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At the heart of general practice since 1960

The quango with big plans to plug the NHS' £15bn black hole

The NHS' efficiency guru tells Pulse about her plans – which include closing wards and GPs seeing their patients less.

By Nigel Praities

The NHS' efficiency guru tells Pulse about her plans – which include closing wards and GPs seeing their patients less.

It may sound a little dull. Its name may not bring more than a flicker of recognition among most GPs. But the NHS Institute for Innovation and Improvement is not going to stay beneath the radar for much longer.

This is the body that is leading the NHS efficiency drive, from tough generic prescribing targets to early discharge to a push for each PCT to cut its GP referral rate.

And if you thought those measures had already proved intrusive and unpopular, that is nothing compared with what GPs can expect in the next few years.

Last week, Pulse travelled to the institute's rather anonymous headquarters in a nondescript University of Warwick campus building in Coventry to meet Dr Lynne Maher, its head of innovation practice.

She is almost entirely unknown in GP circles, but it is her job to dream up plans to help plug the estimated £15-20bn NHS black hole – and she is thinking big.

Ward closures

Dr Maher says the financial situation is so serious it demands not just a continued reduction in spending in areas such as referrals, but perhaps even the closure of entire hospital wards in an attempt to find greater efficiencies.

‘You have to look at things in the macro. Even if you make a reduction of 20 bed-days at a hospital, it is actually hard to take cash out unless you shut the ward,' she claims.

‘What are some really big things we can do to reduce length of stay safely, so that we can shut a ward? That is taking cash out and we haven't thought in that way before.

‘I have been in the NHS my whole life and have worked in primary and secondary care and I don't think we have the systems set up as well as we could do to take waste out.'

Dressed in a scarlet suit, with shiny red nails, Dr Maher is polished, professional and affable. But that doesn't disguise the controversial nature of her proposals, which will anger many GPs and surely leave blood on the carpet of the NHS.

The institute has already produced a string of reports, in clinical areas such as heart failure and musculoskeletal medicine, designed to accelerate the shift of work from secondary to primary care.

Yet closing wards will not make her popular with hospitals, and shifting work to GPs won't be popular either, unless it comes with funding to match.

Then there are the institute's Better Care Better Value indicators, a series of league tables that have helped strong-arm PCTs to realise ‘potential savings' by naming and shaming poor performers.

These have been successful at reducing hospital stay and driving up use of generic drugs, but they have gained a bad reputation among some GPs for being motivated by the need to reduce costs ahead of clinical freedom.

In particular, the institute's targets for generic prescribing of statins, PPIs and ACE inhibitors have been blamed for putting GPs under pressure to switch patients to cheaper drugs – potentially exposing them to adverse effects.

It has also pioneered a system of estimating how many GP referrals each PCT should ideally have, which has been used as a framework by many trusts as they pursue controversial incentive schemes to keep them below national average rates.

Practices, says Dr Maher, will increasingly have to look at reducing their costs and finding new ways of providing the same level of care, such as more telephone consultations, paperless surgeries or greater encouragement of self-care for patients with long-term conditions.

‘Some people won't like all of our advice,' says Dr Maher, who comes armed with a stack of glossy brochures, toolkits and flow charts. ‘A big part of our remit is to help GPs reduce costs while maintaining quality for patients.

‘GPs need to take control of their own destiny. They should be looking around and saying: "Who is doing really well, on referrals and so on. How can we translate that for our practice?"'

Dr Maher also spends some of her time teaching at the Kaiser Permanente Institute for Health Policy in the US. ‘They love us over there,' she says. Indeed, the institute's staff speak of Dr Maher as a prophet who has never been properly appreciated in her own land.

She has been looking at how service models in other ‘industries' – such as fast food, airlines and online shopping – could be incorporated into the NHS.

Dr Maher says she has used fast food chain McDonald's, mobile phone giant O2 and the UK's powerful water companies as business models.

‘Typically in healthcare we would not want to associate ourselves with McDonald's because the perception is that it is bad. But there has been some discussion about drive-throughs for district nurses, when they want to drop off specimens or pick up supplies.

‘Things that are normal in other industries we could take and apply, but make sure things we add to the process add value to patients,' she says, adding she has been working with the Department of Health and the RCGP on how methods used by big businesses could be applied to improve the patient's experience in GP practices.

These parties recently held a workshop in which RCGP chair Professor Steve Field shared ideas with O2 and Yorkshire Water.

Target-focused

Dr Maher admits to having concerns about how some PCTs have interpreted its previous plans and been too focused on its targets, without considering the downstream effects on GP practices. But with the next breath she says PCTs need to go further and close secondary care services to reduce costs.

And she believes if GPs are going to take on more work from hospitals, they also need to start doing less themselves.

She suggests GPs should shift the workload of managing chronic illness onto patients themselves and encourage them to self-care by simply avoiding seeing them as often as they do now.

‘We could radically support people to take more care of their own condition by not having them come in every three months. Not everyone with a long-term condition is fully able, but 80% are. Let's make a radical shift with a lot of people that do not want to go to the GP,' she said.

These proposals, along with other money-saving initiatives, may or may not form part of hush-hush plans she says the institute has submitted to the Department of Health for its approval.

GPs no doubt will be waiting nervously for the results, but whatever happens there seems little doubt primary care and the NHS as a whole will become more and more of a business, where saving money is going to be ever more a priority.

Dr Maher is clearly relishing the challenge, even though it may not always win her many friends. Her parting comment is revealing. ‘They didn't like me much at school. My reports always said I was disruptive.'

She seems to be enjoying her rather similar role in the NHS.

Dr Lynne Maher, head of innovation at the NHS Institute, says entire hospital wards may close to save money Closed ward Streamlining the NHS – how the institute is reshaping the health service

Generic prescribing
Cracking down on PCT performance on generic prescribing for statins, proton-pump inhibitors and ACE inhibitors/ARBs.

Reducing hospital stay
Has produced league tables for PCTs on reducing length of stay, preoperative bed-days and follow-up appointments. Producing reports in various clinical areas encouraging more care to shift to the community.

GP referrals
Estimated the expected numbers of GP referrals based on patient demographics and advised some PCTs to cut referrals by 10% or more.

Patient safety
Launched a ‘trigger tool' for GP practices earlier this year to go through practice records to identify areas where patient safety may be compromised.

Patient experience
Working with the RCGP, the Department of Health and
business leaders on ways to improve patient experience in
GP practices.

Patient feedback
Working with NHS Choices on their GP ratings website.

Dr Lynne Maher's CV

• A trained nurse with an MBA and a PhD, Dr Maher worked in management posts across the NHS for 18 years before becoming national director for booking at the NHS Modernisation Agency in 1998
• She joined the NHS Institute for Innovation in 2005 and is head of innovation practice
• Her role includes looking at how new processes can achieve ‘transformational change' in the NHS
• She is a faculty member for Kaiser Permanente's improvement leaders course in the US and also reviews papers for the BMJ and the Institute for Health Care and Improvement

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