There is a saying "there is nothing new in the world", while my great grandfather might be a bit surprised by a mobile phone there are history lessons all around us. Here is a history lesson for the NHS from one of my previous roles in the mid 90's. I used to work in packaging manufacturing, we used to make the McDonalds clamshell "Big Mac" boxes. We made "A LOT" of them with large parts of the plant knocking out McChicken/Big Mac and many other promotions 24/7. We were good at it, McD's was expanding hugely in the UK and Europe at the time and we were a key partner, happy days. One day we had a visit from the Suits and we ended up with a great deal on the price and a promise of bigger slice of the action as expansion went on. Oh, in the small print was a year on year reduction of 5% price, you know for efficiency savings that volume would bring. (sound familiar anyone?). Year one we found 5% literally on the floor. Year 2 we found 5% down the back of the sofa, it was buried but we found it. Year 3 there was nothing left, we were facing a loss at a 15% price reduction. That was on double the volume from when the agreement was signed. Oops. We had cut everything we could, done all the obvious things, we had to do things differently. From the moment the polymer hit the plant, every single process, measurement, control and setting was measured and analysed. All departments working together to create a better product. Turns out we were actually a bit rubbish at process control with many key things not measured, not understood and some of those having a huge impact on the overall product. Things that made one department work well, impacted the next. In the end the process, material and equipment were re-engineered and the box ended up 20% stronger and 1 gram lighter. The box only weighed ~4g so this was a 25% weight saving, we could see profit again. Year 4 we were ready but then McD decided to move to plastic coated printed card boxes which at the time were 3x the weight and (at the time) non-recyclable.  We were "a bit shocked", all the pressure on us to deliver more efficiency, less waste was thrown out the window for marketing. It's long enough in the past to say it was the correct commercial decision. Environmentally that's a more complex question for another time.

Lessons

1) YoY price reductions have a VERY limited effectiveness. In fact by year 3 they are a massive price cut. Tariff anyone?

2) Volume does not create de facto efficiency. In fact cost per unit can often rise as investment in both staff and equipment can outstrip a stable cost base at lower volumes.

3) A system wide approach was the only way do things differently. Asking one part of the system for a saving is like cutting off your arms to make your legs carry you faster.

4) You have to invest in understanding the whole system. The current level of understanding of flow, cause and effect, movement of patients and the effectiveness of preventative measures is very much in it's infancy, just as we were, we thought we were brill just because we did it millions of times a day before we understood the process properly.

5) Despite the best efforts of everyone involved, the suits can change the rules of the game and there is nothing you can do to prevent that.

It is our NHS, stand up for it or lose it.