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Godlee’s call for the National Institute for Health and Care Excellence to keep close to its radical roots is interesting, not least because NICE has never claimed this for itself.1 Radical or not, NICE applies thorough and robust approaches to assessing health technologies. This helps patients access innovative treatments that help them live longer, better quality lives while providing value for money. The …

A shake-up in NHS leadership aims to deliver value for money, innovation, and efficiency, finds Gareth Iacobucci

ObjectivesTo develop an interactive tool that estimates what potential benefits are needed for the robot to provide value for money when compared with endoscopic or open surgical interventions.DesignA generic online interactive tool was developed to analyze the (health) effects needed to compensate for the additional costs of using a surgical robotic system from a healthcare perspective. The application of the tool is illustrated with a hypothetical new surgical robotic platform. A synthesis of evidence from different sources was used combined with interviews with surgeons.SettingFlexible tool that can be adapted to flexible settings.ParticipantsAny hospital patient group for which robotic, endoscopic or open surgical procedures may be considered as appropriate treatment alternatives (eg, urology, gynecology, and so on).InterventionRobotically assisted surgical interventions.ComparatorEndoscopic or open surgical interventions.Main outcome measuresThresholds of how much (health) effect is needed for robot-assisted surgery to provide value for money and to become cost-effective.ResultsThe utilization rate of the surgical robotic system and a reduction in complications appeared to be important aspects in determining the value for money. To become cost-effective, it was deemed important for new surgical robotic systems to have added clinical benefit and become less costly than the current system.ConclusionsThis paper and its assisting interactive tool can be used by clinicians, researchers, and policymakers to gain insight in the benefit needed to provide value for money when using a (new) surgical robotic system or, when the effects are known or can be estimated, to assess the value for money for a specific indication. For robotic surgery to provide most value for money, we recommend assessing for each indication whether the necessary effects seem achievable.

I agree with Moynihan and colleagues1 that the pandemic offers a “natural experiment in less medical care,” and that the results may help identify some interventions that do more harm than good to most people. I also agree that the financial crisis will focus our minds on the desirability of maximising value for money. I am, however, …

> It is not long since a medical congress was an event of the year, but such congresses are now so varied and numerous that they extend throughout the entire twelve months… (Editorialist 1903)1 Does anything change? Why do we attend congresses? Such meetings are also popular in science and engineering, literature and the arts, business and finance. But it is time to consider what is gained. Worldwide, there may be as many as 100 000 medical meetings every year.2 Flocks of young and not so young physicians, surgeons and others take time away from their patients and labs and fly to faraway destinations to listen to others (often the same experts at different meetings), invited by somewhat obscure selection processes to entertain and instruct their peers and juniors. Several thousand may attend the larger congresses. Taxis, trains, airlines, hotels, restaurants, tailors and dress-makers, luggage manufacturers and professional conference organisers are kept busy. Continuing Medical Education (CME) points are gained, much jetlag is engendered and a great deal of carbon released into the atmosphere—as much as 10 000 tons for a middle-sized conference.3 It is undeniably exciting to go somewhere new, perhaps to another country, to meet one’s colleagues and friends in a new environment, to make new acquaintances and perhaps to learn something. But the reality is different: one often sits on uncomfortable, gilt-steel hotel chairs in a cold, over-air conditioned ballroom to listen to a resume of material one has already read or ought to have already read, the whole accompanied by a blizzard of visual aids, often presented on several enormous multimedia screens. Inevitably, attention levels vary. People come and go during the presentations, chat to each other and fall asleep as their jetlag and breakfast overwhelm them. Often, one finds oneself seated behind someone …

Background Telephone-based smoking cessation services (quitlines) offering counselling for smoking cessation without nicotine replacement therapy may be important components of tobacco control efforts in low and middle income countries, but evaluations in such resource-limited settings are lacking. We aimed to evaluate the usage, effectiveness and cost of the Thailand National Quitline (TNQ). Methods Analysis of retrospective data for callers to the TNQ between 2009 and 2012 and a follow-up survey in 1161 randomly selected callers. Results Between 2009 and 2012 there were 116 862 callers to the TNQ; 36 927 received counselling and at least one follow-up call. Compared with smokers in the general population, callers were younger, more highly educated, more likely to be students, and more likely to smoke cigarettes rather than roll-your-own tobacco. Continuous abstinence rates at 1, 3 and 6 months after calling were 49.9%, 38.0% and 33.1%. The predicted rate at 12 months was 19.54% (95% CI 14.55 to 26.24). Average cost per completed counselling was $31 and the average cost per quitter was $253. Assuming all (and two-thirds) TNQ callers who succeed in quitting would have failed to quit without the assistance of the TNQ, cumulative life years saved (LYS) for the 4-year period were 57 238 (36 733) giving a cost per LYS of $32 (50) (about 7.93 LYS per quitter) and an estimated return on investment over 4 years of 9.01 (5.78). Conclusions A low-cost quitline without nicotine replacement therapy is a promising model for smoking cessation services and likely to offer good value for money in Thailand.

Many clinical commissioning groups and hospital trusts are failing to show that the money they spend is good value, the parliamentary public spending watchdog has said. It has called for greater transparency from all public bodies that provide local services and said that the government must demand more so that citizens can hold their services to account. MPs on the Public Accounts Committee found that more than 20% of local public bodies, including local authorities and fire and police services as …

Auditors’ “red flag” warnings about financial instability in NHS and other public bodies are being met with “inadequate or complacent responses,” the financial watchdog has said. The National Audit Office (NAO) said the number of organisations in England with “significant weaknesses” in their arrangements for delivering value for money was “unacceptably high and increasing.” Aymas Morse, who heads the NAO, said, “I am shocked by the persistent high level of qualified audit reports at local public bodies. A qualification is a judgment that something is seriously wrong.” He said local and national bodies must take seriously, and act appropriately, when local auditors highlight weaknesses or concerns to maintain public confidence. A NAO report on …

ObjectivesHealthcare budgets are limited, and therefore, research funds should be wisely allocated to ensure high-quality, useful and cost-effective research. We aimed to critically review the criteria considered by major Australian organisations in prioritising and selecting health research projects for funding.MethodsWe reviewed all grant schemes listed on the Australian Competitive Grants Register that were health-related, active in 2017 and with publicly available selection criteria on the funders’ websites. Data extracted included scheme name, funding organisation, selection criteria and the relative weight assigned to each criterion. Selection criteria were grouped into five representative domains: relevance, appropriateness, significance, feasibility (including team quality) and cost-effectiveness (ie, value for money).ResultsThirty-six schemes were included from 158 identified. One-half of the schemes were under the National Health and Medical Research Council. The most commonly used criteria were research team quality and capability (94%), research plan clarity (94%), scientific quality (92%) and research impact (92%). Criteria considered less commonly were existing knowledge (22%), fostering collaboration (22%), research environment (19%), value for money (14%), disease burden (8%) and ethical/moral considerations (3%). In terms of representative domains, relevance was considered in 72% of the schemes, appropriateness in 92%, significance in 94%, feasibility in 100% and cost-effectiveness in 17%. The relative weights for the selection criteria varied across schemes with 5%–30% for relevance, 20%–60% for each appropriateness and significance, 20%–75% for feasibility and 15%–33% for cost-effectiveness.ConclusionsIn selecting research projects for funding, Australian research organisations focus largely on research appropriateness, significance and feasibility; however, value for money is most often overlooked. Research funding decisions should include an assessment of value for money in order to maximise return on research investment.

Objective The purpose of this study was to identify the association of premedication with the adverse drug reaction (ADR) rate in infliximab infusions. Design A retrospective chart review of 684 patients who received 4077 infusions in a network of community clinics over 16.5 months. Data collected included age, weight, sex, diagnosis, dose, premedications and ADR information, which was coded for time of onset, severity and outcome. Setting Community infusion clinics located in Ontario, Canada. Patients Patients aged 12–91 years who receive regular infliximab infusions to treat their autoimmune condition, mainly either Crohn9s disease or rheumatoid arthritis. Main outcome measures The number of infusions to the occurrence of an acute ADR by presence of premedication. Results ADRs are not significantly different (χ2(1, n=644, p=0.651)=0.204) between those who always received premedications and those who never did. When controlling for age, sex, weight and diagnosis, patients receiving premedications were just as likely to experience an ADR as patients who never received any (OR 1.1, 95% CI 0.7 to 1.9, p=0.5). When assessing the number of infusions to the occurrence of an ADR using the Kaplan–Meier method, no significant difference was found between the two groups. Conclusions The use of premedications is not associated with a decreased risk of ADR in patients receiving infliximab. This held true for patients who had never had an ADR prior to receiving premedications and while controlling for age, sex, weight and diagnosis.

Background Screening known cirrhotics for hepatocellular cancer (HCC) has long been a contentious topic. Studies to date have failed to conclusively prove or disprove the validity of α-fetoprotein (AFP) and hepatic ultrasound as screening mechanisms for HCC among cirrhotics, particularly in the American population. It is not clear whether these screening mechanisms provide any benefit in terms of reduced morbidity and mortality. Methods The study examined all patients with liver cirrhosis who developed HCC at the Michael E DeBakey VA Medical Center between 1999 and 2005. Those who were screened with AFP and/or imaging (either ultrasound, triphasic liver protocol CT or MRI) were compared with those patients who were not screened at all. The screened and unscreened patients were compared in terms of Barcelona Clinic Liver Cancer (BCLC) stage at the time of diagnosis. Results Statistical analysis revealed a significant difference between the screened and unscreened groups in terms of BCLC stage at diagnosis, with the unscreened group being diagnosed at later stages than the screened group. Of the 155 patients observed, 26 were appropriately screened, and 129 were not. The BCLC stages at diagnosis for the two groups were as follows: screened patients: 34.6%, 38.5%, 7.7% and 19.2% for BCLC stages A, B, C and D, respectively; unscreened patients: 12.4%, 24.8%, 27.1% and 35.7% for BCLC stages A, B, C and D, respectively. The different trend in the two groups was found to be statistically significant, with a p value of 0.004. Furthermore, among the screened group, no particular method of screening (AFP vs imaging vs combination) was shown to be superior to another. Conclusions Screening for HCC among cirrhotics using AFP and/or imaging every 6 months does correlate with HCC diagnosis at an earlier BCLC stage, thus portending better treatment options and improved prognosis. Therefore, screening all known cirrhotics for HCC may lead to decreased mortality.

To determine whether the Glasgow-Blatchford bleeding score (GBS) or pre-endoscopy Rockall score was better at accurately identifying patients with acute upper gastrointestinal bleeding (AUGIB) who were at low risk of the need for clinical intervention and death and therefore suitable for outpatient management.Retrospective database and case note review of all patients admitted to the emergency departments with AUGIB from 1 January 2008 to 31 December 2009.Two tertiary centre teaching hospitals.432 patients met the inclusion criteria.None.Clinical interventions (blood transfusion, endoscopic therapy and surgery) and death.Of 432 patients, 40 (9.3%) had a GBS of 0 and none required intervention or died. In contrast, 13/104 patients (12.5%) who had a pre-endoscopy Rockall score of 0 and 23/125 patients (18.4%) who had a complete Rockall score3, required clinical intervention. The performance of the scores at these cut-offs were: GBS (sensitivity 100%, specificity 16.1%, positive predictive value (PPV) 37.8%, negative predictive value (NPV) 100%, accuracy 82.3%), pre-endoscopy Rockall (sensitivity 91.2%, specificity 32.0%, PPV 41.2%, NPV 87.5%, accuracy 70.9%) and complete Rockall (sensitivity 84.5%, specificity 50.7%, PPV 55.8%, NPV 81.6%, accuracy 76.2%). For prediction of the need for intervention or death, the accuracy of the GBS (0.82; 95% CI 0.78 to 0.86) was superior to the pre-endoscopy Rockall score (0.71; 95% CI 0.67 to 0.76).The GBS but not the pre-endoscopy Rockall score identifies patients with upper gastrointestinal bleeding who may be suitable for outpatient management, therefore potentially allowing for more efficient use of hospital resources.

During the last 10 years, the management of gynecological cancer has been undergoing a great deal of change. This is due to a drive to reduce ineffective treatment and associated morbidity while at the same time maximizing the benefits of currently available treatment. The foundation for this approach has been high-quality clinical trials which have been performed in increasing numbers. These trials can provide strong evidence that treatments are equivalent or that a new drug adds superiority to previous treatment.The access that women have to the most effective forms of treatment often depends on the availability of healthcare resources and their affordability within the healthcare system. Healthcare decision makers increasingly require not just clinical effectiveness of treatments but also cost-effectiveness to be demonstrated. While health economic methods have been applied to many forms of cancer treatment and screening, there have been very few rigorous economic studies performed in gynecological cancer.This article discusses how economic analysis can be incorporated into clinical trials and how it can provide the sort of value for money determination that payers of healthcare are now requiring. Economic analysis may add a little to the cost of trials, but in the end, it may increase access to treatment by convincing decision makers of cost-effectiveness.

The Cancer Drugs Fund (CDF) has not “delivered meaningful value” to patients with cancer and may have exposed them to “toxic side effects of drugs,” an analysis has found.1 The CDF was established in 2010 in England to provide “patients with faster access to the most promising new cancer treatments” and to ensure “value for money for taxpayers.” It funded drugs that were not available through the NHS because the drugs had not been appraised, were in the process of being appraised, or had been appraised but not recommended by the National Institute for Health and Care Excellence (NICE). The fund was overhauled last year. Ajay Aggarwal, academic clinical oncologist at the London School of Hygiene and Tropical Medicine and a lead author of the analysis, said, “From 2010 when it started to 2016 when it closed, the Cancer Drugs Fund cost the UK taxpayer a total of £1.27bn [€1.51bn; $1.64bn], the equivalent of one year’s total spend on all cancer drugs in the NHS. “The majority of …

NHS trusts continue to believe they are overburdened by demands from regulators which remain too frequent and provide poor value for money, a new survey has found. The poll1 of senior trust leaders by NHS Providers, the body representing NHS trusts in England, found that two thirds (68%) thought that demand from regulators including NHS Improvement and the Care Quality Commission had increased in the past 12 months. While this was lower than the 87% who said that demand from regulators had increased when the organisation last surveyed trusts …

The NHS in England wastes nearly £1bn (€1.31bn; $1.47bn) every year treating older patients in hospital who no longer need acute care, the National Audit Office (NAO) has said. On 26 May the public spending watchdog published Discharging Older Patients from Hospital ,1 in which it said that health and social care services’ management of discharging older patients from hospital did not represent value for money. The NAO estimated that the gross annual cost to the NHS of treating older patients in hospital who no …

The financial watchdog could not say whether the commissioning of specialised services by NHS England was good value for money. In a review of how NHS England commissioned the 146 specialised services provided in England—for example for kidney disease, specific mental health problems, and rare cancers—the National Audit Office found that the budget for these services in 2015-16 was £14.6bn, 14% of the total NHS budget.1 This year spending was set to increase by 7% to £15.6bn, double the rate of increase of the NHS budget as a whole. Since NHS England took responsibility for commissioning specialist services in April 2013 the agency has not been able to stay within budget, …

The government must provide a clear plan for reducing the unsustainable level of deficit among NHS hospital trusts, the UK’s national spending watchdog has urged. In a report published this week the National Audit Office (NAO) said that acute care hospital trusts in England had seen their finances worsen severely in the past 12 months and that the position was set to get even worse by the end of 2015-16.1 With demand for healthcare services continuing to rise, the NAO said that it was imperative that the Department of Health for England and its arm’s length bodies got to grips with the deficit and ensured that value for money was achieved. The auditors highlighted that NHS trusts and foundation trusts posted a cumulative …

One of the few examples of explicit rationing in the National Health Service is provided by in vitro fertilisation. Of six purchasing authorities examined three have decided against buying in vitro fertilisation while three have decided in favour. The decisions reflect local factors such as the absence or presence of local providers and the views of the public and health professionals. But in vitro fertilisation also illustrates some of the wider issues involved in all decisions about purchasing: questions about what should be provided by the National Health Service, about what procedures should be compared when weighing up value for money, and whether equity demands national decisions about what to provide.

Gordon Brown may be having second thoughts about market reforms in the NHS. Last week Nick Timmins described how the government is cutting back its use of the private sector ( BMJ 2007;335:1066; doi: 10.1136/bmj.39405.462431.94). Expansion of the private sector is still the official line, but only as long as it provides value for money, Mr Brown told this week's conference of the Confederation of British Industry. Beleaguered as he is on almost every front, if Brown is rethinking healthcare markets he'll find support in this week's BMJ . Steffie Woolhandler and David Himmelstein argue that US health care, the biggest system in the world …

The struggling private healthcare sector has become “complacent” and has failed to convince enough people that it offers value for money, a senior BUPA executive has said. Alex Perry, general manager of the private health insurance scheme BUPA UK, said that 2014 had been “another year of decline” for the sector and that it now required fundamental reform to deliver future growth. He said that a bright future was possible but that the sector must overcome “historic divisions,” seek regulatory change, and make a better case for itself to bring more people into the market. “We need to cut through the accusations and myths that surround private healthcare; we need to positively promote the impact that we all can and do have on the nation’s health,” he said. Perry spoke at a summit on UK private healthcare held in London on 23 June at the …

For several years the UK government has used corporate advertising agencies to deliver public health campaigns. But how do we know whether they work and offer value for money, asks Chris Mahony

The National Institute for Health and Care Excellence’s decision not to recommend abiaterone for men with advanced prostate cancer before chemotherapy, which was based on inadequate evidence of cost effectiveness, illustrates a common challenge for novel anticancer agents.1 Tension exists between the NHS obtaining value for money, patients obtaining access to new drugs, and …

A senior MP has warned of a “serious governance failure” in the monitoring of GP out of hours services, after an official audit found that NHS England was failing to adequately monitor the variation in quality and value for money being achieved across the country. Margaret Hodge, chairwoman of the parliamentary Public Accounts Committee, said that the report by the National Audit Office1 had revealed deficiencies in the current system that needed to be tackled urgently. The report noted that, while some commissioners were achieving value for money with their spending on out of hours GP services, this was “not the case across the board.” It also criticised NHS England for taking a year to issue guidance to its 27 area teams about how to seek assurance on out of hours services, and it questioned whether the current monitoring arrangements were fit for purpose, as clinical commissioning groups …

Public health should be put at the top of local government agendas in England, as it provides good value for money, says the health think tank the King’s Fund. The charity has produced a set of resources to help councils prioritise public health interventions (www.kingsfund.org.uk/iph). Since April local authorities have been given renewed responsibility for public health, but the King’s Fund said that as yet there have been few resources to help them identify what works. The resources, together with a report, Improving the Public’s Health: A Resource for …

Large pay rises of between 24% and 28% for consultants 10 years ago had failed to lead to more productivity for the NHS and had not been value for money, MPs said. The parliamentary public accounts committee published a report on 2 July on the management of consultants, in which it said that pay rises had not achieved what they should have and that management of consultants’ performance was poor. Doctors’ leaders, however, have rejected many of the report’s claims, saying that the statistics used were inappropriate, did not reflect the quality of care, and unfairly criticised doctors for spending too much time with patients. In October 2003 the Department of Health for England introduced a new consultant contract, which was designed to improve the management of NHS consultants. Most consultants are now on the contract, which increased their pay in 2003-04, with the bottom of the consultant pay band rising by 24% and the top by 28%. MPs on the committee said the contract represented a “missed opportunity” to …

Background Transcription mediated amplification (TMA, Aptima Combo II) is currently unlicensed for the detection of chlamydia and gonorrhoea at extragenital sites. Accumulating evidence suggests TMA has high sensitivity and specificity for pharyngeal and rectal infection. We have offered pharyngeal and rectal TMAs to all patients presenting since April 2009 reporting receptive oral or anal intercourse. Methods The TMA and culture results of heterosexual women receiving extragenital screening between 01/01/12 and 30/06/12 were retrospectively reviewed. Results 1315 women were screened (1520 extra-genital samples), 79 tested positive for at least one infection at one site. 62 (4.7%) patients had genital chlamydia. 9 (0.7%) patients had genital gonorrhoea. 33 positive results were extragenital (detection rate 2.17%) with 10 patients having isolated extragenital infection. Rectal chlamydia detection rate was 3.8%. Of the 8 patients with rectal chlamydia, 7 had co-existing genital infection. 14/1309 (1.1%) patients had pharyngeal chlamydia, 5 had isolated pharyngeal infection. 6/211 (2.8%) patients had rectal gonorrhoea, 1 had isolated rectal infection. 5/1309 (0.4%) patients had pharyngeal gonorrhoea, 3 had isolated pharyngeal infection. There were no positive extragenital gonorrhoea cultures and no cases of extragenital dual infection. Conclusion Detection rates for extragenital chlamydia (both sites) and rectal gonorrhoea exceeded that of genital gonorrhoea. Without extragenital screening we would have failed to treat 10 women with isolated pharyngeal or rectal infection, i.e. 12.7% of all women testing positive. Regarding the 8 women with rectal chlamydia, 7 could have been suboptimally treated with azithromycin and one would have been missed. This has implications for onward transmission, enhanced transmission of other STIs, and missed opportunities for partner notification. Failure to screen women extragenitally may reinforce the misconception that these sites are not as significant in STI transmission and encourage risk taking behaviour.

NHS England plans to review all personal medical services (PMS) GP contracts in 2013-14 to “identify ways of improving value for money for the future.” The aims of the review are to establish equitable “core” funding between general practices on PMS contracts and those on general medical services (GMS) contracts and to ensure value for money from investment in non-core “enhanced” services. NHS England has said, however, that it does not plan to change the “quantum” of PMS funding this year while the review is under way. NHS England has instructed its local …

Elective hernia surgery presents value for money for the NHS, a study has found, contradicting recent guidelines suggesting that the operation was of “low clinical value” and that commissioners should consider restricting it. The latest analysis used patient reported outcome measures (PROMs) from nearly 17 500 patients who had a hernia operation in England between 1 April 2009 and 31 Match 2010. These data have been collected routinely in the NHS since 2009, before and at least three months after patients undergo hernia repair. Researchers from the think tank the King’s Fund and Imperial College London combined these outcomes with costs …

Consultants have received significant pay rises since their contracts were renegotiated but are being far less productive, MPs have claimed. The parliamentary public accounts committee tackled Department of Health officials over the matter during an evidence session on 18 March for an inquiry that was sparked by the report published earlier this month by the National Audit Office (NAO) on managing NHS hospital consultants.1 The health department, however, denied this view, saying services had improved and were proving to be better value for money overall. The new contract for hospital consultants, introduced in October 2003, was designed to give a career structure and pay package to reward consultants who made the biggest contribution to the NHS. The committee’s chair, Margaret Hodge, Labour MP for Barking, said: “The introduction of the new consultants’ contract cost the taxpayer a lot of money and benefited consultants enormously—a 24% to 28% increase in their potential rate of pay—yet …

Economic evaluations conducted alongside randomised controlled trials enable analysis of detailed, patient level data on efficacy, cost, and quality of life in a controlled setting. They can provide timely and reliable assessments of value for money, to inform decisions on coverage and reimbursement.1–3 The BMJ recently decided to consider trial based economic evaluations for publication only if the clinical results are submitted to the journal as well.4 We assessed the extent to which cost utility analyses are conducted alongside trials, estimated the time lag between the publication of trials' clinical and economic results, and compared the characteristics of journals publishing the clinical trial data and the cost utility analyses. We conducted a systematic search for original English language cost utility analyses published in 1976-2001 by using Medline and other electronic databases. Two readers independently reviewed each study and came to a consensus on whether the analysis was conducted alongside a trial (data on both efficacy and resource use from the trial were used for the analysis). We …

Some NHS organisations are still rationing some drugs despite the fact that they have been approved by the National Institute for Health and Clinical Excellence (NICE) as being cost effective, according to the findings of a new report. The report published today by the Health and Social Care Information Centre found that medicines in six treatment areas were prescribed at rates lower than would have been expected from disease prevalence.1 All have been backed by NICE as good value for money. The Association of the British Pharmaceutical Industry (ABPI) said that the findings showed that the UK was “consistently lagging behind international counterparts on the uptake and access of medicines.” Stephen …

A UK independent advisory body has called for a change in the law so that the possession of small amounts of controlled drugs would be a civil rather than a criminal offence. The UK Drug Policy Commission report, A fresh approach to drugs , says that much of the £3bn (€3.7bn; $4.8bn) the UK spends annually on tackling illegal drug use may be wasted as it is not based on evidence. The six year study calls for a new body to be established to coordinate research and ensure that politicians and practitioners are aware of the evidence of what works. It says that drug policies should come under rigorous and continual scrutiny to ensure that they provide value for money. The commission, made up of leading scientists, police officers and academics, says that the current ABC classification system for drugs has substantial weaknesses and for many people has lost credibility. It calls for a wholesale review of the Misuse of Drugs Act and for decisions about drug classification to be taken by an …

The growing costs of running a general practice mean that GPs’ income has fallen to a five year low—declining £6000 since 2005-6. Figures from the NHS Health and Social Care Information Centre show that the average income for contract holding GPs before tax was £104 100 in 2010-11—a fall of 1.5% on the previous year and almost £6000 (€7500; $9700) lower than in 2005-6.1 The BMA said that GPs were providing an “exceptional value for money service” and were effectively accepting a pay cut so that they could maintain a high level of service to patients. The report took into consideration the earnings and expenses of full and part time GPs and covered …

A fundamental change is needed in the way that healthcare and social care are delivered, the King’s Fund concludes in a new report.1 The focus should switch from structures to services, and “outdated ways of working” that provide poor value for money and a lack of responsiveness to patients should be abandoned, it says. If the financial challenges that lie ahead are to be met, “salami slicing” of budgets and incremental adjustments to existing services will not be enough. The NHS has fallen behind other sectors such as banking and retailing, where the use of new technology has transformed relations between service providers and their customers, say the authors of the report, Chris Ham, Anna Dixon, and Beatrice Brook. Ham, the King’s Fund’s chief executive, acknowledged that the message was not new. “So, what’s different this time round?” he asked at a meeting at the fund to launch the report. “How are we going to make it different? What are the routes to improvement?” He suggested that two possibilities were the entry of new providers and the decommissioning of existing services. …

Oncology treatments which have come onto the market during the last few years are extremely expensive per treatment course. This is true for biotech products, like monoclonal antibodies and the most recently approved ipilimumab, and for small molecules, like azacitidine and clofarabine, and even orally administered products like lenalidomide or various tyrosine kinase inhibitors. Why are the prices of these products so high? The manufacturing companies argue that research and development costs are very high and that the number of years protected by patent rights after approval is decreasing. Therefore the life cycle of the products is reduced and return on investment needs to be achieved in a shorter period of time. For biotech products high manufacturing costs are also a factor. However, as oncology drug treatments are developed more and more as targeted treatments for specific patients the number of patients eligible for treatment is decreasing and the number of patients treatable within the licensed indications (in-label) is limited. These so-called individualised antitumour therapies often offer only a modest gain in overall survival …

Introduction Upper GI (UGI) cancer patients are at high risk of malnutrition increasing risk of complications post-operatively. Surgeons and Oncologists at Ninewells Hospital, Dundee funded an UGI Oncology Dietitian who oversaw nutritional care of patients through neoadjuvant chemotherapy, preparation for surgery and into follow-up. Previously at Ninewells, dietetic care of patients was ad-hoc resulting in reduced nutritional status during chemotherapy, admissions for feeding and delays to surgery. Once the post-holder joined the MDT it was important to show value for money and clinical effectiveness so data were gathered on outcomes for patients who had undergone UGI cancer surgery in the year before the post-holder started (n=49) and for 1 year afterwards (n=22). Methods A literature search was performed using MEDLINE in order to compare results against other centres but no similar studies were found. Subsequently the MDT decided on clinical standards based on current evidence and acceptable limits including: Patients will be referred to the Upper GI Oncology Dietitian prior to surgery. Patients will maintain their weight during chemotherapy and surgical admissions within 5%. All patients will have a jejunostomy tube placed at the time of surgery. Data were gathered from medical and dietetic notes for each group on; whether patient was referred before surgery, weight (kg) at start and end of chemotherapy and on admission and discharge from surgery, whether jejunostomy placed at time of surgery, length of stay (LOS). Results Conclusion Results showed the positive and cost saving impact of a dedicated dietitian on standards measured especially during chemotherapy and on LOS. The number of feeding tubes inserted fell in the group with dietetic input reflecting the types of surgery performed. Improved communication and leadership between the dietitian and the MDT helped to prevent admissions for pre-operative feeding and reduce delays. Further large studies are required, particularly in the peri-operative period, to further promote dedicated dietetic input. Competing interests None declared.

NHS diabetes services are not delivering value for money because patients are not getting regular checks and treatment to control their condition and are ending up in hospital as a result, says a report by the National Audit Office. The report estimates that the NHS in England could save £170m (€210m; $270m) a year if patients received basic assessments and follow-up care to control their diabetes and to help prevent complications.1 Programme budgeting data from the Department of Health indicate that in 2009-10 the NHS spent £1.3bn on care of patients with diabetes, up from £0.9bn in 2006-7. But David Moon, director of health value for money studies at the National Audit Office, pointed out that this was a substantial underestimate and that the true cost was likely now to be at least £3.9bn. “We estimate that by managing patients better and potentially preventing readmissions the NHS could save at …

Department of Health spending on neurological conditions increased by almost 40% over four years yet there was little to show for it, says a report from the National Audit Office. The report, which focuses on Parkinson’s disease, multiple sclerosis, and motor neurone disease, says there has been little progress since the national service framework for long term conditions was introduced in 2005. In the UK, two million people are estimated to have neurological conditions, excluding migraine. “We don’t believe the current spending is value for money,” said David Moon, director of health value for money studies at the National Audit Office and author of the report. Health spending on neurological services increased by 38% in real terms from £2.1bn (€2.5bn; $3.26bn) in 2006-7 to £2.9bn in 2009-10. This was part of local commissioners’ general budget and was not ring fenced by the Department of Health. The national service framework set out 11 quality requirements that were supposed to be fully implemented by 2015. “Implementation of these quality requirements has been poor and …

The Care Quality Commission halved the number of inspections, or “compliance reviews,” it carried out last winter, while it struggled to meet deadlines for registering providers, says a report from the National Audit Office (NAO). Between October 2010 and March 2011, the commission completed only 47% of its planned compliance reviews, which aim to ensure hospitals and other providers are delivering safe care, after diverting staff to meet statutory deadlines for registration, according to the public spending watchdog. It concludes that the commission is not yet delivering value for money in regulating the safety and quality of health and social care in England. The NAO said the commission, created in 2009 from three former regulators, missed deadlines for registering care providers, while its compliance work more than halved in its attempt to meet the deadlines. Blame for the failure to achieve value for money lies with both …

NHS trusts are losing millions of pounds because they are failing to buy expensive high tech equipment for hospitals in bulk, claim MPs. They found that the way that equipment such as magnetic resonance imaging (MRI) and computed tomography (CT) scanners and linear accelerator (linac) machines are bought and used is not providing value for money for the taxpayer. The report, published on 25 October by the parliamentary public accounts select committee, finds that in the past three years NHS trusts in England spent around £50m (€57m; $80m) a year on buying MRI and CT scanners and linear accelerators and that the current value of these machines in the NHS is around £1bn. MPs on the committee said that since 2007 the Department of Health has devolved responsibility for procuring and …

At least 20 NHS trusts face such severe financial problems that they have declared that they will not be able to reach foundation trust status in their current form. A report by the National Audit Office (NAO) says out of the 113 trusts that are currently hoping to become self governing by 2014, at least 20 will be unable to do so. Financial concerns are the most common problem, but poor clinical quality or governance or both are also to blame. The NAO said that these problems were often “deep seated and long standing.” Mark Davies, director of health value for money studies at the audit office, said: “There are at least 20 trusts out there that have declared themselves unviable at this point in their current form. They don’t believe that whatever they do locally they can meet Monitor’s requirements [to become foundation trusts].” He said more may identify themselves as …

The UK is now covered by separately commissioned neonatal transport services. This has required significant investment and it is essential that meaningful comparisons of activity levels, outcomes and value for money be made. The UK Neonatal Transport Interest Group devised a dataset in 2005 to compare transport teams. The major problem encountered was defining mutually exclusive categories of transfer. The terms ‘planned’ and ‘unplanned’ were agreed, with ‘time-critical’ added following publication of the Neonatal Toolkit.1 Unplanned/time-critical transfers are subject to scrutiny as part of the Neonatal Quality Standards.2 There is a wide …

Rich countries that provide wasteful, inefficient, and inequitable health services should be more accountable for the money they spend and should adapt cost effective models of care pioneered in poor countries, delegates agreed at a meeting last week on global health. The meeting was held by the Salzburg Global Seminar (www.salzburgglobal.org) and the Dartmouth Center for Health Care Delivery Science in Hanover, New Hampshire (www.dartmouth.edu/~tdc/). Al Mulley, director of the Dartmouth centre, drew attention to the low investment in research into how health services are organised and delivered and to the failure to assess rigorously whether they provide value for money in terms of outcomes that matter to patients and populations. Poor countries have had to innovate to provide essential services, and there is plenty of scope …

UK taxpayers could be faced with a bill of £1bn a year by 2035—double what it is now—for rescuing people who fund their own social care when they run out of money, concludes a report by the National Audit Office, unless more stringent oversight arrangements are put in place. The public spending watchdog’s report, which looks at choice and competition in care services for people who use private funds (self funders) or local government funds (personal budget holders) to buy care services of their own choosing, says that the market is beset by variable levels of support and information and a lack of formal oversight. Unless these shortcomings are dealt with, it warns, the opening up of the market won’t represent value for money in …

What really makes a difference when it comes to improving outcomes in the NHS? Certainly not wholesale dismantling of systems and processes that are working well or pitting groups of professionals against each other and inviting commercial providers to pitch for services to reduce costs, argues Roger Boyle. He retired last week after 11 years as England’s national director for heart disease and stroke, because he disagrees so strongly with the coalition government’s plans for the NHS. “No reorganisation ever saved anybody’s life. The thing that remains the same, year after year and reorganisation after reorganisation, is the clinician, the patient, and the disease, all in a room together. Everything else is secondary to that. “Whether this is in primary, secondary, or tertiary care, it is this relationship—and how it is dealt with—that is absolutely crucial.” Professor Boyle acknowledges that NHS care must be cost effective, but he considers that the complete dismantling of NHS structures is unnecessary and won’t help improve efficiency. “I get fed up with people decrying the NHS. We vie with the Netherlands and Scandinavia for having some of the best quality health services in systematic comparisons. “In terms of value for money, we always come out as being the most efficient, with some of the …

The government intends to go ahead with its plan to set prices of drugs in the United Kingdom by the value they deliver, in spite of a lukewarm response to the proposal. The consultation on value based pricing, published on Monday 18 July, shows that many of the 188 respondents remain unconvinced. In answer to the key question, “Will the approach achieve the proposed objectives of better patient outcomes, greater innovation, a broader and more transparent assessment, and better value for money for the NHS?” only 15% of respondents said yes, while 19% said no and 66% did not answer. The Department of …

Social enterprises set up in England under a scheme allowing NHS staff to run services themselves are not being evaluated as to whether they deliver value for money, a report by the public spending watchdog warns. A National Audit Office study of the health and social care enterprises, established under the government’s “right to request” programme, stops short of urging the government to set targets but calls on it to “put in place arrangements” to enable it to evaluate whether the programme provides value for money. The Department of Health should also specify what the costs and benefits of the programme should be, what the costs actually are, and whether any benefits are being …

A blistering report by government auditors has dealt what could be a fatal blow to the 9 year old, £11bn (€12.6bn; $17.8bn) programme to computerise the NHS in England. In unusually forthright language the National Audit Office said yesterday that the attempt to install electronic care record systems across the NHS “does not represent value for money” and that prospects for the remainder of the programme are no better. Amyas Morse, head of the National Audit Office, which reports to parliament, said bluntly that the original vision of the NHS National Programme for IT (information technology) will not be realised. “The NHS is now getting far fewer systems than planned, …

The national spending watchdog has issued a warning over future use of any private finance initiatives to build hospitals, saying other ways of funding public projects might be better value for money. The National Audit Office (NAO) says, in a report published on 28 April, that there has been no thorough value for money evaluations of existing private finance initiative (PFI) projects by government departments, so future projects have to be approached with caution. Currently 698 PFI projects have been signed in the UK with a combined capital value of £52.9bn (€59.4bn; $87.3bn). Such projects include agreements in which private companies build hospitals and NHS …