The NHS Getting it right first time (GIRFT) programme aims for better value in acute hospital and mental health care by using trusts’ clinical, operational and financial data for benchmarking and scrutiny of local performance. Along with efficiency, reducing unwarranted variation has gained political attention over recent years.
Ostensibly a clinically-led quality improvement programme, much also rides financially on GIRFT’s success. The government has committed £60m for coordination and support from NHS Improvement over the next three years, but the savings could be as much as £1.4bn per year, or just over a quarter of the financial gap facing the NHS, by 2020/21. Hopes are running high for a big return on investment.
So what will it take for GIRFT to work? We set out our initial views last August, as GIRFT grew from orthopaedics into a further 35 clinical specialties and services. We then asked trusts for their views, which we’ve published in a new briefing. We learned that trusts recognise GIRFT’s opportunities, and hope that where clinical audit and benchmarking have fallen short, the programme’s consolidated analysis, clinical focus, and tailored support can succeed. However, there are challenges for GIRFT to overcome if it is to drive better value care.
Clinical engagement relies on sound data
GIRFT’s ambitions are data-driven and clinician-led, with the latter’s buy-in reliant on the credibility and clarity of the former. The orthopaedics programme’s success was built on robust datasets, but not all specialties enjoy such comprehensive insight into current practice. Trusts have struggled to find clinical and financial performance opportunities when presented with outdated, incomplete and inaccurate datasets by their GIRFT clinical team. If clinicians don’t accept or recognise their data, discussions take longer to reach consensus on where productivity and quality improvement opportunities lie.
The government has committed £60m for coordination and support from NHS Improvement over the next three years, but the savings could be as much as £1.4bn per year, or just over a quarter of the financial gap facing the NHS, by 2020/21. Hopes are running high for a big return on investment.
Trusts can be agents of progress by embracing the programme at this early stage, to shape the datasets to best support local insight and action, particularly for services like mental health where the necessary datasets don’t actually exist yet. Some trusts have started building stronger dialogues between clinicians and coders to improve their datasets. But it’s clear that clinicians are most enthusiastically engaged when GIRFT analysis is presented as the beginning of an open conversation.
Unlocking the savings is complex and contingent on many factors
Though the programme aims for clinical quality improvement, evidence is growing that causes of variation are less often about how clinicians do what they do, and more about to whom, when, where, how often and what happens before and after treatment. Solutions therefore must take account of the intersections between individual practice and operational circumstances.
Where a clinician’s work can be improved, GIRFT data can provide a useful catalyst for action. Where changing the operational approach to services is the solution, trusts are responding there too - consolidating activity in centres of excellence, ring-fencing beds for particular patients, improving procurement, adjusting waiting list management, linking up with other services in the hospital to improve patient experience. But their response to GIRFT may be influenced by other pressures such as the development of integrated care and NHS RightCare for better commissioning. Making the operational changes will also, for most trusts, require some degree of investment – often capital spend – with money they don’t currently have, or will involve costs that are not easily disaggregated from other spend. Financial benefits will take time to accrue, and a focus on better productivity and quality for spend is more realistic than squeezing out cash savings.
Quality improvement capability is essential to sustain the changes
GIRFT has not yet offered much guidance and support to trusts on the mechanisms for change. This is what regional hubs will be for, but they are still in infancy. Quality improvement (QI) is an enabler of sustainable change in healthcare and GIRFT has a better chance of lasting if it works in tandem with local QI activity and capability development. Trusts are at variable levels of capability, but many already have longstanding local productivity and QI work underway, and GIRFT is landing best when it can be incorporated into this.
Regulating GIRFT would undermine the focus on quality
Providers have delivered significant efficiencies that far outpace the wider economy but, as recent performance pressures show, there is no room left to manoeuvre. Trusts are concerned that GIRFT’s unrealistic expectations are exposing them to threat of regulatory levers - too often the default when national bodies want stronger results than trusts can achieve. Given the complexities of delivery, regulating trusts on GIRFT outcomes would not accelerate results; it would disempower clinicians, undermine objectivity, curiosity and innovation, and fracture the collaboration between managers and clinicians needed to make it work.
Quality improvement is an enabler of sustainable change in healthcare and GIRFT has a better chance of lasting if it works in tandem with local QI activity and capability development
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Assurances are that GIRFT sits firmly on the ‘improvement’ side of NHSI’s remit but trusts are already feeling pressure to demonstrate rapid results against specialty action plans. Performance management and regulation often feel much the same for trusts; and new NHS research shows that perceptions of accountability, financial incentives and unclear goals can undermine the effective use of measurement for improvement. Only a true partnership approach can effectively support trusts to integrate GIRFT with local improvement activity.
Trusts see the good potential in GIRFT. The programme will face challenges when it draws heavily on staff and resources already at full stretch. But if trusts are given constructive support, without judgment and fear of failure, then GIRFT can still succeed because it’s the right thing to do for patients. Clinicians value reliable insight into their work, and welcome efficiencies they recognise will make care quality better. But realism, patience, better data and maintaining the commitment to clinical leadership will be essential for GIRFT to sustain its ‘quality first’ agenda in the long term.
This article was first published by National Health Executive on 9 February 2018