Alignment with existing trust activities
Trusts are engaged in a range of initiatives to improve quality and improve operational efficiency that predate the GIRFT programme and indeed the Carter review. This has two important consequences.
First, trusts are delivering existing improvement programmes that are likely pursuing related but distinct goals from those that may be highlighted by the GIRFT programme. For example, there are acute care collaboration vanguard projects which seek to improve the quality of clinical services across a grouping of providers. Some trusts are already using GIRFT data as one of a number of sources to inform specialty reviews undertaken as part of their business planning process. It should be up to trusts to determine how to integrate the work of GIRFT into existing business as usual activities to make best use of the data and intelligence provided. In addition, the GIRFT programme should work with trusts to ensure that any new implementation plans developed locally are fully aligned with existing trust plans to deliver improvements in operational productivity. Where appropriate, GIRFT recommendations that go with the grain of existing improvement plans in trusts will increase the likelihood of delivering long term transformation.
Second, senior operational colleagues in trusts will have detailed knowledge of the particular challenges their trust faces in improving operational productivity. While clinical leadership of the GIRFT process is essential, the GIRFT team must make the fullest possible use of the contextual knowledge the trust’s executive team can provide.
Aligning with system level plans
The programme has started to develop beyond an initial trust by trust review, to one which brings trusts within an STP together, either instigated by the STP in question or required by the specialty under review.
This will work for some STPs but not all, and it should be up to individual trusts and partners to decide the best forum to take the work forward. In some instances, it will be a logical direction of travel given that eliminating unwarranted variation will require system level not just individual trust level change. But, for other trusts, focusing on eliminating clinical variation within a single organisation first might be a better place to start.
Alignment with existing programmes and the national bodies
Given the significant burden on the capacity of trust clinical and operational staff, it is vital that the GIRFT programme avoids duplication and is aligned with existing improvement programmes at any given trust. More broadly, the national level collaboration agreements that are to be put in place between the GIRFT programme and NHS England, RightCare, NHS Benchmarking and NICE must set out in clear terms the responsibilities of each body and initiative.
Realism on pace of change and scale of opportunities
Trusts are doing all they can to deliver unprecedented improvements in operational productivity, and are committed to continuing these efforts. However, the significant lead times for more complex improvements need to be acknowledged. For example, operational productivity improvements that require closing, opening or repurposing estate are not likely to be realised in the short-term, and may require significant capital investment that remains difficult for trusts to access. This reality may stymie progress in a number of clinical specialties, and the GIRFT programme team will secure the confidence of trusts and clinicians if they clearly communicate their awareness of the macro environment trusts operate in.
For example, before conducting any analysis of the performance of a given specialty within a trust, it would be helpful if the GIRFT programme was aware of the relevant productivity and transformation programmes already taking place. The review would help GIRFT understand the specific contextual challenges and opportunities facing the trust, and would enable them to tailor their engagement and analysis appropriately.
The central team has acknowledged that some of the changes necessitated by a full implementation of a specialty review might require substantial clinical reconfiguration which might fundamentally alter change the business and workforce model for a particular trust, for example the creation of a hot and cold site for non-elective and elective work.
This might improve the overall provision of care in the wider health and care economy and savings might also flow to the system. However, individual trusts will typically have fixed-costs which can not be switched off immediately – investment and/or double running might be required. Given the unprecedented financial constraints operating in the provider sector, many trusts would struggle to absorb this cost pressure.
In addition, realism is required on the scale of the operational productivity improvements the GIRFT programme can unlock. There are methodological challenges involved in disaggregating the impact of the GIRFT programme from the existing work of trusts to improve operational productivity; there is a risk, then, of overestimating the headline savings available and placing an unrealistic target on the provider sector.
Trusts frequently reported that they struggled to find the analytical capacity to make the fullest possible use of the data produced by the GIRFT programme. In some areas there may be a gap between the analysis presented in the local trust GIRFT report and the practical implementation support needed to deliver clinical change. As the GIRFT programme in a given clinical specialty moves into the implementation phase, the regional hubs should develop and tailor their support offer directly to the individual needs of trusts.
The GIRFT programme’s analysis is being used by some partners in the local health and care economy to understand the financial implications and opportunities of reconfiguration options at the STP level. Where GIRFT data is used to inform STP level plans, additional analysis capacity should be provided by the programme to enable the development of a robust, shared set of financial assumptions.
The general view from trusts is that they faced a shortage of clinical and management capacity to take some of the GIRFT recommendations forward. Consideration should be given, for example, as to whether NHS Improvement and the regional teams could support in providing or backfilling staff so that clinicians and managers are able to lead the local delivery of the programme.
The GIRFT programme is usefully focused on enabling sustainable improvements in trusts that will embed in their ‘business as usual’ working practices. The GIRFT programme’s regional hubs should focus on supporting capability building within a trust, as well as additional implementation capacity. At the most light-touch level, this might look like the creation of toolkits, process guides, and the sharing of best practice between trusts.
Support rather than regulatory tool
There may be a temptation by NHS Improvement to consider regulatory levers at their disposal, if providers are unable to unlock savings at the scale and pace expected, in an attempt to accelerate change. This would be entirely counterproductive.
"GIRFT must not lose sight of the difficulties of local variation, and not become a stick with which to beat trusts. We have numerous challenges arising from disparate sites, recruitment challenges due to geography, and therefore we need to accept that changes will take time and might require structural and system wide solutions."
Finance Director, acute trust
There are already issues and risks with the model hospital – which the GIRFT data is starting to feed in to – being used for a regulatory purpose to underpin the Care Quality Commission’s use of resources assessment. The true value in the model hospital lies in the transparency of data benchmarking offered to trusts, and overly relying on it to exercise a regulatory judgement might undermine this. To add another regulatory lever in an attempt to accelerate change would undermine one of the key benefits of the programme, which is that it is intended to be non-judgemental. Embedding change can only work fully if owned and implemented at a local level, rather than being imposed or mandated on trusts.