I like the suggested structure. Would also like to know if it goes to front line services or not . This may well be covered in Patient/societal benefit from the function, but a separate heading would help do a quick eyeball of which are the biggest areas of spend where the money does not go to front line staff. (I don't think front line staff should have all the money, but it will allow a comparison with other sectors and other nation's healthcare.) Good luck and thank you!
It may work if the bodies have really distinct remits. If these dabble at different levels of the wiring, it may be difficult to disentangle, and causing all sorts of knots.
An alternative would be to work from the bottom up.
What is needed for an efficient and effective health care system?
And then look at the bodies and see if these fit or have a partial fit? There are likely some areas that you can immediately put in the category 'not essential'.
It could be that the ultimate outcome is that the NHS simply cannot do everything for everyone.
But I would be surprised if it cannot be run more efficiently.
When it was established the population was so much less than it is now ( I can't find the figure)
It is not really a surprise that it cannot do everything for everyone, but people expect it to.
Look at the stats for medication dispensed, it is staggering. Our surgery's in house pharmacy puts up the cost of uncollected repeat prescriptions and it is generally around the £3000 mark a month, times how many pharmacies across the country?
Best of luck. I attempted something similar for the NHS in Scotland a few years back and it took me several weeks just to identify the health boards and similar major entities forming the whole. I was gobsmacked the SNHS did not even have an organisation chart on their website. Just at block diagram level it was almost impossible to determine the hierarchy, relationships and responsibilities, never mind ascertain budgets. I was simply trying to find out who did what, which organisations they communicated with and what IT systems and applications they used. I failed miserably.
My low point was during a meeting when a senior consultant in one of the major hospitals was venting his frustration that he did not know prior to consultations if his patients (young asthma sufferers) were taking their prescribed medication (or at least collecting their prescriptions) and attending the asthma nurse when required. Me, as an SNHS outsider simply asked the person on my left, who happened to be in charge of data analytics, if her organisation could access the pharmacy and GP records and compile a report that would give the information the consultant was requesting. Guess what, the report could easily be provided. And why was it never produced. No one had ever asked for such a report.
The whole organisation is so huge, so complex and so dysfunctional I’m surprised they manage to fulfil any of their objectives, that’s if they have any. NHS England must be the same, only the headaches are x10 more complex.
Nhs England also looks after the corporate records of the NHS, I know that because that's what my mate was in charge of before she was seconded to the covid response. I don't know what she does now, she's been promoted twice since then but I know she moved onto the record retrieval for the inquiry. So NHS England is involved in that too.....so many layers.
I would encourage you to take on this mammoth epic task as some of those who have influence on politicians discretely read your work and they really need to get to grips with the reality of the spider's web of funding and management structures. I imagine you won't even dare to enter the 7th hell of dental contracts and governance if you wish to retain some sanity,but it seems that the oral cavity is hardly considered when discussing NHS matters
And yet, report after report on recruiting for the Armed Forces since the Boer war commented on the poor state of dental health of the youngsters they were recruiting.
No Nik, we are not planning to take on dental care, the rest is enough but wonder if some of you may want to.
I think the workings of it have always been mysterious to most but its importance is second to none.
Sir John Harvey Jones visited an NHS trust in the 90's for a BBC series, a later series with Sir Gerry Robinson focused on Rotherham . Neither, l seem to remembe, could quite fathom the intricacies of NHS management. My lasting impression working with in it was wait 2 years and something else will be implemented if you don't like the current plan or targets.
The Wiring Diagram is solid evidence of the mess you are about to try and untangle.
One issue is trying to determine the product/output and how it is handed off/on to the medical system. A second issue is a distinction between efficiency and effectiveness. The Titanic was efficient about setting a speed record and absolutely ineffective in getting the passengers safely to New York. Presumably all the elements in the wiring diagram are supposed to contribute to the medical system. Do they have definite measures of outputs.? Activities are not outputs. For example, writing checks is an activity. What is supposed to happen because of the activity and does it? Sorting out the wiring diagram is an immense task. One solution might be to design the architecture (framework) for the analysis and ask for help from people who know something about the individual elements in the wiring diagram Tackle a couple of the elements and see if success is possible.
Personal experiences in New Zealand which also has a 'failing' health system due mainly to long waiting lists and delays in emergency departments etc.
Case 1: My wife recently had shingles in her eye. It was noted that the HCW's used a paper based system with data entered into the IT system by back office staff later--very inefficient.
Case 2: My sister was in hospital. Someone came around to take orders for upcoming meals. They had a computer notebook and read out options and recorded them--very efficient.
My wife was fast-tracked through the emergency department and received fabulous care over the next few months from both specialists and nurse practitioners.
My sister received the wrong meal. She suffers anaphylactic like reactions to fish. This is recorded on her electronic records. She received a meal with fish.
The King’s Fund note there are currently around 175 place-based partnerships
across England, typically covering populations of around 250,000–500,000 people.
Place-based partnerships often facilitate the integration
of budgets and planning of health and social care services.
Health and wellbeing boards were established in 2013 under the Health and
Social Care Act 2013. They are committees comprised primarily of local authority representatives, but also including representatives from NHS commissioners.
They are responsible
for promoting greater integration and partnership between the NHS, public
health and local government. They do not disclose financial information.
For instance "The joint forward plan and integrated Care Stratergy" published by NHS Devon includes no budget.
Including NHS England and NHS Providers, the department's **£626million** bill for management consultants in 2021/22 was up £123million from the previous year. The figures come as ministers were revealed to have quietly dropped restrictions on spending controls.8 Feb 2023
An abandoned [NHS](https://www.theguardian.com/society/nhs) patient record system has so far cost the taxpayer nearly £10bn, with the final bill for what would have been the world's largest civilian computer system likely to be several hundreds of millions of pounds higher, according a highly critical report from parliament's public spending watchdog.
Spending on preventive care was **£35.1 billion in 2021**, more than doubling from 2020 because of the government response to the coronavirus (COVID-19) pandemic.
For a more recent estimate, it quoted a figure of 13.5% of overall NHS expenditure spent on "management and administration salary costs" from a York University report written in 2005.
"Our regulatory cost forecast for assessing integrated care systems in 2024/25 is **£5.5 million**."
NICE
"The National Institute for Health and Care Excellence (NICE) is funded by the Department of Health and Social Care. In 2020/21, NICE's total revenue funding was ==£73 million, which is approximately USD 96 million==."
I'm not sure how granular you can get (or if even feasible) but it would be interesting to see a rough estimate of how many people work in each chunk/block. I'm curious if chunks may be very top-heavy/bloated with management far outnumbering non-management staff.
I like the suggested structure. Would also like to know if it goes to front line services or not . This may well be covered in Patient/societal benefit from the function, but a separate heading would help do a quick eyeball of which are the biggest areas of spend where the money does not go to front line staff. (I don't think front line staff should have all the money, but it will allow a comparison with other sectors and other nation's healthcare.) Good luck and thank you!
It may work if the bodies have really distinct remits. If these dabble at different levels of the wiring, it may be difficult to disentangle, and causing all sorts of knots.
An alternative would be to work from the bottom up.
What is needed for an efficient and effective health care system?
And then look at the bodies and see if these fit or have a partial fit? There are likely some areas that you can immediately put in the category 'not essential'.
It could be that the ultimate outcome is that the NHS simply cannot do everything for everyone.
But I would be surprised if it cannot be run more efficiently.
When it was established the population was so much less than it is now ( I can't find the figure)
It is not really a surprise that it cannot do everything for everyone, but people expect it to.
Look at the stats for medication dispensed, it is staggering. Our surgery's in house pharmacy puts up the cost of uncollected repeat prescriptions and it is generally around the £3000 mark a month, times how many pharmacies across the country?
Best of luck. I attempted something similar for the NHS in Scotland a few years back and it took me several weeks just to identify the health boards and similar major entities forming the whole. I was gobsmacked the SNHS did not even have an organisation chart on their website. Just at block diagram level it was almost impossible to determine the hierarchy, relationships and responsibilities, never mind ascertain budgets. I was simply trying to find out who did what, which organisations they communicated with and what IT systems and applications they used. I failed miserably.
My low point was during a meeting when a senior consultant in one of the major hospitals was venting his frustration that he did not know prior to consultations if his patients (young asthma sufferers) were taking their prescribed medication (or at least collecting their prescriptions) and attending the asthma nurse when required. Me, as an SNHS outsider simply asked the person on my left, who happened to be in charge of data analytics, if her organisation could access the pharmacy and GP records and compile a report that would give the information the consultant was requesting. Guess what, the report could easily be provided. And why was it never produced. No one had ever asked for such a report.
The whole organisation is so huge, so complex and so dysfunctional I’m surprised they manage to fulfil any of their objectives, that’s if they have any. NHS England must be the same, only the headaches are x10 more complex.
Nhs England also looks after the corporate records of the NHS, I know that because that's what my mate was in charge of before she was seconded to the covid response. I don't know what she does now, she's been promoted twice since then but I know she moved onto the record retrieval for the inquiry. So NHS England is involved in that too.....so many layers.
I would encourage you to take on this mammoth epic task as some of those who have influence on politicians discretely read your work and they really need to get to grips with the reality of the spider's web of funding and management structures. I imagine you won't even dare to enter the 7th hell of dental contracts and governance if you wish to retain some sanity,but it seems that the oral cavity is hardly considered when discussing NHS matters
And yet, report after report on recruiting for the Armed Forces since the Boer war commented on the poor state of dental health of the youngsters they were recruiting.
No Nik, we are not planning to take on dental care, the rest is enough but wonder if some of you may want to.
I think the workings of it have always been mysterious to most but its importance is second to none.
Best, Tom.
You really want to take on yet another enormous, labrynthine structure? You have my admiration! It is most certainly worth doing.
Sir John Harvey Jones visited an NHS trust in the 90's for a BBC series, a later series with Sir Gerry Robinson focused on Rotherham . Neither, l seem to remembe, could quite fathom the intricacies of NHS management. My lasting impression working with in it was wait 2 years and something else will be implemented if you don't like the current plan or targets.
The Wiring Diagram is solid evidence of the mess you are about to try and untangle.
One issue is trying to determine the product/output and how it is handed off/on to the medical system. A second issue is a distinction between efficiency and effectiveness. The Titanic was efficient about setting a speed record and absolutely ineffective in getting the passengers safely to New York. Presumably all the elements in the wiring diagram are supposed to contribute to the medical system. Do they have definite measures of outputs.? Activities are not outputs. For example, writing checks is an activity. What is supposed to happen because of the activity and does it? Sorting out the wiring diagram is an immense task. One solution might be to design the architecture (framework) for the analysis and ask for help from people who know something about the individual elements in the wiring diagram Tackle a couple of the elements and see if success is possible.
I also wonder how much is lost through fraud. I suspect this is vastly under-detected.
Personal experiences in New Zealand which also has a 'failing' health system due mainly to long waiting lists and delays in emergency departments etc.
Case 1: My wife recently had shingles in her eye. It was noted that the HCW's used a paper based system with data entered into the IT system by back office staff later--very inefficient.
Case 2: My sister was in hospital. Someone came around to take orders for upcoming meals. They had a computer notebook and read out options and recorded them--very efficient.
My wife was fast-tracked through the emergency department and received fabulous care over the next few months from both specialists and nurse practitioners.
My sister received the wrong meal. She suffers anaphylactic like reactions to fish. This is recorded on her electronic records. She received a meal with fish.
The King’s Fund note there are currently around 175 place-based partnerships
across England, typically covering populations of around 250,000–500,000 people.
Place-based partnerships often facilitate the integration
of budgets and planning of health and social care services.
Health and wellbeing boards were established in 2013 under the Health and
Social Care Act 2013. They are committees comprised primarily of local authority representatives, but also including representatives from NHS commissioners.
They are responsible
for promoting greater integration and partnership between the NHS, public
health and local government. They do not disclose financial information.
For instance "The joint forward plan and integrated Care Stratergy" published by NHS Devon includes no budget.
https://onedevon.org.uk/about-us/our-vision-and-ambitions/our-devon-plan/
Where does the money go?
Private Finance Initiative
The 109 contracts still active will cost the trusts involved a combined £2.15bn to service in 2020-21, rising to £2.5bn in 2030.
https://www.theguardian.com/politics/2019/sep/12/nhs-hospital-trusts-to-pay-out-further-55bn-under-pfi-scheme
Management Consultants
Including NHS England and NHS Providers, the department's **£626million** bill for management consultants in 2021/22 was up £123million from the previous year. The figures come as ministers were revealed to have quietly dropped restrictions on spending controls.8 Feb 2023
[https://www.dailymail.co.uk/health/article-11727761/Department-Health-spent-record-626MILLION-taxpayer-cash-management-consultants.html?ito=native_share_article-nativemenubutton](https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.dailymail.co.uk%2Fhealth%2Farticle-11727761%2FDepartment-Health-spent-record-626MILLION-taxpayer-cash-management-consultants.html%3Fito%3Dnative_share_article-nativemenubutton&data=05%7C02%7C%7Ce27eb96423b944066d9c08dcd8d41ace%7C84df9e7fe9f640afb435aaaaaaaaaaaa%7C1%7C0%7C638623652685873551%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=%2Bul1fvuPs9e5ag7xekcGPG7vnELUa10qKGbtgOSJRr4%3D&reserved=0 "Protected by Outlook: https://www.dailymail.co.uk/health/article-11727761/Department-Health-spent-record-626MILLION-taxpayer-cash-management-consultants.html?ito=native_share_article-nativemenubutton. Click or tap to follow the link.")
Computer Information Systems
An abandoned [NHS](https://www.theguardian.com/society/nhs) patient record system has so far cost the taxpayer nearly £10bn, with the final bill for what would have been the world's largest civilian computer system likely to be several hundreds of millions of pounds higher, according a highly critical report from parliament's public spending watchdog.
[https://www.theguardian.com/society/2013/sep/18/nhs-records-system-10bn](https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.theguardian.com%2Fsociety%2F2013%2Fsep%2F18%2Fnhs-records-system-10bn&data=05%7C02%7C%7C1713c6314ebe44baa96608dcd8d466c8%7C84df9e7fe9f640afb435aaaaaaaaaaaa%7C1%7C0%7C638623653957028336%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=Rnu6K%2BechbneKYhYIwfrh%2Bf5XoqEQQkAFwXUDFLBIs0%3D&reserved=0 "Protected by Outlook: https://www.theguardian.com/society/2013/sep/18/nhs-records-system-10bn. Click or tap to follow the link.")
Illness prevention strategies (with limited evidence base)
Spending on preventive care was **£35.1 billion in 2021**, more than doubling from 2020 because of the government response to the coronavirus (COVID-19) pandemic.
https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.ons.gov.uk%2Fpeoplepopulationandcommunity%2Fhealthandsocialcare%2Fhealthcaresystem%2Fbulletins%2Fukhealthaccounts%2F2021%23%3A~%3Atext%3DGovernment-financed%2520healthcare%2520expenditure%2520was%2C(COVID-19&data=05%7C02%7C%7C09a0ebb8063f42de2ef008dcd8d4d031%7C84df9e7fe9f640afb435aaaaaaaaaaaa%7C1%7C0%7C638623655725672745%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=GAkyC8NYhdTbIu497cNJQeAbOieW8SGlEUi9lmFW5Ho%3D&reserved=0
Management internal market
For a more recent estimate, it quoted a figure of 13.5% of overall NHS expenditure spent on "management and administration salary costs" from a York University report written in 2005.
https://fullfact.org/health/how-much-nhs-market-system-costing/
Quality assessment
CQC
"Our regulatory cost forecast for assessing integrated care systems in 2024/25 is **£5.5 million**."
NICE
"The National Institute for Health and Care Excellence (NICE) is funded by the Department of Health and Social Care. In 2020/21, NICE's total revenue funding was ==£73 million, which is approximately USD 96 million==."
One wonders if it's designed to be messy so the movement of tax payers dingo dollars into big pharma's grubby pockets isn't so easy to see.
Perhaps connections between "bodies", the importance of that connection to each and the cost of those connections.
I'm not sure how granular you can get (or if even feasible) but it would be interesting to see a rough estimate of how many people work in each chunk/block. I'm curious if chunks may be very top-heavy/bloated with management far outnumbering non-management staff.