Value for money in the NHS - Health Committee Contents

Memorandum by the NHS Institute (SAV 05)



  Having been formed four years ago from the merger of the Modernisation Agency, the NHS University and the NHS Leadership Centre, the NHS Institute is a young organisation that has rapidly evolved and developed with a strong reputation both nationally and internationally for producing high quality products and services that drive innovation in improvement in healthcare. Latterly, following both the demands of its customers and the direction provided from its sponsors in the Department of Health the NHS Institute has focused all of its work on supporting NHS organisations to improve quality and productivity in response to the financial challenges facing the country as a whole.


  The NHS Institute was assessed independently by the Department of Health as having developed three out of the six interventions within the whole of the NHS with the greatest probability of delivering productivity and quality improvement at scale. Our own research suggests that if these approaches were implemented at scale the gains to the NHS would be of the order of £6-£7 billion:



  The NHS Institute was founded and did much of its early work in an environment characterised by a benign external financial position and increasing funding for the NHS year on year. In this environment the primary focus of our products and services was to release the time, energy and capability of NHS staff so that it could be better focused on patient care. A range of approaches was used. These included:

    1. Benchmarking data—allowing organisations to compare themselves with best in class eg. through the development of the Better Care Better Value indicators.

    2. The introduction of Lean techniques into the NHS combined with innovative approaches to ensure buy in and ownership by frontline staff eg. the "Productive Series".

    3. Identification, for some of the highest volume care pathways of those characteristics that differentiate highly productive care pathways from less productive ones—the High Volume Care Series.

    4. The embedding of improvement approaches into leadership programmes both for senior managers and clinicians eg. the Delivering Through Improvement programme and the Medical Leadership programme.

    5. The use of innovative diagnostics to identify avoidable patient harm and through an organisation wide training programme to develop and support the implementation of a holistic approach to patient safety.


  In the current environment it is inevitable that the business case for change will shift towards releasing cash and supporting large scale movement in patient activity from secondary care to primary care settings. We believe that the NHS Institute's products and services are equally relevant in this environment. However they will only be effective if they are implemented as part of an integrated cost savings programme underpinned by strong leadership and a positive staff culture. Used this way we believe that we will be able to support NHS organisations to reduce cost safely and to reduce the risk of adversely affecting patient outcomes, quality and patient experience sometimes associated with more traditional cost reduction approaches. Nonetheless, it should be pointed out that this case is less established than the pre recession case.


  The NHS Institute believes that such change programmes are most likely to be successful when the following components are present and aligned:

    — Strong consistent leadership framing the productivity and quality challenge to staff, partner organisations and the wider community in positive and unifying ways rather than simply focusing on cost cutting.

    — Measurement at every level in the system which enables staff to gain feedback regarding the impact of their actions and supports them in fine tuning improvement activities to suit their local situation.

    — Tools and techniques with a strong evidence base and a proven track record of successful development and implementation within the NHS.

    — Capacity building—to ensure that staff, whether clinicians, managers or frontline workers have the right knowledge, skills and attitudes to make the necessary changes.


  The Productive Ward is the NHS Institute's best known product. Co-produced with frontline clinicians it draws on the principles of approaches such as Lean and Six Sigma and applies them to the NHS. Ward staff are given tools such as observation (eg. how to video ward activities), measurement (eg. how to create display boards to show patient status at a glance) and improvement methods. This helps them identify and eliminate waste: after implementing the programme, typically around 15% of additional ward staff time is available for direct patient care activities. At the same time patient satisfaction improves and there is strong evidence that the programme contributes to improving patient safety.

High Volume Care—total knee

  This programme was co-produced with orthopaedic clinicians from a range of disciplines and takes a total clinical pathway approach to identify those actions which statistically are most likely to contribute to reductions in length of stay and improvements in patient satisfaction. For example, it has been shown that early mobilisation of patients following surgery is one of the single most important actions that differentiate highly productive from less productive units: everything from the first outpatient appointment to discharge embeds that objective and in particular the availability of high quality physiotherapy services is given very high priority.

Leading Improvement in Patient Safety (LIPS)

  This programme's objective is to help build an NHS where every member of staff has the passion, confidence in skills to eliminate the possibility of harm to patients, by helping NHS teams to develop the capacity and capability to improve patient safety. This is an organisation wide leadership and skills development programme which promotes the use of the global trigger tool (used for case note reviews) to identify and then reduce preventable harm to patients. The underlying assumption is that safer care is more cost effective care (since patient errors cost money to rectify). As a consequence we see this programme as underpinning the overall objective of reducing cost safely.


  Much of the evidence created to date has been produced during a benign financial environment when the focus of improvement has been to increase the proportion of time spent on patient care activities rather than to reduce cost. We believe that the same principles should be applicable to much more challenging current financial environment but this will only be effective if the NHS Institute's products and services are implemented as part of an overall cost reduction programme. In other words, the NHS Institute can help organisations reduce costs safely in a way which minimises the impact on quality; it cannot on its own deliver the level of cost savings required.

  Our evidence suggests that to deliver sustainable improvement as much attention has to be paid to winning the hearts and minds of staff and ensuring that they are deeply involved in the implementation process as in designing and disseminating technical solutions. The NHS Institute has adapted many successful social movement techniques to suit the context of the NHS; it will require consistent leadership at national, regional and local levels to ensure that as the financial impacts begin to be felt more severely there is not a reversion to traditional pure cost cutting approaches.

  Our experience also indicates that although there is much expertise in the NHS there are also many areas where there are substantial gaps in capacity and capability and these will need to be strengthened in order to achieve mobilisation at scale.

March 2010

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