There has been much reported in the media of NHS staff being asked to sacrifice their annual leave in orderto branch the financial precipice that the NHS is currently peering over. This issue is compounded further bythe onset of the challenging winter months and holiday seasons.
This was an unprecedented and somewhat desperate move by the sector, which could suggest that the NHS is losing its way. With more and more trusts facing financial peril, there is a requirement as never before to find new ways to increase productivity and drive out costs. However a common complaint across the NHS is that cost cutting and efficiencies are looked for in the wrong places. It is clear that time is running out and that NHS Trusts need to focus in the right places and at the right level to release the financial pressures.
For several years now, ‘lean thinking’ has been a cause celebre for the Department of Health. The Institute for Improvement and Innovation produced their ‘Productive…..’ series of guides to help improve the efficiencies of wards, operating theatres, leaders etc. The series claimed to have adopted efficiency techniques previously used in car manufacturing and aviation industries. Newton Consultancy claim on their website to save up to £10 million p.a. for every trust they work with by increasing productivity and quality of care in theatres and procedure rooms. Ignoring the use of the phrase ‘up to’, the picture is clear, there are savings to be made by improving processes at the very low level of clinical procedures and activity. However, it may be true that a trust can improve the efficiency of its activities but those activities themselves maybe inherently loss-making. So focusing at this micro level is just ‘too small’.
Service line reporting, an accounting methodology pushed by Monitor, the independent regulator for NHS Foundation Trusts, helps trusts identify those services that are profit making from those that aren’t. The big consultancy firms have earned millions in the last few years telling trusts that in order to reduce their deficit they should do more of these profitable services and less of the loss-making services. While this statement of the obvious, sorry – advice, might be helpful from a strategic perspective, it says nothing about how to reorganise those services. So this level of information is often ‘too high’ and of limited value.
To use a sailing analogy, focusing on cost savings from the macro level is like sailing a boat with a map but no rudder, whilst focusing at the micro level means that your small boat is no match for the strong tide you are trying to sail against. In isolation, the micro level is ‘too small’ but the macro level is ‘too large’. So at what level should trusts focus their cost saving activities – what level is ‘just right’?
I am going to make a bold prediction. At any one time in the NHS, a significant proportion of NHS resources, say theatre space, clinical rooms or MRI scanners, are not being used. This underutilisation could be as much as 20%*. Improving this utilisation would allow the NHS to smash through Sir David Nicholson’s productivity challenge and make the required £20bn savings over three years look like small beer.
But why are these resources not being used? The answer is straightforward – poor organisation and lack of transparency at the level of staff and resources. Consultants are the main drivers of clinical activity in a hospital. Overall productivity in the trust is reduced when their work is not organised to maximise the use of the hospital’s resources. Further to this, consultant activity will determine the activity of other worker groups such as nurses, junior doctors and allied health professionals. When information about consultant activity is not transparent and updated quickly the allocated staff and resources are wasted when they could have been deployed in other areas. So poor resource utilization results in a double hammer blow of reduced productivity and wasted costs.
What is required is advanced planning, with the production of clear rosters to give full oversight of which doctors are available at any given time. In the past, managing staff availability and scheduling treatment was often considered a time consuming task and a diversion from patient care. However, advances in technology have not only transformed these processes, they have also led to immense efficiency gains.
Modernisation is clearly the cornerstone of reform in this area. NHS trusts have to be realistic about what can be achieved with outdated technology and paper-based processes. If efficiency and cost reduction is the end goal, it’s time to equip staff with the means to achieve more with fewer resources.
With a move by some trusts to focus on organising their staff rosters specifically around the use of their resources, this approach will, I believe, drive much greater productivity gains much quicker than changes to the mix of service provision or the order in which scalpels are used in theatre.
The NHS is entering a tumultuous period of change and focusing on the areas of improvement that are ‘just right’ will make its passage less painful for us all.
*The figure of 20% is a prediction based on my own conversations with managers in many trusts. If readers have data to support or challenge this figure I would be very happy to receive it.
At Zircadian software we currently help over 147 NHS organisations better manage and utilise their junior doctor and consultant services.