So then Fell – how WOULD you go about solving the cost crisis

So then Fell – how WOULD you go about solving the cost crisis

I was asked at by CCG chair in a board meeting … “so what IS the answer then” (with regard to cash crisis and value).

off the cuff and absolutely on the spot I gave him a truly terrible answer….

so I thought about it…. and a more considered response is below…..


From: Greg Fell Sent:To:Subject: the “cost problem”

Hi both


when you put me on the spot last week about “how to solve the cost problem” I gave you a singularly terrible and waffly answer.


I’ve thought about it now… more considered response is below. the short answer is “I don’t know”…. but then nobody else does.

A more considered response



Limited clinical value stuff

Many remain of the notion that this is an area for easy and ready “savings”.

I don’t buy it. I’ve sent you a separate email detailing why.

I get asked a lot about “procedures of limited clinical value” – about once a month. Im not suggesting I have the “right” answer to the question… but I’m not overly convinced there’s much by way of cash savings to be had here.

Maybe I’m wrong, I hope I am. I’ve played this game now four or five times at the behest of various folk. Each time we’ve not saved much cash and hacked a load of people off in the process.

were this concept of “procedures of limited clinical value” a drug – there would be an enormous black triangle against it I feel.




lists of stuff – see above.

Many have made a point about “more lists wont solve it”.

of course they are right…. but it is the specific things where the cash savings can be found.

and it IS about implementing stuff – specific schemes and ideas

and there is no single thing …. lots of little stuff

Choosing Wisely is exceptionally interesting – but will be MOST effective if focused on culture and more macro concepts rather than zeroed in on specific lists.


That said – I add 3-4 things per week to my lists based on published evidence. I simply never can implement them all…

last month I’ve added a) shared care follow up of AMD – by optom or GP, b) using intensive DMARDS no biologics in RA (non inferior to aTNF may save a fortune), c) dose tapering in RA  (ditto), d) a bunch of new wheezes to get us out of the anti VEGF hole in ophthalmology, e) patient initiated follow up for OP care of LTCs (patient decides when they should be seen).

I cant keep up.

Next month I’ll add more


re NICE approved sort of stuff – a question of how brave do you want to be?



changing patient expectations

I briefly raised the issue of BMDC approach to new deal last week – pure and simple it is about raising thresholds and changing the boundaries of state v self funded. More importantly it is about changing the expectations of the public and ensuring a greater two way relationship. Call it “activation”, “self care”, “shared decisions” – doesn’t matter. We ignore this at our peril.

obviously self funding in NHS is a political no no… (for the time being?)… and the evidence clearly suggests co payment type of stuff is very counter productive

if I had to apply it to NHS then it would look something like 1) – basically prevention, self care and shared decisions on large doses of steroids + serious and very public debate about “the offer” + thresholds of care

the “deal” part of the new deal is interesting – “what we expect from you in return for good health care”

It needs careful and methodical implementation



“transforming planned care”

I get asked this question alot also.

Last time I had to answer it is attached



Over implementing things the evidence tells us adds cost when we want to remove cost.

Im forever struck by the energy and attention that we put into things where there’s good evidence don’t make a difference cost wise


  1. a) – look at what is growing fastest cost wise it’s almost certainly outpatient and planned care (certainly was when I last looked, and KF analysis confirmed) – also I’d bet new diabetes medicines and inhalers of various descriptions are growing like crazy… and outcomes are fairly static?

So value is decreasing

eg b) –virtual wards, intermediate care and whatnot.

Hospital at home type models are excellent, but theres a tricky balance of step up and step down beds.

in its current inception with a preponderance of step down beds, I seriously question the value of the investment in virtual wards from a CCG point of view. I guess you’ve got to get into the tricky economics of the perspective of provider (the hospital will sweat its assest to its best advantage), trim points and number of spells etc

Yes I know that’s a contrarian and difficult view.


  1. c) or more broadly….thinking about OP Care…seems to be growing rather rapidly…..

both some incentive issues and some culture issues inherent in this growth

I don’t know the profit margins on OP care from a provider perspective – seems like a money spinner

so maybe something to be said about exploring options

  • no follow up
  • nurse FU
  • telephone FU
  • risk stratified FU
  • patient led follow up

all of which have some research base.




we ignore culture at our peril

Muir tells me that the recipe for success is culture 50%, systems of care for populations 40% and org structures 10%

he’s probably right

but we often ignore the former two in our rush to sort out structures and organisations.

and when we do “do” culture and systems its almost universally as a group of GPs, or as a group of consultants…. never (or rarely) all together…

looking from the outside, with some exceptions, there is a gargantuan gulf between cultures in hospital medicine vs General Practice… of course to be expected …. but…..

yes I accept that our organisational issues get in the way (however)



maybe something to be said about what level


most of the above should be at the level of the consulting room and or service level – where “lists of stuff” and population focused systems are sorted out…. but I’ve never seen it happen. Ever.


I’ve never ever seen a service development proposal from a service provider which is about spending less cash…. only more……

back to programme budgeting ? pick a system – lets say Rheumatoid within MSK…. what is the investment, what are the services, what are the key interventions, what outcomes are achieved, what’s on the wish and hit list…..we don’t know where we spend the cash, and we don’t know whether we get good value.

system by system, programme by programme – the analysis itself doesn’t make decision…. but doing it collectively with the right clinicians in the process at least goes some way to getting everyone in same place culturally.


should commissioner role be basically about setting overarching framework and culture – then at macro level – commissioner role becomes one of managing the overall system

extent that moving towards value based payment. % of budget that is aligned to outcome being achieved

and you know I’ve alot of time for where the USA is heading – both the ACO stuff and the stuff that Michael Porter writes about re system design and value. Both are relevant and important, but subtly different

Im note sure what to actually DO here though??? Personally I feel that till we have got over the issue of single aligned budget with real understanding of cost / and outcomes and preferably single population focused system… I feel we wont get very far…. but that takes us back to Muir’s point re culture vs org structures.

I know all of this is easy to say and hard to do…..and apols for longish email….and I am sorry its rather downbeat…..if there were an easy answer we would have done it years ago

maybe we should come back to examining the value in some of our systems? use of tools like STAR to do it, combined with some contractual muscle to make it happen and some serious attention to cultural stuff?


and apols I wasnt able to think of this in the two mins Helen was talking…….




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