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Cash-strapped London health services must consolidate HIV specialist provision
Lansley missing cost savings that could also benefit care quality
The Coalition Government is failing to realise productivity gains that are crucial for protecting the quality of NHS services, according to a new Civitas report. Andrew Lansley has wasted time by trying to force through wholesale changes to health commissioning, reforms which are now widely accepted as unworkable. But the Government could save millions of pounds by focusing commissioner attention on reconfiguring specialist services that have been inefficiently managed for years.
Commissioning London's HIV Services uses the case study of HIV care in London to show how specific health services could be reformed without the costly overhaul of NHS commissioning as a whole. Unless these genuine savings through increased productivity are made, patients will face poorer health services with longer waits as budget cuts begin to bite.
Obstacles to better care
Currently, many specialist services are neither cost effective for taxpayers, nor provide the best available care for patients. It is widely acknowledged by clinicians that services can be improved by closing mediocre or failing hospital departments and concentrating expertise in centres of excellence. Commissioning London's HIV Services reveals that key stakeholders know where efficiencies and improvements can be made to HIV provision, but that a status quo bias amongst hospital consultants and management is holding back reform. Government weakness in the face of producer interests is a key factor:
Many interviewees drew attention to the lack of support afforded to commissioners to take difficult decisions around service reconfiguration. Political rhetoric remains focused on institutions, not services... (p.14)
Changing face of HIV
When HIV first emerged in the 1980s, patients typically had critical and intensive-care needs. But HIV has since become a stable, long-term condition, not typically requiring specialist consultant input on a regular basis:
As HIV care has shifted further towards the domain of evidence-based or 'precision' medicine, the need for consultant specialist input in the routine management of HIV has decreased. (p. 13)
But services have not been adapted to long-term care. Many hospitals remain equipped to receive HIV cases throughout London:
23 hospital trusts deliver HIV outpatient services in London; ranging from small units that see 200 patients to larger ones catering for up to 6,000 patients. (p. 9)
These hospitals lack the on-call expertise to deliver world-class evidence-based medicine in acute cases, but are not cost-effective at providing outpatient services for those with stable conditions. They continue to have patients referred to them, because they continue to be paid by weak commissioners:
While nine hospital trusts are commissioned by the HIV Consortium for HIV inpatient care, others still provide this but bill on a case-by-case basis. Commissioners recognise that there is oversupply and variable quality; and that services are commissioned more on the basis of historic precedent than quality. (p. 9)
Savings needed now spending tide is out
The report finds that commissioners have been unwilling to tackle inefficient and poor quality providers. While health budgets expanded, it was possible to protect bad providers without having a visible impact on overall quality:
Interviewees argued that the significant increases in the NHS's budget over the past decade have enabled commissioners to duck difficult decisions on service reconfiguration and continue paying for poor quality. (p. 15)
Now, as the NHS faces significant reductions in planned spending, and economic growth continues to stagnate, bad providers are a luxury the NHS can no longer afford. The report argues that commissioners must concentrate resources on the best HIV health services in London and close unnecessary and inefficient services. Primary care providers, such as GPs and clinics away from hospital sites, should be reconfigured to deal with the needs of stable HIV-positive patients, while the best hospital centres could concentrate on patients with complex needs:
Commissioners, whether PCTs or the new GP consortia now known as clinical commissioning groups, must 'take some balls' and be prepared to take the difficult decisions they have thus far ducked away from: to reconfigure and decommission services. (p.17)
A model for effective reform
HIV provision is just one example of where failure to reconfigure services, close poor hospital departments and pull services into the community is both wasting taxpayer money and resulting in poor patient care. Earlier this year, a King's Fund study reported that a proposed reconfiguration of services across the hospital sector in South East London, including centralising A&E services, could produce a net annual saving of between £25-30 million per year, while improving patient care.
International evidence shows that focused centres deliver better results than centres that try to do parts of everything:
- The Texas Heart Institute in the US does only cardio-vascular operations. It obtains better outcomes for 44% less cost than the average Medicare payment.
- The Coxa Hospital for Joint Replacement in Finland does only orthopaedic operations. Its complication rate is 0.1% against the average of 10-12% in other hospitals. Yet it is 30% cheaper.
The same logic applies for disease-specific networks that treat and help people manage chronic diseases, such as Healthways in the US, rather than people being sent from hospital department to general practice and back again.
James Gubb, director of the Civitas health unit said: 'Encouraging specialisation and excellence in specific areas is more likely to find real savings than the Government's broad brush commissioning reform.'
For more information contact:
James Gubb on 07930 243570
Civitas 020 7799 6677
Notes for Editors
i. Rosalind Miller holds an MSc in Public Health and is a Research Assistant at the London School of Hygiene and Tropical Medicine.
ii. James Gubb is director of the health unit at Civitas, a post he has held since 2007.
v. Civitas is an independent social policy think tank. It has no links to any political party and its research programme receives no state funding. Civitas's health policy research seeks to take an objective view of health care in Britain. It aims to offer an improved perspective on how best to deliver equitable and high standards of health care for all.