Memorandum by the NHS Institute (SAV 05)
SAVINGS IN THE NHS
BACKGROUND TO
THE NHS INSTITUTE
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.
ACHIEVEMENTS TO
DATE
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:
FROM IMPROVING
QUALITY AND
VALUE TO
RELEASING CASH
THE POSITION
PRE RECESSION
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.
THE POSITION
POST RECESSION
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.
CHARACTERISTICS OF
SUCCESSFUL PRODUCTIVITY
IMPROVEMENT INITIATIVES
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.
SOME EXAMPLES
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.
SUMMARY
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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