Money, money, money

The theme of this year’s NHS Confederation conference was money – and how the health service is going to cope when it has much less of it after 2010-11. Delegates were keen to discuss the importance of leadership and human resources; but reluctant even to mention the word technology. Lyn Whitfield reports.

The ACC in Liverpool is so new that the NHS Confederation had to book it for its annual conference before it was completed.

A lot of regeneration money must have gone into the bland concrete and glass building, with its obligatory light-filled atrium and ring of oddly-shaped chain hotels.

Yet it feels disconnected from the city centre, and the credit crunch has done for many of the flats that must have been planned for the windswept development sites on its edges.

As it happened, the ACC was a weirdly appropriate venue for Confed 2009. Inside, the main topic of debate was whether the NHS will also be left with little to show for the billions that have been lavished on it over the past few years, as it heads into harder economic times.

£15 billion and counting

Confederation policy director Nigel Edwards underlined just how much harder those economic times will be in a paper published to coincide with the start of the event last week.

It explained that if government spending grows by 0.7% over the comprehensive spending review period that starts in 2010-11, and debt repayment and benefits soak up most of this money, other departments will see their spending fall by 2.3% overall.

As shadow health secretary Andrew Lansley tried to explain on Radio 4’s Today programme, protecting NHS spending will mean even bigger cuts for some.

Yet the Confederation’s paper calculated that even if the health service sees its funding stand-still or increase slightly, increased demand plus higher costs will leave it facing a real-terms shortfall of up to £15 billion over five years; more if hard cash has to be released from the system.

One of the paper’s aims was to try to head off some of the political debates and short-term managerial thinking that sapped the energy of the health service during the 1990s.

Then, there was constant discussion of whether Britain could afford the NHS, as waiting lists lengthened and managers let hospital ceilings cobweb over to save the cost of cleaners climbing ladders.

Yet the paper’s immediate result was to trigger a political row, with new health secretary Andy Burnham seizing on Lansley’s comments to get up a new line on “Tory cuts.”

As it got underway, the Department of Health at least tried to shore up the message to managers, with conference speaker after conference speaker urging that co-operation, innovation and quality – rather than budget disputes and salami-slicing – were the way forward.

“The worst case scenario is that we talk about future financial challenges now, but don’t actually do anything,” said NHS chief executive David Nicholson. “I don’t want to see us running around trying to sort out the problem when the money dries up in 2011.

“We’ve got time to plan, organise and invest in people and services now. The worst thing would be to hide in our bunkers and stop driving reform.”

Worse and worser

In a final debate titled “how bad is it going to get?” Mike Farrar, chief executive of NHS North West, warned delegates that the NHS was “on a burning platform for change we should have done, but might not have done because we were cushioned by the money coming into the system.”

“If the problem is to improve efficiency and quality and to engage patients and staff in how to do that, then that is what we should have done four years ago,” he said. “So if this is a catalyst for that, then it could be a good thing.

“However, my concern is that we are having lost of debate at the macro-level, when we need to talk about developments that will deliver real, countable benefits at the local level.”

Indeed, if there was a weakness in the event, it was that it failed to generate practical examples of the type of innovation and quality improvement the NHS should be looking for. In particular, there was a hole where the role of technology in driving and supporting change should have been.

In the final debate, only one of the five high-powered speakers even mentioned IT. Michael O’Higgins, chair of the Audit Commission, held up telemedicine as a technology that could improve services while also saving money.

“There are technologies that are win-wins,” he told E-Health Insider in a brief conversation after the debate. “For example, online check-in is cheaper for airlines, but I use it because it is more convenient for me.

“There are places where the NHS is adopting this kind of thinking. We have flagged up some great work that is happening in Kent, where people are able to take their own blood pressure at home and send the results back to health service staff.”

However, he suggested that “technology” was not a concept that played well in the health service, “which is perhaps why people are talking about innovation.”

Don’t mention the tech

Other delegates were blunt about why technology was missing from the debate. “If you mention the word technology, chief executives think you mean the National Programme [for IT in the NHS] and they just don’t want to go there,” said one policy expert.

This view was supported by trying (and failing) to vox-pop managers about their views on IT, and by Brian James, chief executive of The Rotherham NHS Foundation Trust, which was sharing a stand with McKesson and some of its partners to highlight the work it is doing outside the programme.

“NPfIT has killed it,” he said. “By 2011, there is no way we will get Lorenzo, so people are discounting technology from what they are going to do. Unless they are prepared to do what we have done – and then they should have started two years ago – they are stuck.

“We could see the money running out in 2011, so we decided to make sure we could go paperless by then. We are hoping to get our new patient administration system and 15 systems in by next June, and we are working with Perot Systems to adapt their pathway redesign approach to make sure we get the benefit out of them.

“But most people are not going to see a technological solution by 2011, so they are not building technology into their response.”

Having said which, plenty of companies believe that the NHS is going to have to invest in some technology in the challenging years ahead.

The huge exhibition attached to the conference drew in a large number of consultancies, outsourcing and shared services companies and business intelligence specialists; alongside NHS agencies dedicated to helping it make better use of information.

Kevin Fickensher, executive vice president, international healthcare, at Perot Systems – which has also been installing RiO in London for BT – said it had had seen an “evolution” in managerial thinking about technology.

“When we started, there was a disconnect, with trusts pretty much saying ‘this is your project, get on with it’,” he told EHI. “Now the foundation trusts, in particular, are seeing that they need to invest significant resources because they need to improve productivity and efficiency.

“It also seemed like there was very little discussion about what people wanted to achieve in terms of quality, or whatever. That was very different to the US, where a big hospital group would set targets for bed days, put in IT, and then measure whether it delivered them.

“But that is changing as well, and we have had a lot of interest in our approach.” Fickenscher also predicted that trusts would become increasingly interested in out-sourcing their IT support and even their applications through ‘cloud’ computing.

“In the past, there was no reason for trusts to think about these things, because their money was allocated centrally,” he said. “In the future, it will be different.”

The future lies in the past

The nagging fear, however, is that post 2010-11 future will not be different, but a return to the paper based, cheese paring past.

In a show of hands, only 40% of those attending the “how bad is it going to get debate” thought that the NHS could make the savings it would need to make by innovating for efficiency and quality. And that must have included a fair few who thought it could – but might well not.

Link: Dealing with the Downturn: the greatest ever leadership challenge for the NHS?