1. Given the history of the NHS it is impossible to work with a blank sheet of paper, ie create a new system from scratch. Thus, subject to the constraint that health outcomes should not suffer, how do we minimise cost? In other words, frame it as an optimisation problem.
2. Both supply and demand side should be examined. Our model should be to plug all known gaps and then innovate design models that could be practically introduced.
3. Supply would be positively affected by the following:
(a) The NHS spends about 10% on damages claims by dissatisfied patients. Most of these arise because lawyers on both sides get paid by time. Legislate compulsory mediation for three months before the legal stage is reached. Privatise the litigation handling arm of the NHS and pay it on the basis of results.
(b) The NHS spends about 10-20% on “locum”, “bank”, agency doctors and nurses, ie temporary or zero-hours staff, while maintaining vacancies in its approved payroll. It spends at least two times the cost of permanent employees in this. Legislate that such staff should maximum get 10% more than a permanent employee. Privatise the temporary hiring function for the NHS and pay it on the basis of results.
(c) Renegotiate contracts with hospital doctors and consultants so that they get paid by piece-rate, ie, number and types of intervention, rather than salary (doctors, not nurses, earn fat salaries and also earn privately, and this will increase productivity).
(d) Offer reasonable bonuses (say, £10,000 each) to all executive and non-executive directors of a trust for delivery of annual break-even or better subject to at least a satisfactory rating by the safety and care regulator, CQC. Require change of leadership if such results are not delivered two years in a row.
(e) Require all GPs to annually offer patients the choice to register with another surgery (so that they carry a risk that they could lose income since it is paid by patient numbers and visits).
(f) When booking a hospital visit for a test or procedure offer patients the choice between three different trusts rather than hospitals within the same trust (so that similar to Israel trusts work hard to gain patients since they get paid by number of tests or procedures).
4. Demand would be positively affected by the following:
(a) Give a tax incentive to employers (and insurance companies) to offer employees private health insurance for age 60 onwards (since demand increases then and private health care is very small in size).
(b) Give pensioners the option of getting subsidised private health insurance by having, say, 10% deducted from their state pension (since older patients are the worst affected by NHS wait-lists).
(c) Give charities tax-breaks to invest in and run more and more nursing homes (since charities cost less to run and learning from hospices “continuing health care” funded by NHS would then be much cheaper).
(d) Give local authorities incentives to expand and improve means-tested social care (since in many cases division between social and health care is difficult and social care is much cheaper than the NHS).
5. Model changes would be positively affected by the following:
(a) Stop asking for NHS and social care “integration” (because the only need is moving some patients after treatment to social-care; it just needs contact between two sides and integration in Northern Ireland has not delivered benefits) as costs and incentives are very different. Privatise the transfer of patients to care home and pay by results.
(b) Legislate that all hospitals participate in an efficiency examination every five years with a consultancy from an approved bank paid by results (since number of managers, doctors and nurses and outputs generated from systems used is the critical determinant of the business model) and offer a fund for resultant changes to be implemented on an economic model, ie benefits more than cost.
(c) Offer the private sector incentives to start new internet, telephone, video and home visit services for self-care support and home care (since self or home care are much cheaper and unnecessary visits can then be reduced). 6. To manage politics, issue such a consultation document and set up a cross-party commission before resultant policy is agreed every 10 years.
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