Editor's blog Friday 31 July 2009: The DH 10 workstreams for the worst-case financial scenario

The DH has outlined ten 'workstreams' for addressing the worst-case scenario for the economy. At one level, this should not get us too excited; at another, it should get us very excited indeed.

The tremulous ten are:
1. Medicines - including the notion that 30% are not taken at all (or are taken by someone else)
2. Secondary care - beds, theatres, clinics, patient flow
3. Community services
4. Appropriate clinical care, decommissioning, demand management, etc
5. New models of care
6. The health-social care interface
7. Workforce and education
8. Back office procurement
9. Reviewing the £20 bilion that doesn't come to commissioners (central DoH budgets)
10. System changes including; regulation, management system and reviewing the NHS offering - to both staff (in the form of terms and conditions) and to patients (in terms of services provided free at the point of delivery).

Reasons for unexcitement
The obvious concern about this list is that it's pretty broad. Now admittedly, a list is just a list. But even so, it just looks slung together without clear strategic thought.

The first obvious question that arises is this: if you are reviewing secondary care, what the hell about primary care? Community care is understood as being something different and smaller - it's a sub-set of primary care.

Primary care commits the bulk of the non-fixed costs of NHS spending through its treatment and referral decisions: mainly GPs, but nurse prescribers are starting to have an impact. As with the National Leadership Council scenario, it looks as if the NHS as in National Hospital Service is alive and well and living in Richmond House.

A primary care-led NHS this ain't.

Variation? Productivity? Outcomes? Efficiency?
Next, the absence of a workstream on variation, productivity, outcomes and efficiency is striking to the point of stunning.

The closest it comes to a measurement is the mention of patient flow. Nosokinteics is highly important and very under-rated, and Peter Millard's work should be better-known. Great if this gives it some more profile, but the subject is properly much broader.

On medicines, the list suggests that 30% are thought to be mis-taken or not taken. I always understood that with long-term conditions medicines (which must be most of them), the figure was deemed to be 50%. Now there will always be studies and studies, but 20% out seems statistically significant to me.

There is also no review of the cost-effectiveness of the use of market mechanisms in the NHS: highly topical as the ISTC contract turnover hits the news. It is time for one.

Finally, the one way you could make significant savings fast - wage cuts - is only very slyly alluded to at the end. Redundancies cost money in the short term and worsen the economy through higher unemployment costs.

Wage cuts would be staggeringly disliked, but they are already a reality in no smallpart of the private sector. If this is worst-case scenario planning, they should be named. It's not Voldemort to talk about it.

Reasons for excitement
This is the best the DH can do as a list in response to what is the major policy challenge since 2000. Then, it was how to spend the money wisely. Now, it is how to deliver the same if not more with less money.

This list does not give the impression that careful or systematic thought has gone into its preparation. That should make us all quite excited.

But not in a good way.