Feature / Helping hands

The skills needed to redesign services are not widespread in the NHS, so many trusts have turned to external consultants. Seamus Ward discovers how one trust has used an innovative partnership to drive efficiencies and increase quality.

Lean, Six Sigma, re-engineering and redesign have become part of the NHS vernacular as it seeks to squeeze more from every pound it spends. But these initiatives require skills that are often in short supply in NHS organisations. Trusts tend to buy in external support, get trained in Lean methods and spread those skills through the trust. The Royal Wolverhampton Hospitals NHS Trust, however, has taken a slightly different route.

‘About two years ago we recognised we had to partner with an external organisation to re-engineer services and modernise the way we do things,’ says chief financial officer Kevin Stringer. ‘We didn't have the skills internally to make changes in a substantial way – some people with Lean skills, others with Six Sigma but not enough to make a big difference.’

The trust went to the market and awarded the contract to cost and efficiency specialist Newton, which works with the trust to improve quality and productivity. ‘We didn't want somebody who would come in and write a report that we would stick on a shelf. They help us work through the redesign and are part of the solution – they get paid only if they help deliver the specified savings and redesigned services.’

Project by project

The partnership deal operates on a project-by-project basis. The trust identifies an area or group of services it believes requires attention; the consultants then conduct a high-level review and come back to the project board with a proposal, setting out the outcomes of its proposed redesign – efficiencies to be delivered, processes simplified or how the patient experience will improve. Much of the work is based on Lean principles and, while many of the techniques will not be new to NHS organisations, Wolverhampton appears to have found a formula that engages staff, making success more likely.

Mr Stringer explains the initiative was prompted by the wish to improve quality and meet efficiency targets. The trust has to find efficiency savings of about 4% (£15m) in 2012/13 on a turnover of £370m – a relatively fortunate position compared with the savings requirements for some trusts. Nevertheless, he says, this is a substantial challenge. And while the local health economy is not financially distressed, the local primary care trust still requires £4m in savings this year in addition to the trust’s 4% target.

While mindful of the need to make its contribution to the overall £20bn QIPP savings target, quality improvement is the prime motivation behind the re-engineering project. ‘Quality is about patient experience and outcomes,’ says Mr Stringer. ‘They are the things we have always looked to improve. It’s about making sure they have a good pathway and are not being kept in a hospital bed unnecessarily or made to wait at outpatient clinics, for example.’

The focus on quality encourages clinical engagement. ‘You need to talk about their services and how to provide better quality. If you get that right, you can genuinely improve quality and cost will come out as a result of getting rid of variation, for example.’

No salami slicing

He adds that the work is firmly not about salami slicing services to make efficiency savings. ‘Salami slicing is dangerous and can have unintended consequences. This is about sustainable change. We are redesigning the way we provide care in a way that’s best for patients and it’s more cost-effective.’

The partners first examined the outpatient department, where they aimed to increase rheumatology, dermatology and diabetes clinic productivity by 11% over a period of six months. Data from studies looking at clinicians’ start and finish times and when appointments were scheduled was combined with analysis of historical data and feedback from clinicians and patients to identify problems and set targets.

Improving the efficiency of the clinics and reducing DNAs (did not attends) were key aspects of the work on the outpatient booking process. This included minimising the number of times an appointment is rescheduled (a common complaint from patients) and phoning patients before their appointment to remind them (the trust is currently looking at introducing text reminders too).

Staff timetables and clinic setups were benchmarked against peers within the trust and nationally. Working closely with medical and nursing staff, the trust was able to redesign practices to ensure they were operating as efficiently as possible. Finally, new reporting schemes were introduced to improve the accuracy of outpatient treatment data capture.

‘It was about getting the flows right so patients are being seen at the right time by the appropriate person. It is important, for example, that consultants see patients on

their first appointment so you get the right decisions about their care from the start. More junior staff are more likely to order a lot of diagnostic tests or tell the patient they need to come back to see a consultant as they are not quite sure what’s presenting,’ Mr Stringer says.

DNAs have fallen by 13%, while improved staffing has led to an extra 3,400 appointment slots each year – together yielding savings of £545,000 a year. ‘We benefit from increased throughput of patients but some costs also come out from redesigning services – for example, through reallocating some of the nurses’ and consultants’ job plans.’

More accurate reporting of outpatient treatment has generated income of £140,000 a year. In a separate project, a paper-based system was established to improve data capture for inpatients, but the trust is now looking to move to an electronic system. Better data capture is important, Mr Stringer says. ‘An analysis showed comorbidities were missing in up to 25% of our patients, so the complexity of patients treated was not being recognised in the HRGs. The new system ensures this is captured in patients’ notes so the clinical coders can see straight away the patient has comorbidities as well as the presenting condition.’

While accurate coding is essential to ensuring trusts receive correct levels of income, it is also important when presenting trust mortality rates. ‘We are mindful our mortality rates have to properly reflect the complexity of our patients,’ he adds.

Clinical buy-in

Clinical buy-in has been key to the success of the project. This has been gained through the careful building of an evidence base and a bottom-up approach – through observation, data analysis, interviews with clinicians and patient feedback – and clear presentations to clinical staff that allow them to see quickly where the opportunities for better quality or efficiencies lie within their departments.

The work has also focused on procurement, which has resulted in reduced stock levels and unit cost reductions. The trust got a one-off cash gain by reducing stock levels of various products as many departments were unsophisticated in their purchasing and therefore kept stock levels ‘just in case’.

There have been other projects – in orthopaedic surgery (see box) and the trust’s ophthalmology clinic. The ophthalmology department had difficulty meeting demand and had a backlog of 9,000 follow-up patients on its waiting list. It needed to increase its capacity by around a third to meet demand and allow for trends, such as the ageing population and an increase in diabetics.

Following an initial assessment, the trust and Newton aimed to increase capacity by 21% through efficiency improvements, with the remaining 13% through the appointment of an additional consultant. Working with staff, clinic timetables and staff skill mix were revised to match availability to demand and ensure patients were seen by the most appropriate clinician. The appointment booking process was redesigned and utilisation improved with a bespoke information system.

These efficiency improvements delivered a 27% increase in capacity, which together with the consultant appointments has enabled the trust to meet demand, cut waiting times, ensure follow-ups and reviews are held at the appropriate times and led to a closer working relationship between managers, clinicians and support staff. It has avoided costs of £454,00 a year – the cost of appointing several consultants to meet the demand.

The trust is planning further work with Newton. It is in the early stages of planning a redesign of community services, which were integrated into the trust in April 2011 under the Transforming community services initiative. ‘We are hoping to examine whether any acute services could be done in the community in a more effective way, producing benefits from clinical and patient perspectives, and improve our cost base.’

While the trust clearly has the appetite for redesign and re-engineering, Mr Stringer warns it is not an easy process. It has involved a lot of hard work and continued vigilance – the trust has developed metrics to ensure it does not slip back into the old ways of working.

He adds: ‘Finding the idea is fine. Investigating it is fine and to some extent understanding the solution is fine. The hard work is in making sure it is sustainable. This is where winning hearts and minds is important.

‘The challenge going forward, like all NHS organisations, will be to improve quality while reducing cost,’ he adds. ‘And this can only be done on a significant scale by changing the way we work. The real issue is you cannot afford not to do it, so do you have the skills and processes to make it happen.’