News analysis: productivity revisited

There are critical and unwarranted variations in all key resource areas across mental health trusts and providers of community services and addressing these could release up to £1bn a year, according to Lord Carter’s latest productivity review.

Lord Carter has previously looked at productivity improvement in acute trusts, with his 2016 report estimating acute providers could realise £5bn of efficiencies from their total spend of £52bn by addressing variation in their sector. This follow-up report expands the area of scrutiny to the £17bn spent on mental health and community services in England.

Both the mental health and community sectors are critical areas for the NHS in the coming years. Community services are vital to the vision set out in the Five-year forward view, with Lord Carter suggesting average length of stay in acute hospitals will need to shorten from seven days to something approaching the 5.5 days found in Denmark. To achieve this, community services would need to be ‘considerably strengthened’.

In his foreword to the new report, Lord Carter said that in contrast, the key challenge for mental health services is to meet significant levels of unmet demand. ‘Even taking into account the significant expansion in children’s mental health services, workforce constraints mean that by 2020/21 we only plan on meeting the needs of a third of children with diagnosable mental health conditions,’ he said.

He added that improving productivity in both sectors was an important part of the answer to these challenges.

The report identifies four areas where operational improvement needs to be made. Unsurprisingly, staff head this list – with some £10.4bn of total spending on these services consumed by staff costs.

Staff were praised for their hard work and brilliant services despite significant pressure. But the report recognises that, with critical labour shortages in all grades, using staff time to the best effect is of utmost importance.

Despite this, the review found that more management attention could be given to important areas such as staff rostering, job planning and managing sickness absence.

The other key areas include:

• Contract specification – inconsistent and overly bureaucratic
• Technology – lagging behind other public sector services, with a quarter of trusts’ community nursing services operating paper-based systems
• Delivery – central leadership could be better.

Lord Carter’s work also identified a number of structural issues that were well recognised but had not been adequately dealt with. Delayed transfers of care, for example, account for about 5,000 beds at any one time, with the main reason for delays because patients were waiting for further non-acute NHS care.

In some good practice examples, effective use of community health services and social care had reduced average length of stay in acute beds by four days, the report said.

Wound care is another known problem area. While the NHS spends an estimated £5bn a year managing wounds, undertaking 40 million patient visits, most trusts do not capture clinical information or operate within nationally defined pathways, the review found. 

The report recommended an extension of the Getting it right first time (GIRFT) initiative to community health services.

Some areas have inpatient community hospitals, while others don’t. But the report said it could find no evidence that ‘the often expensive provision of inpatient community hospitals improves outcomes’.

A much clearer idea of ‘what good looks like’ was needed, but the report said that an isolated 10-bed inpatient facility was ‘unlikely to be clinically or financially secure’.

The report also called for a much greater focus on elderly patients – pointing out that nearly half of the lifetime health and social care costs of an individual in England are incurred after the age of 65.

The report makes 16 recommendations, many of which aim to drive standardisation across mental health and community services.

In addition to the extension of GIRFT to community services, in particular for wound care services, Lord Carter said an extension of the initiative to support mental health services should help support the elimination of inappropriate out-of-area placements for adult mental healthcare by 2021.

The review worked with a cohort of 23 trusts to understand a number of key metrics on how clinicians spend their time. These included:

• Total time spent with patients each day
• Number of patient contacts a day
• Average duration of contact
• Number of contacts per patient over the reporting period.

Using these measures to understand productivity, it then drilled down into two specific services – community nursing and adult community mental health services – and found significant variation.

For example, in community nursing it found the average time clinicians spent delivering care to patients ranged from 33% to 80%, with some services delivering twice as many contacts per clinician per day compared with others. There was also a 75% difference in the average duration of face-to-face contacts, and the number of contacts per patient over the reporting period ranged from 14 to 45.

While some of this could be explained by case complexity, geographies and the way services are commissioned, the report concluded that ‘variation of this scale is unwarranted’. If the direct care time for all community nursing services were improved to the median, this would free up nearly 300,000 days per year nationally and allow these services to support nearly 90,000 more patients – the equivalent of an additional 1,600 staff.

Similar variation was found in mental health services. If all direct care time were moved to the median, this would free capacity of more than 90,000 days per year and enable a further 20,000 service users to be supported – the equivalent of an additional 500 staff.

While this variation was found across a range of services, most trusts do not review data on their clinical workforce productivity, with performance reports typically focusing on volumes of activity without considering the resources used delivering them.

The report recommended that trusts should be given access to this type of benchmarking data through NHS Improvement’s Model Hospital, noting that the introduction of patient-level costing would enable increasingly robust comparisons across providers. Some new compartments should be added to the Model Hospital as soon as April 2019.

The report also called for changes to the contracting process. Just 4% of mental health service providers currently use an episodic payment approach, with a further 2% using a capitated approach. However, it highlighted promising examples in Oxfordshire of areas developing outcomes-based models.

This should be supported, the report said. ‘[NHS Improvement and NHS England] should further develop currencies and the payment systems for mental health and community health services to allow a clear categorisation of services, and incentivise the collection of high quality activity, cost and outcome data,’ it added. This would support longer-term benchmarking between providers.

NHS Providers’ head of policy, Amber Jabbal, said the review’s findings addressed many of the concerns raised in its own report on community services (see box). ‘Highlighting unwarranted variation in key areas for the first time presents a new opportunity for trusts to improve their productivity,’ she said.

‘This report is right to draw attention to the complex commissioning and contracting environment, discrepancies in the way performance is measured, and the importance of harnessing IT to provide better care.’

However, Ms Jabbal added that improving productivity was not the answer to all the services’ challenges. ‘Above all, these services need adequate funding, and action to address staff shortages,’ she said.