The Carter review is about culture, not toilet paper

05 August 2015

In June 2015 Lord Carter published his interim report on operational productivity in NHS providers. If you are short of time flip straight to page 20 and read the two short paragraphs in the ’Next steps’ section. These are the most important part of the report to me because they highlight the differences between Lord Carter’s work and other approaches to procurement and efficiency benchmarking.

What did the Lord Carter review team do differently?

Firstly, Lord Carter kept his work simple and focused. That is not damning the work with faint praise - when I meet new non-executive directors of NHS providers they often want an initial route in to more detailed conversations about the efficiency of their organisations. The adjusted treatment index (ATI) created by the Lord Carter team does this.

Lord Carter sets a realistic timescale and a credible level of expectation for productivity improvements

The ATI is not perfect. It builds on existing reference cost indices and suffers from the same data quality issues, it is purely acute-focussed for the moment, it potentially under-represents the cost of complex specialised care and structural factors such as working across multiple hospital sites. I would not want my job to hang on whether my ATI was 104 or 108. But if I was on a board of a hospital, the ATI would be one of the first things I would look at to kick-start conversations internally and with other multi-site specialist trusts, for example, on how we could improve efficiency.

Secondly, Lord Carter sets a realistic timescale and a credible level of expectation for productivity improvements. Undeliverable savings over undeliverable timeframes defeat rather than inspire, and I have seen too many waterfall charts and financial bridges that assume heroic in-year savings.

The review makes clear that (i) it will take several years to realise these potential productivity gains,  even with a lot of hard graft by NHS providers, and (ii) the improvements identified in the report are not the magic solution to the £22 billion efficiency savings the NHS needs by 2020/21. 

When launching the NHS Procurement Atlas of Variation to compare the prices hospitals pay for common products, Dan Poulter said "we can celebrate the savviest buyers and shame the worst offenders for all to see". Lord Carter chose to go in a different direction with his engagement and messaging and this was the final and most important differentiating factor for me.

The Carter metrics were co-developed with a group of 22 NHS providers, and information was shared with the trusts prior to publication so they could sense-check the material as partners. We will never universalise best practice through the tyranny of the benchmarked price of toilet paper, because improvement is something you do with organisations, not to organisations.

The work of Lord Carter and his team has the potential to pay dividends for the provider sector and the public it serves

I understand the frustration from a central policy maker’s perspective, I really do. If you want NHS providers to further improve productivity then what ‘levers’ can you pull to get them to do it? You can write improvement trajectories into contracts, or make them a condition of accessing central funding support. But as Lord Carter points out, that will utterly fail to inspire the very people on the ground who must find the headspace to deliver these improvements in the face of rising operational pressures.

There is a lingering perception in some quarters that the provider sector is an archipelago of 240 islands which seek complete autonomy and shun collaboration, which look at a benchmark and stand pat if they are on the right side of the line but question the data if they are on the wrong side. I have seen the opposite over the last ten years – trust boards and staff that are hungry for new information and who reach out to learn and share good practice with each other to deliver better value for patients. Lord Carter and his team reflected this in their approach. As a result their work has the potential to pay dividends for the provider sector and the public it serves.

This blog was published by National Health Executive on 5 August 2015.

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