Future Health Care in the UK

This morning’s headlines say 50,000 front line NHS jobs have to go because of ‘cuts’, even though the cuts referred to are actually a budget freeze. Like many, my first instinct is that this is at least partly a political response from the health service to show how painful the ‘cuts’ are. I also am certain that inefficiencies could easily be made to maintain costs as they are or even greatly reduce them, rather than cutting provision of front line care. Since the NHS budget has doubled in the last few years, they should be able to manage if they are even modestly competent and well intentioned. If they can’t, then it is time to say enough is enough, abandon the NHS as the right way to provide health care, and start again from the ground up. To throw ever increasing spending at an organisation with ever-reducing standards is madness. Costs must be saved, and they can, even as health care can be improved.

Firstly, our doctors are paid far more than French or German doctors in spite of delivering worse results , and that’s clearly where much of the extra funding has gone. The previous government showed great incompetence when negotiating their new contracts.And it isn’t just that we have happier doctors, therefore better service. Overpaying actually reduces the quality of service they deliver, if only because overpaid people are less willing to work long or unsocial hours for a bit more cash – the incentive to take on such extra work is greatly reduced. Staff remuneration needs to be brought down significantly. If their contracts can’t be renegotiated, then a ban on bonuses should be implemented – they should not automatically get bonuses regardless of performance, and a ban on external working alongside NHS work. An indefinite freeze on rewards is necessary until inflation and natural wastage brings them back into line. Meanwhile marked increases in their personal pension contributions should be demanded, since doctors, like other public sector workers, pay far too little into their pensions for the rewards they expect to receive. A windfall tax on doctors’ excess remuneration could even be considered in the light of their inappropriate over-reward.

Secondly, the NHS makes far too little use of basic existing technology and common sense approaches to service provision, ensuring extreme levels of financial waste. For example, people are often called to hospital appointments only to spend ages in waiting rooms. In fact, it is not uncommon for many people to be given the same appointment time, with the excuse that the staff don’t know precisely how long each appointment is likely to take. This contempt for patient time is obvious throughout health care. It would actually be easy to set up a web-based appointments system that automatically uses neural networks in the booking systems that can reliably estimate appointment duration, so that people could be give an approximate time when they are likely to be actually seen. This would require far fewer receptionists and appointments clerks, and I for one would much rather deal with a computer program than a difficult receptionist. Furthermore, with extensive use of text messaging by so many companies to keep in touch with customers, the NHS should be expected to be able to send text messages to patients when their appointment time is coming up instead of demanding they come hours in advance. So patients could wait at home or in the office until it is time to make their way to the hospital, GP surgery, clinic, or dentist. One result would be better patient satisfaction, another, less loss of temper and less staff abuse. Another, less need for waiting room space, saving costs and liberating much needed space. Another, less demand on car parking spaces, saving costs, reducing congestion and even freeing up space that could then be rented for park and ride schemes. Another, lower infections rates from other patients sharing the waiting room, especially at GP surgeries. With so many benefits, it is hard to see why this isn’t done already – the technology has been available for several years, so there really is no excuse. Apps should be freely available for phones that can automatically register their arrival and then guide people to the right clinic so far fewer receptionists would be needed. Already, it is clear that current technology could make many existing NHS staff unnecessary. Increasing use of robotics for transportation of patients and more use of IT to send patient records instead of human couriers – all this would see staff needs drop year on year. Cleaning too is generally a rather primitive and ineffective affair, resulting in thousands of unnecessary deaths every year, far more than the number of road deaths. Approaches such as use of ultraviolet sterilisation, oxidation and other approaches could make cleaning more effective, save lives, and still be cheaper. Technology in the cleaning field is rapidly developing and needs to be used more as it becomes cost effective. Organisationally too, there is surplus. Any visit to a hospital ward confirms that nurses spend a lot of time chatting around the desk, suggesting that there are often more than required. However, patients sometimes go uncared for, so this suggests that organisational structures are not correct, or improved response mechanism are needed.

Thirdly, AI is beginning to be used effectively in health care, even in NHS Direct, allowing relatively low skilled nurses, technicians or even website bots to give advice that would previously have needed a more highly skilled (and paid) doctor. But now that expert systems can often outperform GPs in diagnosis, and AI is improving quickly, we should use AI ever more extensively. Also, many people who go to see the doctor already know what is wrong and know what they need. We should trust people more to self diagnose, especially when assisted by such AI systems (with full logging). A simple licensing system (with  a license revocation threat if abused) could bypass doctors altogether for many common conditions and even pharmacists for that metter, since an electronic license could easily be interrogated by shop tills to ensure that medicines are tracked propoerly. Again, this combined and extended use of AI across appropriate tasks could greatly reduce the number of clinical staff. We would need fewer GPs, nurses, surgeries to house them, and the associated staff. It will take much longer to reduce the numbers of surgeons and direct operating theatre support staff, as robotics is merely a useful tool at the moment and it will be a long time before operations can be fully automated end to end.

Even with such basic changes, some of which are long overdue, enormous cost savings could easily be made, while improving front end care. With fewer receptionists and clinical staff, more automation and use of the web and mobile phones, we would also need far fewer managers and administrators (and the self driven need for other managers and administrators to look after them). A virtuous circle of reducing size and costs and improving efficiency and effectiveness would result.

But all that assumes the NHS is still structured and funded more or less as it is, and it really shouldn’t – though I can’t redesign it in this blog. Other countries fund health care via insurance schemes, with the state picking up the costs of people who need financial assistance. This allows full health care with good competition between companies offering care, ensuring good service and effective costing. Private companies naturally eliminate any waste they can because otherwise it saps profits, whereas state organisations have little incentive to reduce waste and even have perverse incentives to increase it (e.g. to make sure they spend all their allowances so they will get the same next year, or to increase the size of their empires to justify extra status and remuneration). So a private, insurance-based scheme would undoubtedly offer better efficiency and still deliver better quality.

Of course, when new companies start up in the private sector, they generally make full use of the capabilities of new technology, so would presumably immediately absorb the trends listed above. I say presumably, because it is entirely possible to make a mess of it when privatising, so that suppliers are incentivised wrongly, based on imposition of obsolete solutions by regulators. A genuinely free market would work best, with competition driving best practice.

The numbers of staff that could in principle be made redundant (or at least significantly downgraded to lower skills with AI support) far exceeds the 50,000 mentioned. It is probably in excess of 50% of total staff using today’s or near future technology and suitable redesign, i.e. 750,000 rather than 50,000. Staff costs account for 60% of NHS revenue, so this would give a 30% saving, offset somewhat by increased technology costs, so altogether perhaps a 25% saving, and another few percent could be saved from reduced building costs. Further savings from more use of preventive medicine in place of expensive drugs could save another few percent.  The potential reductions would keep increasing with developing technology.So, it ought to be possible to reduce health care costs by around 30-35% over time, without compromising health. Of course, the NHS provides employment for many who might not be able to do other work, and the rest of the economy could not quickly absorb so many people, so it may not be economic good sense to make everyone redundant who could be, but the numbers of potentially surplus staff are certainly vast and suggest that NHS costs are more of a political problem than a technological or organisational one. But I think we all knew that anyway.