How can NHS organisations cut waste to improve patient care?

20 September 2010

The NHS is being urged to cut waste. No-one is going to disagree with this, but how should it be done? The traditional view is a 'top down' approach to cut budgets and staff numbers. But this is to ignore where the waste actually is.

Waste is largely invisible because it's not a feature of most management reports. This makes it hard to quantify, although we all know it's there.

Firstly, we need to know what we're looking for. We know about waiting lists and requesting duplicate tests as examples of waste. But there's also waiting for 'stuff' to arrive, checking
for and fixing mistakes, excess staff movement such as looking for equipment that isn't in the right place, and unnecessary transport of patients.

Secondly, we learn to see these things by mapping out the patient journey and quantify them by measuring how much and how often.

Thirdly, once we 'see' the waste we can take steps to remove it, measuring as we go so we know we're making an impact.

Using these three simple steps, four theatres reorganised their main storerooms to identify overstocking, resulting in financial reimbursement of £27,500. So how much waste are
you hiding?
Mike Davidge
Head of Measurement
NHS Institute for Innovation
and Improvement



Almost every National Audit Office report about a health issue points out areas of waste and inefficiency. The recommendations that we make would lead to better clinical outcomes as well as savings.

Since the NAO's second report on healthcare associated infections in 2004, the Department of Health and local NHS trusts have made savings commensurate with spending on reducing MRSA bloodstream and
C. difficile infections. And our latest report, published in June 2009, concludes that if the department was to monitor other HCAIs properly and then start to tackle them, this would lead to significant savings on further treatment costs, as well as improving patients' quality of life, decrease discomfort, disability and, for some, death.

Drugs make up a significant proportion of NHS spending, and in 2007 we recommended that the NHS prescribe cheaper, generic drugs for common illnesses. By using the generic versions, patient outcomes would not be compromised, but the NHS drugs bill could be cut by £200m per year. In 2008, by following this recommendation, PCTs in England saved £394m.

Other areas where the NAO has highlighted scope for efficiency savings are end of life care and dementia. For example, 40% of patients who die in hospital do not have a clinical reason to be there. If these patients were provided with the care and support to enable them to die at home or in a hospice this would often improve the quality of their care, save money and free up resources. The NAO estimated that for cancer patients alone, whose last year of life costs around £1.8bn, reducing emergency admissions and length of stay could release some £104m and enable people to be cared for in the place of their choice.
Karen Taylor
Director of Health Value for Money Studies
National Audit Office



Healthcare associated infections are expensive. This is widely known but rarely acted upon, yet there is huge potential for savings for the NHS in improving the efficiency of the service. There is some evidence that organisations are beginning to look at the costs of infection. A
recent publication by Tanner et al (2009) implemented Post-Discharge Surveillance (PDS) of surgical infection, looking at the financial and other related impacts of infection in colorectal surgery. Demonstrating the potential savings that could be made if PDS was implemented, the results convinced the organisation that the PDS programme should be extended to other branches of surgery as a patient safety and cost-benefit realisation initiative.

Further evidence that infection prevention interventions are effective was provided by the Keystone project (Pronovost et al, 2006), where the adoption of care bundles significantly reduced the central catheter related bloodstream infection rate across the state of Michigan, a project that is being replicated in England under the banner of 'Matching Michigan'.

All of these initiatives are supported by infection prevention and control specialists, who advise clinical colleagues on the most effective interventions to reduce infections and are skilled at implementation strategies.

In the present financial climate, there is an opportunity for infection prevention to become a key component of organisational cost containment and cost reduction strategies, and the Infection Prevention Society calls upon all providers of healthcare to fully utilise the specialist knowledge of their practitioners in this field.
Martin Kiernan
President
Tracey Cooper
Vice President
Infection Prevention Society



Cutting the hundreds of millions of pounds wasted on manage­ment consultants in the NHS would be a step towards improving patient care. This could also stop the cull of back office jobs, which is a
false economy.

Cutting admin staff simply means frontline nurses and doctors will have to spend more of their time completing paperwork and less time with patients. It would be much better for the NHS to cut back on agency staff, which is costing it millions.

We need to get rid of the NHS market, as the Commons Health Committee recently reported that the market's transaction costs could be as high as 14% of the NHS total.

If the government is determined to cull quangos, it could start with the Cooperation and Competition Panel, which duplicates the work of Strategic Health Authorities and has no place in the NHS. Partnership working should be embraced, with the NHS Social Partnership Forum having demon-strated considerable success in boosting efficiency.

There should be no more wasteful PFI contracts and the interest rates of existing contracts could be renego­tiated. Drug companies should be made to lower their costs, and good initiatives – including the Experts Patient Programme and the Productive Ward – could be extended.
Karen Jennings
Head of Health
UNISON



Everyone knows there is waste in the NHS. On whatever measure you choose to take there are significant variations in practice, quality and efficiency worth several millions (if not billions) of pounds.

The problem is not merely solved by cutting here and there, and focusing attention on a few 'biggies' will not suffice. With near-to-zero real terms increase in funding and ever escalating demand for care, the King's Fund and IFS estimate the NHS will have to get in the region of 4-5% more bang for its buck year-on-year over the next five years, just to maintain standards of care. This is worth some £40-50bn – a huge ask.

So what does this mean? It means that the NHS will have to embrace radical 'disruptive' change. Healthcare needs to fit patients and the diseases they have (largely chronic conditions), rather than historic patterns of provision and real estate. We need, for example, fewer hospitals and more integrated services for conditions such as diabetes, focused centres for elective operations such as orthopaedics, and telemedicine.

But how do we get there? Academic research is clear: such 'disruptive' innovation does not tend to come from incumbents that carry institutional baggage and a powerful inclination towards the status quo. To survive and prosper, the NHS must open its doors to new providers with new ways of doing things.
James Gubb
Director, Health Unit
Civitas



Sadly, there is plenty of waste in the NHS, so it is relatively easy to compile a list of things that, in these financially straightened times, could be stopped without harming patient care. PFI schemes, for example, are valued at £10.9bn, but are set to cost the taxpayer £62.6bn by the time the final payments are made in 2048. Then there are the manage­ment consultants; in 2007-2008 SHAs, PCTs and NHS trusts spent £308.5m on external consultants. There are also too many tiers of NHS management. Since 1995, Department of Health statistics show that the number of senior managers has risen by 91%, more than double the 35% increase in the total number of doctors and nurses – evidence of the sheer level of bureaucracy and micromanaging in the NHS.

Other things, such as parts of NHS Direct and Darzi Centres, need looking at more carefully. Cost-effectiveness reviews could determine where there is waste or duplication and where cuts could be made that wouldn't affect patient care. Beyond that there are still likely to be tough choices ahead, but it would be wrong to make those without first trimming the obvious and unnecessary fat.
Dr Laurence Buckman
Chairman
BMA GPs' Committee


After years of growth, the NHS is facing one of the most difficult challenges in its history. While the new government has ring-fenced its budget, it faces a productivity gap of around £14bn a year by 2014, assuming that previous spending assumptions about pay and procurement, reducing waiting times and capital investment are revised. In short, the NHS must improve its productivity levels if it is to maintain quality and avoid cutting services. A tall order, but by no means impossible.

Andrew Lansley recently announced that he would cut the NHS managerial budget by 46%, signalling a determination to slash bureaucratic waste. But the NHS must look much further to deliver the productivity improvements needed.

We've heard frequently from politicians that frontline services are the heart of the NHS and it is here that the opportunity lies to cut waste by reducing variations in care. The front line spends the majority of NHS money, but variations across the board in clinical and operational practice, such as hospital stays, referral and admission rates, and prescribing are estimated to cost the NHS billions of pounds, as shown by the NHS Institute's 'Better Care, Better Value' Indicators.

The NHS needs its clinicians and managers alike to focus on eliminating unjustified variations in care. By emulating the top performers across the system, NHS organisations can close the productivity gap and strive for the best of both worlds: better patient care and better value for
the taxpayer.
Mark Jennings
Director of Health Care Improvement
The King's Fund




The NHS is undoubtedly facing an unprecedented challenge, and one for which there are no silver bullets. Safeguarding the health service for future generations will require a combination of tough decisions and radical new ways of working.

There is enormous potential for ICT to support more efficient and effective working both in the back office and in frontline care delivery. Clearly organisations need to ensure they are making maximum use of their existing ICT infrastructure. But with pressure to restructure they should also be looking to solutions that can help them make best use of their staff and resources through shared business services solutions and systems to support workforce and asset management. For clinical systems, the important thing is to ensure that systems are interoperable and allow care professionals access to a broader range of information relevant to the treatment of the patient; this is vastly more efficient and improves the quality of care.

But perhaps the biggest prize could come from using ICT to support patients in their homes. Telehealth has been shown to dramatically reduce expensive hospital admissions. It also empowers patients, particularly those with long-term conditions, to take better care of themselves and to live more independently for longer. Ultimately, this technology can help us move towards a more sustainable, integrated health and social care provision that is truly tailored to patients' needs.
Jon Lindberg
Healthcare Programme Manager
Intellect UK