The second main type of intervention in the efficiency agenda is productivity - finding ways of doing more work with the same resource. This is sometimes known as technical efficiency. Figure 4 demonstrates that trusts believe reducing unwarranted clinical variation offers the most potential to make better use of existing resources and improve quality in the next five years.
This will typically involve streamlining working practices within a department, specialty or ward to reduce wasted time, effort and resource. This may lead to improvements in quality, and increased activity for providers – for instance, an increase in the number of operations a trust performs in a week. However, under an activity-based payment model this will cost commissioners money.
This chapter explores two major initiatives to improve productivity with a focus on how clinical staff work: NHS Improvement’s GIRFT programme and 'lean' working. It also looks at the difficulty that trusts can face in improving productivity when they are under major operational strain.
The second main type of intervention in the efficiency agenda is productivity - finding ways of doing more work with the same resource. This is sometimes known as technical efficiency.
The appetite among trust leaders for reducing unwarranted clinical variation is encouraging for proponents of GIRFT, which seeks to identify unwarranted variation in cost and patient outcomes, find out why it exists, and eliminate it. GIRFT is divided into workstreams by clinical specialty and directed by leading medics in their field.
The clinically-led nature of GIRFT has proved helpful for trusts that have in the past struggled to engage senior clinicians. Acute finance directors often say their consultants see attempts to introduce more efficient working practices as being an attack on their clinical judgement and autonomy. However, GIRFT is seen as being more successful in opening these conversations because it is clinically-led and uses clinical outcome data, rather than being manager-led and based on financial data.
One acute finance director told us: "GIRFT is the glue between performance, workforce, quality and finance".
However, trusts that are positive about GIRFT tend to be reluctant to put a figure on the added productivity gains it may bring, and whether that can be generalised across the whole NHS. To attempt to do so may be "simplistic", in the words of one acute finance director.
Trust leaders also see GIRFT as a long-term approach. One interviewee said: "GIRFT is a cultural change programme. It will take five or ten years to do properly – why would you attach a savings figure to that?"
Trusts that are positive about GIRFT tend to be reluctant to put a figure on the added productivity gains it may bring, and whether that can be generalised across the whole NHS.
While GIRFT is attracting attention as a centrally run standardisation programme, trusts have been making inroads in this direction on their own. Though GIRFT is not yet focused on community care, we heard of one community trust running a programme under its own dedicated transformation team working with clinicians to change their interactions with patients, with the aim of using technology more and standardising processes.
Finally, we should also recognise that the GIRFT approach will not necessarily improve productivity in the same way in each specialism it tackles. GIRFT began in orthopaedic surgery, which typically has high volumes of relatively straightforward procedures which are easy to cost. While variation will exist and should be reduced in specialisms where there is more long-term condition management and less surgery, it will be more difficult to come up with evidence-based targets.
In 2015, five trusts, with the backing of national leaders, brought the Virginia Mason Institute to England to work with them to improve cost effectiveness, safety and quality. Those trusts’ gradual adoption of 'lean' working practices is bearing fruit and attracting attention. One trust, which had several years of implementing lean working, listed a series of small improvements they had made internally that had made their organisation more productive.
- Putting all items needed for steroid injections on a standard trolley. Previously, the items had all been in different places. The intervention cut the time it took to set up an injection from 85 seconds to 5 seconds.
- Improving processes for managing cases of diarrhoea which have cut diagnosis times from two days to six hours, reduced the time spent by nurses gathering supplies for personal care from 7.5 minutes to 1.5 minutes, cut the time taken to implement a treatment plan after diagnosis from 29 hours to 30 minutes and brought down the time needed for patients being put into an isolated room from over 20 hours to four hours.
- Using a computer on wheels during ward rounds for elderly care reduced "non-value added time" spent with patients from 19 minutes to just under 12 and eliminated defects in reporting.
- Cutting set up times for ultrasound guided injections from 13 minutes to seven minutes per patient.
In 2015, five trusts, with the backing of national leaders, brought the Virginia Mason Institute to England to work with them to improve cost effectiveness, safety and quality. Those trusts’ gradual adoption of 'lean' working practices is bearing fruit and attracting attention.
As with GIRFT, trusts are confident that such improvements have eliminated waste and resulted in better care. One trust told us:
"Our focus has always been on quality, safety, experience and outcomes. What this work does is add an additional strand which focuses on the relentless pursuit of reducing waste while putting the patient first and reducing the burden of work on staff. We rarely mention reducing costs or increasing productivity or efficiency because this seems to be just the wrong motivator for staff. We simply don’t have the resources to track all of the financial benefits and if we did it would only be proper to track the costs too. We know this is the right thing to do, we know there are cost benefits which help our financial performance but we aren’t looking to track everything to the nth degree as that process in itself could be considered a waste."
National leaders should bear in mind that it is difficult to objectively say how much any given intervention "saved", and that giving staff the space and opportunity to change processes to improve patient experience may be more valuable than trying to put a number on it. It will also be essential to share the learning and positive experience of the 'lean' approach from these trusts widely across the sector.
Operational pressure and capacity
One of the greatest challenges facing trusts is operational pressure – across acute, mental health, community and ambulance services.
National leaders should bear in mind that it is difficult to objectively say how much any given intervention "saved", and that giving staff the space and opportunity to change processes to improve patient experience may be more valuable than trying to put a number on it.
This issue manifests itself quite clearly in the lack of inpatient capacity. A hospital that had 95% of its beds full may appear more productive than if it was running at 85% occupancy. In fact, as occupancy rates tip over 90 %, hospitals become less efficient. This is because as inpatient beds become scarce, elective operations are cancelled, increasing the risk of complication and duplicating the process of booking a patient in for their operation. Furthermore, patients that are admitted may be placed in any bed that is available, rather than on the most suitable ward. The finance director of a large acute trust told us this results in "safari ward rounds", where staff have manage patients dispersed across the hospital instead of in one site. This cuts down patient contact time.
In our report The NHS funding settlement: Recovering lost ground (NHS Providers, 2018) earlier this year, we argued that hospitals with insufficient inpatient capacity will be less able to hit the four-hour A&E standard because they cannot achieve the necessary levels of flow.
This is a productivity issue. Investing in surplus capacity will be needed to ensure hospitals can maintain basic effective processes and will also improve efficiency beyond the acute sector. Ambulance trusts currently lose time queuing at hospitals unable to take patients because they have no beds to admit them to. Increasing hospital capacity could improve use of resource across the whole system.
Increasing capacity will be necessary to improve productivity in the short term. However, trusts are also clear that this is not a permanent fix and that without system reform, the same problems will arise when the demand increases to fill any extra capacity that can be created. A long-term answer will involve designing a more efficient local system with greater investment prevention and in primary care, community services and social care.