Disinvestment

experts guide to saVing Money in health

Academics and politicians have recently argued that NICE should pay more attention to disinvestment to help the NHS to save money. But what can be done at an individual specialty level? sophie Cook asks some experts
NHS funding has done well under Labour with real NHS spending almost doubling since 1999-2000.1 However, changes in the economy mean that growth will not be sustainable. A report by the Kings Fund and the Institute of Fiscal Studies predicts that at best the NHS will see low growth over the next spending period (2011-17), and even this scenario requires substantial cuts and increased productivity.1 When making cuts it is important to maintain high standards of care and patient safety. Last year, Tony Delamothe, deputy editor of the BMJ, proposed his top nine ways in which the NHS could save money (the tenth was for readers to contribute),2 garnering some interesting responses. So we asked front line professionals for their views on how their specialties could save money while maintaining high standards of care. References are in the version on bmj.com Sophie Cook is editorial registrar, BMJ, London WC1H 9JR scook@bmj.com
Cite this as: BMJ 2010;340:c1281 see eDitorial p 605, analysis p 628, Personal vieW p 657 622

Cardiology Adam Timmis, consultant interventional cardiologist and professor of clinical cardiology, Barts and The London NHS Trust We should stop revascularisation of patients with stable angina before they have been given optimal drug treatment,3 extensive coronary stenting in diabetic patients with multivessel disease (in whom bypass surgery is the preferred method of revascularisation4), and Holter monitoring of young patients presenting with palpitations and a history indicating ectopic beats (who require only reassurance)5, according to Professor Timmis. Non-invasive diagnostic tests for patients with a pre-test probability of coronary disease that is above 90% or below 10% should also be discontinued as this adds little or nothing to diagnostic precision. Cardiology patients tend to be elderly, and Professor Timmis says for patients who were coping well at home before admission every day spent in hospital is a disaster as patients lose their independence and are at risk of hospital acquired infections. Patients often have to wait to see a social worker before they are discharged from hospital to assess their ability to cope at home, which can add days or weeks to the length of stay. This assessment would be better performed after discharge in the patients home environment, freeing up beds and preventing further deterioration.

CardiothoraCiC surgery Tom Treasure, professor of cardiothoracic surgery, Clinical Operational Research Unit, University College London Professor Treasure thinks that there are two practices in cardiothoracic surgery that could be cut. The first is extrapleural pneumonectomy for mesothelioma.9 He says surgery alone is known to be ineffective,10 but the best efforts with elaborate chemotherapy and radiotherapy still produce no survivors.11 The only justification for this procedure is that at least we give hope. However, he says that these softer outcomes are not reported and he doubts that they are measured. The second candidate is pulmonary metastasectomy for advanced colorectal cancer, which has had no advance in its evidence base in 40 years12 but is performed with increasing frequency. He thinks that the apparent increased five year survival rate is more likely to be the result of patient selection than of the surgery. He is currently conducting a trial to look at this,13 but believes there is already enough doubt of benefit to suggest that (apart from removal of solitary lung nodules when the possibility of primary lung cancer cannot be excluded) this surgery should be conducted only within a trial.

ChemiCal pathology
Stuart Smellie, consultant chemical pathologist, County Durham and Darlington Acute Hospitals NHS Trust Various estimates suggest that around 30% of tests, many of which are repeat tests, may be avoidable, Dr Smellie says. Unnecessary duplication can be prevented by improved information technology systems and education for users to enable them to reassure patients without the need for further testing. Another common problem in laboratory medicine is that tests are often requested in routine panelsfor example, urea and electrolytes and liver function tests. Dr Smellie says that historically routine panels contain a number of tests which add little to patient management in most routine situations, and use of such tests should be reserved for specific situations where there is likely to be clinical benefit. Occasionally, these panels will produce a slightly abnormal result that can then lead to a cascade of further investigation because clinicians are unsure how to respond. To prevent this, clinicians need to make better use of the laboratory as a knowledge resource. As this resource is already there, this need not cost much if anything. Dr Smellie also says there is a need to invest to disinvest because using certain tests may prevent further expensive investigations. Example candidates for this are brain natriuretic peptide for the exclusion of heart failure and faecal calprotectin for the exclusion of inflammatory bowel disease, which could reduce the need for costly echocardiography and colonoscopies.
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bmj.com podcasts Listen to a podcast about disinvestment with Peter Littlejohns, the clinical and public health director of NICE http://tr.im/RWu6
psyChiatry Steven Reid, consultant liaison psychiatrist, St Marys Hospital London In mental health most of the money goes on workforce and organisation. Dr Reid thinks that psychiatry could save money by using a restricted drug formulary that avoids the use of expensive me too drugs. It also needs to stop the perpetual introduction of specialist teams in mental health, which are usually implemented with minimal supporting evidence. Money would be saved from ending the relentless rounds of recruitment and service reorganisation and having to bolster deserted inpatient services. The improving access to psychological therapies programme (www.iapt.nhs.uk/) should also be scrapped. The targets set by the programme, which has a budget of 173m (190m; $260m), were always rather optimistic (900 000 people receiving talking treatments by 2011, half of them recovered, and 25 000 people off benefits) and so far, unsurprisingly, they dont look set to meet these. respiratory mediCiNe John Rees, Dean of Undergraduate Education, Guys, Kings College and St Thomas Hospitals In respiratory medicine, the driving forces are common sense and the evidence base. Adequately powered trials to provide evidence of effectiveness are costly. Consequently, many of these are funded by the pharmaceutical industry and the application of these findings has sometimes been extended beyond the evidence base, says Professor Rees. For example, Inhaled corticosteroids are useful in most patients with asthma but their use in chronic obstructive pulmonary disease is more limited.23 24 However, they are often reflexly prescribed in all airways problems without adequate thought. Restriction to patients with severe disease and frequent exacerbations would save considerable amounts as inhalers can cost over 30 for a months supply. rheumatology Jane Dacre, consultant rheumatologist, Whittington Hospital Focusing on the prevention of rheumatic conditions through, for example, health promotion for obesity to reduce osteoarthritis and early intensive treatment of inflammatory arthritis with biological drugs could save money in the longer term. Professor Dacre acknowledges that this requires some initial investment. Cuts could also be made by preventing overinvestigation through vetting and reviewing requests and stopping radiography for lower back pain as per NICE guidance. Routine measurement of anti-nuclear antibody in patients with non-specific symptoms should be stopped because in a local audit most requests made no difference to the management of the patient. Reorganisation and streamlining of the flow of patients to cut non-attendance rates, reducing or even eliminating follow-up for noninflammatory conditions, and stopping direct referral to rheumatology for soft tissue conditions and simple back pain would also create savings. She also thinks the responsibilities of clinical nurse specialists could be increased. maNagemeNt Irene Gray, chief operating officer, University Hospitals of Bristol NHS Foundation Trust There is a need to strengthen community services to maintain patients at home and to prevent admissions, according to Professor Gray, who began her career as a nurse. This is particularly important for elderly and infirm people, who once admitted, stay much longer than necessary, incurring cost to the NHS and cost to themselves in terms of confusion resulting from a strange environment. We also need to look at ways to align the community care, acute care, and social care systems to ensure that we can discharge patients quickly, take patients home immediately post-operatively, and only keep patients in hospital who have a need to be in an acute setting. This is as important as, if not more so than, stopping activities. Neurology Charles Warlow, emeritus professor of medical neurology, University of Edinburgh Professor Warlow says that there is a shortage of neurologists in the UK and patients with acute neurological problems arriving in accident and emergency tend to be admitted unnecessarily by nonneurologists. He thinks money could be saved by relocating some neurologists from outpatients to medical admitting units so that patients could be promptly assessed and discharged.

geNeral praCtiCe Carl Heneghan, deputy director, Centre for Evidence Based Medicine, Department of Primary Health Care, University of Oxford We may have to spend and invest first before we see the reductions in spending and disinvestment in the longer term, says Dr Heneghan. We need to move towards a culture of using clinical decision rules to prevent the inappropriate use of testing, such as the well known Ottawa ankle rule,18 which clinicians accept is a useful diagnostic tool but rarely use.19 Decision rules are particularly important when introducing new technologies such as point of care testing; otherwise, we will see inappropriate usage, over-testing, and potentially more false positive results. For example, point of care D-dimer tests for patients with suspected deep vein thrombosis need to be used in conjunction with a clinical decision rule to maximise the positive predictive value.20 We should also stop seeing patients as passive recipients of care and empower them to become active in their health care. A recent meta-analysis of 14 randomised controlled trials found that self management improved the quality of oral anticoagulation and that patients who could self monitor and adjust their own therapy had fewer thromboembolic events and lower mortality than those who could only self monitor.21 Dr Heneghan and his colleagues have undertaken pilot work in Oxford where general practitioners have been working in the accident and emergency department. They found that 40% of walk-in patients to accident and emergency could be seen and managed by GPs. Dr Heneghan says GPs take a different approach to assessment and use of tests in acutely unwell patients, which has the potential to save money. Doctors must stop thinking about primary and secondary care as us and them and start considering how we can optimise working together. Strengthening community support will also save money. We cant sustain a health system where everyone who is discharged from hospital gets care at home. He cites the successful programme in Canada22 where a network of community volunteers offer support to patients in the community. Dr Heneghan suggests GPs could keep a list of volunteers to provide help such as distributing meals, visiting patients after discharge from hospital, and providing transport, but he says it would require funds to enable volunteers to get on with the job. This is a classic example of needing to invest to disinvest.

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Do you think the nHs can cut costs while improving care? Send us your views and suggestions (through our rapid responses on bmj.com) for treatments that could be stopped in your area of practice

iNteNsiVe Care mediCiNe Jonathan Fielden, intensive care consultant, Royal Berkshire NHS Foundation Trust Critical care outreach is an important aspect of cost cutting in intensive care. Evidence is increasing that early recognition and intervention in severe illness improves outcome, reduces length of stay, and thus should save beds and money in the long term. Traditionally, patients presenting to hospital are seen initially by the most junior member of the team and decisions are not made until they are seen by more senior clinicians. Patients should be seen early by consultants, which would save time, unnecessary investigations, admissions, and money, says Dr Fielden. Since 60-70% of hospital costs are staff, they need to be used as cost effectively as possible for quality patient care. Running a closed unit, where all decisions are made by (or through) the intensive care unit team can improve consistency of care, decrease unnecessary treatments, and investigations and bring better value for money. Careful attention to the use of care bundles and protocols is also important. Dr Fielden thinks that decisions about expensive treatments for intensive care patients should be decided by the consultant according to strict protocols so that they are reserved for those most likely to benefit. Consultants should also decide who to admit to intensive care on the basis of likelihood of survival. For those unlikely to survive adequate palliation on the ward might be more appropriate.

oBstetriCs aNd gyNaeCology Donald Peebles, head of research, department of obstetrics, University College London Professor Peebles thinks we should reduce the number of procedures routinely carried out in pregnancy where therapeutic benefit is unproved. These include: Caesarean section without medical indication Induction of labour for large for dates fetuses Fetal karyotyping on the basis of age alone in the absence of screening tests, and Cervical cerclage when transvaginal scanning shows a short cervix. Better use of powerful diagnostic imaging techniques such as transvaginal ultrasonography could also reduce costs by reducing the number of invasive procedures, patient visits, and duplication of imaging.

dermatology
Hywel Williams, director, Centre of Evidence Based Dermatology, Nottingham; and Alex Anstey, senior lecturer and consultant dermatologist, Cardiff School of Medicine Professor Williams identifies three ways to save money in dermatology: Abolish routine laboratory tests for the first visit of patients with urticaria14 Use all topical corticosteroids once daily rather than twice or more frequently15 Stop using antibiotic-topical corticosteroid combinations for eczema (clinically infected or otherwise).16 Professor Anstey (below) has further suggestions, including prescribing the new generic form of the acne drug isotretinoin and employing more dermatologists rather than using general practitioners (GPs) with a special interest in dermatology. Research has shown that costs of GPs with a special interest in dermatology were 75% more per patient compared with those of the local consultant led specialist clinic.17 He thinks that wider provision of phototherapy services for patients with moderate or severe psoriasis would save money by improving treatment options for patients before they move on to costly biological treatments. He also advocates strict adherence to NICE guidance on improving the outcomes for people with skin tumours including melanoma, which permits the removal of low risk basal cell carcinomas by suitably trained GPs with a special interest but excludes those working outside skin cancer multidisciplinary teams.

gastroeNterology
Chris Hawkey, president of the British Society of Gastroenterology Professor Hawkey says on the whole, the practice of British gastroenterology is fairly-evidence based and strongly quality assured. The societys website (www.bsg.org.uk) has a room 101 for services to be discarded, but he says all that is there are follow-up coeliac clinics and conventional anorectal physiology testing. However, he points out that we need constantly to disinvest so that we can afford to offer patients the best treatment. For example, anti-tumour necrosis factor agents are central in the management of many patients with Crohns disease, but three years debate with NICE has yet to produce guidance. Spending on diagnostics has been less scrutinised, Professor Hawkey says. He thinks money could be saved through a clearer protocol so that we spend less on unnecessary (and harmful) computed tomography and more on magnetic resonance imaging. There should also be an embargo on measuring C reactive protein except in defined circumstances because this either tells us what we know clinically or we disregard it if it tells us what we dont want to know. He calls for less diagnostic upper gastrointestinal endoscopy (todays equivalent of the barium meal examination) and more therapeutic endoscopy. There should be a reduction in surveillance colonoscopies without imaging or proper biopsy protocols in very low risk patients and more well organised high quality surveillance in high risk patients. A similar approach should be taken in patients with polyps, in whom up to 10% of preventable right sided lesions may be missed.6 7 Savings from stopping endoscopy in patients with trivial gastrointestinal bleeds (Blatchford score of 08) could be used to provide a comprehensive 24 hour service for other patients. Caring for more patients with acute diarrhoea at home to prevent hospital acquired diarrhoea in other patients, would also save money. Professor Hawkey says there should be a more integrated approach to management across primary and secondary care in patients with alcohol related disease and that once you have one service that bridges primary and secondary care you can have others. He says we need to abolish the primary-secondary care division, getting rid of the currently distorting payment by results in the process. He would like to see electronic hospital records established by downloading the information that already exists in the primary care records to prevent the need to establish separate secondary care records. By fully integrating the two systems, long term secondary care follow-up clinics could be abolished as the common plan and common record would ensure coeliac patients had the bone density checked and (appropriate) inflammatory bowel disease patients had their (proper) surveillance colonoscopy.

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