Beware foolish efficiency targets

Let’s start with a note of caution: frontloading the extra funding, as promised, is better than zero. But this increase is not enough to cover the growth in demand.

I completely agree that the NHS should become more efficient: there’s real scope for improvements in many areas. However, when setting targets, you absolutely must be realistic. If you ask me to walk 15 miles in a day, I can do that. Maybe 20, at a push. But if you ask me to do 50 miles, with a 60kg pack on my back, I know I can’t and I’ll think you’re a fool for asking.

Unreasonable, foolish efficiency targets just make people think ”well, then I may as well be hung for a sheep as a lamb”, so you’ll tend to lose financial control if you set wholly unrealistic targets. And I think there’s been a lot of that around the nation.

We need realism

We need realism. If you set an efficiency target for 2016-17, then it has to be about 2 per cent (as NHS Improvement boss-to-be Jim Mackey has suggested). NHS England needs to see that asking 8.8 per cent this year was being way, way too tough. And that target was un-hit-able. In my trust, we told Monitor we’d aim for 3.3 per cent, which we think is just doable but definitely not sustainable. If you set a target too high, you effectively remove the incentive to achieve anything.

‘System leaders need to avoid the false premise that unrealistically high targets mean higher achievements’ 

System leaders need to avoid the false premise that unrealistically high targets mean higher achievements. They don’t: they just make people decide not to try, and then you lose financial discipline.

The second point: we know some changes to provision are necessary - issues around organisational forms, mergers and new organisations or chains. The issue is that the process of organisational change takes too long and is too bureaucratic. The best-case scenario for change being a 15-18-month wait before a new management team can exert full discipline, with the Competition and Markets Authority, and the politics of “no changes to local hospital” campaigns. The NHS is going to need real political support for the changes required, and not the usual ”the NHS has to change, but just not in my constituency” stuff.

Let commissioners commission

The third point is that commissioners have to actually commission. So if we can’t afford to do everything, it’s time for commissioners to decide what we stop doing. Is IVF life- or limb-saving - is this a health issue? Likewise tattoo removal: if you paid to put it on, you can pay to have it removed.

‘Is IVF life- or limb-saving? Is this a health issue?’

And we have to think about waiting times for non-life-threatening non-debilitating conditions, few as they are. There are some things where 18 weeks is just not critical. If we’re not being funded to operate on a consumerist basis, we need to be candid about that. Quality, speed of access or financial balance: pick any two.

Social care is a bit hidden and poorly-understood. And there’s a strong case that both health and social care should be under one umbrella. Currently, social care doesn’t have the transparency and discipline of targets, yet health and social care are being asked to integrate. But if social care comes under the NHS umbrella, how do we fund it, given the delays to Dilnot? Even if council tax can go up 2 per cent?

The frontloaded money is welcome, but it’s not hard to see it getting swallowed by accommodating the social care deficit in added hospital bed days with frail older people and delays in discharge.

Julie Moore is chief executive of University Hospitals Birmingham FT and interim chief executive, Heart of England NHS FT