Balancing budgets or protecting patient safetyBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6943 (Published 22 November 2013) Cite this as: BMJ 2013;347:f6943
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Prof Chris Ham paints a gloomy picture of the problems facing the NHS in England. In particular, he seems to draw the conclusion that there are only two viable options: to increase staff numbers and not balance budgets; or to cut costs and staff, “even if it means compromising patient safety and quality”. His third option “that there is a way of protecting patient safety and quality and balancing .. budgets” receives no critique.
However, I think this third option is not only viable but is the only option that is capable of providing both safer and less costly care. Chasing costs may help in the very short term (3-6 months) but not in the medium to longer term. The loss of good will and the destabilising effect of fewer permanent staff will lead to reliance on more costly agency staff who neither know internal processes nor have any particular commitment to the organization. The remaining staff spend their energy looking over their shoulders – or looking for another job – rather than spending it on improving the organization.
What is the alternative? In September 2013, Eiji Toyoda died at the age of 100 (1). He was responsible for the creation of the Toyota Production System, among other things, defining waste as anything not done (maximally) effectively first time. However, he also created something more profound: a working Creative Ideas & Suggestions System. The company receives annually an average of 50 ideas per employee, of which over 96% are implemented. If we had this in NHS in England, the 1.4 million employees would generate 70 million ideas. If only 80% were implemented and saved less than £2 per week each, our patients would benefit from a more effective, less wasteful service. In addition, we would have saved £5.6 billion in the first year; £11.2 billion in the second etc, because of permanent system improvements rather than short-term cost-cutting. (As an aside, this makes the Nicholson Challenge (2) look not only achievable but almost unambitious.) Furthermore, because we are implementing ideas from staff, both morale and commitment to the organization are likely to rise.
The aim should be to provide a continually improving service for patients; in an environment that is safe for patients, carers and staff, physically, emotionally and professionally; without waste. This will require a retreat from the current paradigm of ‘low cost or low quality’ but will be in the long term interests of the service and the patients we aim to serve.
(1) Eiji Toyoda obituary: http://www.nytimes.com/2013/09/18/business/global/eiji-toyoda-promoter-o...
(2) Nicholson Challenge: http://www.publications.parliament.uk/pa/cm201011/cmselect/cmhealth/512/...
Competing interests: No competing interests
We would like to write in support of Mr Ham’s concern of the potentially irreconcilable tension between balancing the books and the delivery of high quality healthcare. During an NIHR-funded Safer Delivery of Surgical Services (S3 Study) we have been fortunate to work alongside front-line nursing, medical and managerial staff in a variety of NHS hospitals (district general, teaching and specialist centres) as they attempt to improve their working systems using a number of different quality improvement techniques (standardisation of work, lean process engineering and crew resource management). We will be reporting the effects of these interventions in the near future, however one overarching finding is the universal lack of time in the system for front-line staff to undertake pro-active service evaluation or to recommend, implement and evaluate change. This is in stark contrast to most successful industrial and manufacturing organisations. We postulate that the availability of this time may in fact form a suitable marker of the effect of real-term spending reductions, as the wider NHS seeks to utilise all staff time for the direct delivery of clinical care. We are concerned about the possibility that focusing on this noble aim without thought to the consequences may in fact be to the detriment of service improvement and quality maintenance, as well as the training and investment in the next generation of clinicians.
This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Reference Number RP-PG-0108-10020). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests: No competing interests