A Systemic Look at Cutting Costs in Healthcare

By Rebecca Juster

In the West, there is a post-Enlightenment tradition of isolating systemic problems and suppressing them as far as our scientific capacity will allow us. We are a bunch of control freaks. This ‘isolate and conquer’ tactic applies to all areas of our life, so much so that we are left with this persistent feeling that we are always battling some problem – if only we could just overcome it. We sincerely believe that no area of our life should be out of our control therefore we are failing when we have not managed to firmly close the lid on that brimming suitcase full of life’s challenges. We conquer one challenge, only to have another problem pop up in its place; we are treating the symptoms in our lives, not the underlying causes.

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Before I go on a philosophical tangent about the merits of Eastern philosophy – because believe me, I could go on – I wish to get to the point of this article. This hyper ‘rational’ and anti-systemic mindset I talk about is particularly prevalent within our approach to reducing costs in the ever-burdened health sector. While metrics are important because we do need to save money, we must also consider our choice in cuts and in our attribution of value within health. This is an area where consultancy really comes in to its own.

How Can Consultancy Help The Health Service?

Consultancy as an industry is now moving towards the championing of a more holistic and qualitative view on strategy in cost reduction – for example by investing as much in agile leaders as in operational efficiency, because the former may totally transform the business’s culture and thus their finances. Why should this qualitative and systemic notion be applied to healthcare? Although you can measure oxygen levels and recovery from disease, you still cannot neatly measure health outcomes in terms of subjective patient experience (the vague ‘pain on a scale of 1-10’ is a bit like David Brent’s survey ‘not at all, to some extent, very much so, don’t know.’)

Equally, curing one problem does not always treat underlying ones, so we may demonstrably treat something but incur costs further down as a result of not looking to deeper causes. Despite our best attempts, the body is a qualitative human experience as much as a measurable one and we need to ensure we account for this in our approach to the business of healthcare. Not only will that improve subjective patient outcomes, it will actually have a wider quantifiable effect on society. As an example, this could be reflected in more productive work hours as the result of the fact that someone has received adequate support to cope with chronic illness. This is a result both in terms of personal empowerment and economic productivity, but it is contingent on the treatment of the subjective pain and discomfort to the patient. (I don’t like to talk about people’s pain in economic terms but for now I am writing the business case for changes.) We need to apply a more qualitative and systemic approach to cutting costs, as this philosophy of targeting individual issues and making them singularly cost-effective can be somewhat redundant, and often lead to knock-on costs.

Before discussing my four main ideas for investment that would lead to significant wider savings, I should add that by selecting these areas I do not wish to imply that other conditions should fall by the wayside. I am just choosing some handy examples that nicely represent how value can be added, and money can be saved, by changing our approach to treating issues in this way. Equally, it is worth saying that I realise that public health managers and the Department of Health are very much moving towards a systemic approach, partly with the help of digital healthcare which can personalise patient care to treat a whole individual. Thus, I am perhaps only echoing significant changes already underway. Equally, I am not a doctor so admittedly am unable to capture the nuances of the health issues themselves but I can examine some trends. I welcome any input from doctors themselves.

Chronic Disease: How Changes Can Lead To Chronic Savings

My first point relates to chronic diseases that cost the NHS billions of pounds a year. For the sake of time, I shall only discuss one particularly common chronic disease that many of us are familiar with – asthma. According to a 2013 NHS England report on the disease, it costs £1 billion a year in direct costs, and another £6 billion indirectly, and it affects 5.4 million people.[1] When you consider what this means in terms of costs and in terms of the numbers of people suffering (and thus the ‘qualitative’, subjective and indirect impacts of the illness) this is a huge problem which needs to be tackled.  The report discusses in more detail some of the issues associated with treating particularly difficult asthma, which contributes to 50% of the asthma budget. The following is a direct quote from the report, listing explanations for the difficulties in controlling the disease: ‘persistently poor compliance, psychosocial factors, dysfunctional breathing, vocal cord dysfunction, persistent environmental exposure to allergens or toxic substances, untreated or under treated co morbidities such as chronic rhinosinusitis, reflux disease or obstructive sleep apnoea syndrome.’[2]

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Many factors are contributing to the issue, but significantly we can draw out the psychological and social context and also the lack of deeper investigation of causation and co-morbidity, as factors that could be dealt with through wide-reaching initiatives. I plan to later discuss in detail why an increase in psychological support in the health system and longer appointment times are crucial areas for focus. However within this discussion of asthma, it is already evident that these other initiatives would have a beneficial impact upon the condition, demonstrating the multi-pronged results of one idea. Essentially, if we treat healthcare systemically, we may be able to ‘kill two birds with one stone’ (or maybe even three, four, five…) As a simple example, a co-morbidity such as reflux could be challenged in a longer appointment, therefore greatly reducing the impact of the asthma on the patient. They may not need to attend Accident and Emergency that night. They will also be able to turn up for work the next day. (You do the math.)

Secondly, greater psychological support would help to reduce the stress that chronic conditions cause psychologically and socially, and this would likely result in better medication compliance. Therefore, we can see how my three points about chronic disease, psychology and patient-doctor time can be linked up together and treated effectively and efficiently together. This may sound simplistic and reductive, and I do not wish to undermine the complexity of illness, but until we invest in such initiatives, we will not discover the effects that they could have on patients with chronic conditions. We must also consider ‘value’ as not just a ‘cure’ but as the ability for someone to manage a condition and to live the best quality of life they can.

Quality Patient-Doctor Time

I wish to now turn to the issue of increasing the time patients can spend with doctors, which I have already briefly discussed. I am aware that the government has tried to combat this by introducing twenty minute appointments as well as ten minute ones, but this is weighted towards opting for the ten minutes. Why am I so special as to book a twenty-minute consultation for myself? Is my issue really important enough? Google seems to think so, but then Google always says that… As mentioned before, the extra ten minutes with the doctor is the opportunity to discuss the reflux problem, which may in fact be making the asthma so much worse. It is also the opportunity to mention another second concern that may suddenly explain the first concern, and lead to quicker treatment. Lives are saved. Costs further down the line are reduced. The extra ten minutes is an opportunity for the doctor to have a deeper think about the collection of symptoms you present with. Otherwise, they are essentially forced to ‘triage’ you immediately without finding out a bit more about you. Equally, those extra ten minutes might give people more time to gain some reassurance and information about an issue. They may then be equipped to deal with the issue more independently without needing to book ten more appointments, and again, money is saved in a way that we could not have predicted. Time is a more valuable commodity than money and this is evident in the field of healthcare. We may struggle to economically quantify the relevance of this time, but that does not mean it is not having a ‘trickle-down-society’ economic effect – as well as a social one of course.

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Where Lies True Value

Not only questions of time, but also questions of staff, are incredibly important. We must treat the excellent and highly skilled workers in the service as people to be invested in. Overworking and underpaying people does not reduce costs in the long run – it leads to burnout. Productivity and efficiency is much more related to the quality of work than to the time spent. Ultimate value lies in the agility, intellect and quick-thinking of those in the medical profession who have to make life-saving decisions all the time – will we not compromise these traits by overworking doctors, nurses, ambulance crews, receptionist staff and all others who keep the NHS running? Cutting pay understandably creates resentment, and ultimately this will not only affect the quality on the job, but also it will spill in to people’s personal lives. The costs to society of systemic problems are all consuming. Equally, do these initiatives to cut the pay of junior doctors end up saving money when you are highly dependent on expensive agency staff anyway, which according to the Department of Health, cost the NHS £3.3bn last year?[3]

Mind And Body As One

The final point I would like to discuss is the importance of valuing mental health. I have already highlighted how understanding and treating underlying causation in chronic illness reduces the psychological stress of these disorders, and how giving patients more patient-doctor time helps this process. Thus, I would like to now look in reverse at how mental health support can not only facilitate psychological outcomes and lead people to happier and more productive lives, but also how it can have an effect on the burden of physical illness on the NHS. One example is alcoholism. An article by ‘PsychCentral’ focuses on the potential link between alcohol and stress. Although it discusses the limitations to making cause and effect statements about alcohol and stress, it notes that alcoholics: ‘often will describe chronic life stressors as causing their alcohol relapse.’[4] Would greater psychological support and stress management programmes indirectly influence figures related to liver disease?

Public health managers are keenly aware of the imperative to create initiatives that help the public to manage their own health, with regards to alcohol, drugs, cigarettes and healthier lifestyles. This is an excellent idea, but these initiatives could be expanded to include wider psychological support, which would facilitate people’s ability to maintain healthier lifestyles. Therefore in prioritising mental health, we should also find that other medical problems are reduced, as well as of course psychological ones. The mind and body are part of one system and it is time to incorporate this notion in to health strategy.

It’s The System, Man

Having approached some of the above areas in conjunction with one and other, we can see that viewing the body and also the provision of health more systemically helps to reduce costs, because multiple problems can be addressed at the same time. Equally, we can see that it is important to consider the wider knock-on economic effects that deep changes will have. I have talked a lot about saving money and obviously I hope it has been assumed throughout that I still bear in the mind the human impact of changes to healthcare. Whilst the economics is important because healthcare is incredibly expensive to provide, I wish to end this article on the importance of humanity in the issue.

Our true value lies in who we are as people and good health is a priceless gift. We simply cannot put a figure on society’s gains as a result of all the things that go right in the health service. This is why I believe that qualitative measures need to take their rightful place on the mantelpiece along with quantitative metrics and savings. Viewing both the body and the whole healthcare process as systems will lead to deeper transformation. We will be treating the causes, and not just the symptoms.

beccaBy Rebecca Juster

Rebecca is a French and History graduate from the University of Sheffield, who has spent the past year travelling. She hopes to pursue a career in Management Consultancy. Her interests include reading, creative writing and dancing, and she is passionate about healthcare provision and social mobility.

Bibliography:

2013/14 NHS Standard Contract for Respiratory Severe Asthma (adult). (2013), https://www.england.nhs.uk/wp-content/uploads/2013/06/a14-respiratory-sev-asthma.pdf

https://www.gov.uk/government/news/clampdown-on-staffing-agencies-charging-nhs-extortionate-rates

Clampdown on Staffing Agencies Charging NHS extortionate Rates. (2015), https://www.gov.uk/government/news/clampdown-on-staffing-agencies-charging-nhs-extortionate-rates

Stress and Drinking. (2016), Retrieved from http://psychcentral.com/lib/stress-and-drinking/

[1] – 2013/14 NHS Standard Contract for Respiratory Severe Asthma (adult). (2013), https://www.england.nhs.uk/wp-content/uploads/2013/06/a14-respiratory-sev-asthma.pdf

https://www.gov.uk/government/news/clampdown-on-staffing-agencies-charging-nhs-extortionate-rates

[2] – ibid.

[3] – Clampdown on Staffing Agencies Charging NHS extortionate Rates. (2015), https://www.gov.uk/government/news/clampdown-on-staffing-agencies-charging-nhs-extortionate-rates

[4] – Stress and Drinking. (2016), Retrieved from http://psychcentral.com/lib/stress-and-drinking/

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