by Claudio Maria Maffei
Given that attention to waste and inefficiencies must not divert attention from the urgency of consistently increasing public funding of the NHS and clarified that the improvement of both the appropriateness of clinical and organizational processes and the quality of management processes is decisive in contrasting waste and inefficiencies remain to (re)launch the theme of the direct role of the policy that governs regional health in determining waste and inefficiencies.
10 FEB –
In “our” world, the one that revolves around QS, there is certainly no need to explain why the National Health Service (SSN) to be saved and relaunched needs to start from an increase in its public funding and from a removal/ modification of the personnel expenditure ceiling (many are for its removal and I am more for its “controlled” increase). In my opinion, however, the weight exercised by the policy on the costs of the NHS and on the appropriate use of its personnel deserves further study.
The waste and inefficiency of the NHS is a theme that the GIMBE Foundation has been dealing with for years in an organic way and talks about it in various passages also in its latest Fifth Report on the National Health Service of October 2022 in which it lists them as follows: over-use of ineffective, inappropriate or low value healthcare services, underutilization of effective, appropriate or high value healthcare services, fraud and abuse, excessive cost purchases, administrative complexity, inadequate coordination. Again according to the GIMBE Foundation, these six categories – based on the estimates reported in its document to celebrate the first 40 years of the NHS – translate into approximately € 21 billion (± 20% of public health expenditure) spent without any improvement in terms of health . Beyond the reliability of this figure, it is interesting to note that the taxonomy of waste elaborated by Antonino Cartabellotta of GIMBE in 2015 along the lines of the one elaborated in 2012 by Donald M. Berwick for the US health care includes above all those of organizational and professional origin . Probably because the reference model used by GIMBE was born in a context, that of US healthcare, which is very different from the Italian one in terms of the direct weight exercised by politics in planning and organizational choices.
Marco Geddes da Filicaia in his “Sustainable health” (Il Pensiero Scientifico Editore, 2018) released for the 40th birthday of the NHS takes up, comments and in some way integrates the analysis of the GIMBE Foundation, underlining among other things the importance that the The approach to controlling and reducing waste is “encouraged by regulations, which do not apply linear cuts to services without distinction and promote innovative management methods” and is supported, for example, by an investment plan in local services. Even if in both approaches, that of GIMBE and that of Geddes da Filicaia, foresee a role of politics in determining possible waste, in particular in the support involved in the hospital component of the offer of services and in the contextual disinvestment in territorial assistance, this role somehow remains in the background.
In commenting on the GIMBE approach some representatives of the ANAAO a few years ago raised several doubts on the GIMBE approach to the quantification of waste in an articulated way, thus concluding their analysis: “Talking about waste without providing reliable figures is politically dangerous because risks opening the doors wide to those who want to definance the NHS.
In particular, invoking further efficiency improvements based on comparisons with completely different healthcare systems is methodologically incorrect.” And they conclude that the words used by statisticians should also apply to health economics: “in God we trust; all others must bring evidence” (moreover, not to be fussy, in the original formulation instead of evidence, there is data as you can read here too, and the difference is not insignificant).
Given that attention to waste and inefficiencies must not divert attention from the urgency of consistently increasing public funding of the NHS and clarified that the improvement of both the appropriateness of clinical and organizational processes and the quality of management processes is decisive in contrasting to waste and inefficiencies in line with the Berwick model, it remains to (re)launch the theme of the direct role of the policy that governs the regional health systems in determining waste and inefficiencies. Because obviously these will not dissolve if the funding of the NHS as a dutiful will in turn increase and if some economic constraints are removed tout court such as that relating to the personnel expenditure ceiling.
The policy that governs regional health care both directly and indirectly affects the appropriate use of the Health Fund. While waiting for someone to be able to make a Berwick-type structured elaboration of this theme, I suggest here just a few examples. Politics is above all directly responsible for the waste and inefficiencies associated with maintaining a dispersed and non-networked hospital network. Once again, the example of the Marche Region comes easily to me, a true cornucopia when it comes to illustrating what bad politics can do to good health governance, a Region that provides for one and a half million inhabitants between 12 and 13 hospitals with a first level DEA plus one with a second level DEA and 6 hemodynamics. A Region that maintains 4 118 Operations Centers with four different organizational models of territorial emergency systems. Politics is also directly responsible for the underuse of high-cost technologies or the underdevelopment of digitization processes when, as in the Marche Region, the skills dedicated at central and company level are very scarce.
In a Region like the Marches governed in this way, what guarantees are there of an appropriate use of the additional economic and human resources? It is no coincidence that the Marche Region is misusing the funds of the PNRR used, for example, to support that dispersed hospital network (and obviously inconsistent with DM 70) which I briefly described earlier and to build territorial structures in a territorial healthcare system devoid of resources and of organizational innovations. Moreover, in the very recent evaluation made with the indicators of the New Guarantee System commented here on QS, the Marches were among the best Regions in 2020, in sixth place for the prevention and hospital areas and in fifth for the district one, with a score even very high for the latter (91.68). I believe that the validity of the indications emerging from the NSG requires quick thinking in times of strong push towards differentiated regional autonomy.
The final message is twofold and integrated: the NHS needs to recognize and control inefficiencies and waste of politics and is not currently able to do so with the tools at its disposal.
Claudio Maria Maffei
February 10, 2023
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