery of high quality and safe patient care.

This challenge will not be met by salami slicing budgets and cutting management costs and back-office functions. Instead, the focus should be on the myriad decisions taken every day by doctors, nurses, and other clinicians on how to treat patients. These decisions—for example, on which drugs to prescribe, what tests to order, and whether to admit patients to hospital—determine how most of the resources of the NHS are used. Reducing wide and unwarranted variations in decisions between general practices and hospitals could help cut waste and release resources to deal with the increasing demands on the service.4

The autonomy of doctors helps explain why variations in medical practice persist, and why politicians and managers cannot reduce them without the full and enthusiastic involvement of medical staff. Putting general practitioners in charge of commissioning care for patients is an attempt to do this, but it is too early to assess how effective clinical commissioning groups will be. Equally important is to engage doctors providing care in hospitals and other services to see prudent stewardship of scarce public resources as a key part of their role. Recently published research shows that the NHS still has a long way to go in supporting doctors to take responsibility for budgets and services, just at the time when this has never been more vital.5

The importance of doctors leading the quest for improvements in the NHS was brought home to me on a recent visit to several high performing healthcare organisations in the United States. Without exception, these organisations are led by experienced doctors who combine credibility with their peers with a deep understanding of what needs to be done to deliver high quality care within available resources. Medical leaders in Kaiser Permanente in California, for example, explained that in their experience improvements are best achieved by doctors being committed to high quality care rather than having to comply with externally imposed targets and standards. It is this culture of commitment and not compliance that is fundamental to the high standards of care delivered in Kaiser Permanente, as seen in independent national rankings of health plans.6

Intermountain Healthcare in Utah goes further, to argue that in some cases high quality care costs less. This is because of the waste involved when patients do not receive the right treatment first time and have to remain in hospital longer than necessary or in some cases to be readmitted for errors to be corrected. A core strategy in this organisation, widely admired and studied for the excellence of its care,7 is to standardise how care is delivered by medical leaders working with their colleagues to agree on best practice guidelines, thereby reducing variations in care. Intermountain Healthcare enables its staff to make improvements by a long term investment in training in quality improvement techniques.

The same applies in the Virginia Mason Medical Centre in Seattle, which for many years has led the adoption of Toyota’s lean production system in healthcare. Like the other organisations visited, Virginia Mason understands the key role of doctors in leading change and their intrinsic motivation to provide the best possible care. It supports them and their colleagues to do so by honing their skills in reviewing how services can be improved by reducing delays and eliminating activities that are not worth doing.

The good news is that all three of these organisations show what can be achieved when medical leaders focus on tackling variations in clinical practice and reducing waste. The more sobering news is that each has been on a long term journey of quality improvement that has taken years to deliver results and has no defined end. All the more important, therefore, that the NHS takes heed of these lessons as it seeks to deliver more value for patients and taxpayers within a tightly constrained budget. Without effective medical leadership and support to enable front line staff to improve care, the prospect is of ever declining performance and fundamental questioning of whether the NHS model can be sustained.


Cite this as: BMJ 2013;346:f3668


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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