What a waste
Authors: John Main
Journal: Journal of the Royal Society of Medicine (2008)

I love the NHS. At least, I love the idea of the NHS: free treatment for everyone who needs it. Not being completely blinded by the attraction of this idea, I am aware that the NHS has seriously failed large parts of the population, especially in England, at least since the day I became aware of the importance of politicians in the NHS - which was the day Margaret Thatcher was first elected as PM and I was a final-year student sitting in on an O&G clinic. The Senior Registrar, a man whose clinical skill I admired and respected, and whose sense of humour normally brightened the most tedious of Gynae clinics, gloomily informed me that ‘that woman’ would cut a swathe through the NHS.

But training as a kidney doctor through the 1980s, it was clear that the NHS was stronger on fairness (no-one over 60 or diabetic got dialysis) than comprehensive modern health care - a deficiency that extended to any speciality with new but expensive treatment options. The problem clearly seemed to be one of underfunding, and if we could ever match the spending of our European peers we too could surely achieve their impressive results. Eventually, and after two timid years of New Labour sticking to old Tory spending limits, Tony Blair suddenly announced that UK health spending would be brought up to European levels. This is another political moment etched in my brain, a rare political announcement of something unequivocally good, promising a far better future, soon.

And despite the irresponsible carping of many doctors, the money has changed the NHS fantastically, at least in the bits I know anything about. The availability of dialysis, heart surgery, CT scans, MRI scans, expensive cancer treatments, etc., etc., is simply astonishing compared with 20 years ago. Most of the rotten old hospital buildings have been replaced. Waiting times have been slashed. Most staff are significantly better paid. But there still isn't enough money to go round, and one reason is doctors.

I increasingly worry that doctors may be largely responsible for a fundamental problem in the NHS - a cavalier attitude to the cost of anything and everything the NHS does. Maybe the very fact of it being free for the patients, and the doctors therefore being unencumbered with bills or any other reminder of financial reality, renders a sizeable majority of us impervious to financial prudence. Sometimes this is just mental laziness, or ignorance of the cost of tests and treatments and bed days and outpatient appointments. But often it is a deeply ingrained attitude: many doctors, at least in hospitals, take umbrage at the concept that the NHS must be run as a business. I can't quite fathom the rationale, but it might be something to do with thinking a ‘higher calling’ like medicine should not be sullied by contact with dirty money. (A similar quaintly naive view seems to inform many opinions about the pharmaceutical industry, which has the temerity to want to make money from their drugs.) There is also a common attitude, that, in a properly funded NHS, we wouldn't need to worry about finance and do silly bureaucratic things like prepare business cases before we can buy new equipment or prescribe new drugs.

Of course the truth is the exact opposite. We are entrusted with huge pots of taxpayers' money, and it is our duty to spend it carefully. The politicians and civil servants know we are wasteful, because the cost of the same treatment in different places is enormously variable, but they are virtually powerless to fix it because they cannot understand why. As was said about the political situation in Northern Ireland in the 1990s, the only people who know enough to understand it are those least likely to give a fair account. So we finish up with blanket cost improvement programmes, hoping that the reduced funding will cut out waste when it is in fact nearly as likely to damage a reasonably efficient service.

What sort of things am I talking about? Let's start with unnecessary investigations. It is almost inconceivable that you could find me a medical inpatient who has not had unnecessary investigations, ranging from the relatively cheap (some blood tests, some scans) to the quite expensive (fancy imaging). Sometimes these were never really needed, sometimes they have been inadvertently or unnecessarily repeated, and rarely have they been ordered after it was clearly decided the result would influence management. And if waiting for an unnecessary test keeps them in hospital any longer at all, that is also expensive. Outpatient appointments, even in nurse-led clinics, use resources too, especially if they need transport - and far too many staff bring patients back too frequently.

What about drugs - how often do we insist on only prescribing the cheapest reasonable alternative? In some wards maybe quite a lot, but why do we ever use more expensive alternatives? How much is wasted on drugs that really aren't needed - especially the epidemic of unthinking polypharmacy in the frail elderly? And on top of the cost of those drugs, add the financial catastrophe of serious side effects in the same population. An interesting aspect to this issue is that it sheds some light on the increasingly popular question of what doctors, especially consultants, can do that other staff cannot. If there is one thing a broad and lengthy medical training is needed for, it is rationalizing drug treatment in elderly patients with several serious co-existing chronic illnesses.

Why does all this waste happen? Some people just don't believe it is worth the effort: when I mention these things they like to argue, for instance, that blood tests are cheap, that the scanner and the radiographer are there anyway, or that someone else would just fill the bed. I bet they wouldn't say that if they were paying. Secondly, a lot of it is due to ignorance: inadequately trained and supervised junior (and sometimes senior) staff who do not understand why they order the tests they do, or why and when someone needs seen again.

I don't have an answer to this problem, but I think the last two decades have shown that imposing ‘management’ on the medical profession has limited efficacy. Doctors themselves have to understand that they are a big part of the problem and the solution. If we don't get serious about money, I fear the only central solution will be further competition and more and more private provision, until the NHS is just a blue and white logo fading into the twilight.