Feature / Recession: crisis or opportunity

Higher quality services at reduced costs are achievable if clinicians accept fundamental changes in the way they work. And the current economic crisis may offer an opportunity to convince them that change is needed, argue John Yarnold and Dr Steven Allder

Over the past few years, the government has pursued a policy of encouraging consumerism in the NHS. Trusts, primary care trusts and all services have been exhorted to improve the quality of services for patients – for instance by cutting access times, reducing hospital acquired infections and improving the speed at which thrombolysis is given.

At the same time, the government has encouraged new players to enter the market, given patients choice and introduced a payment by results mechanism. It has established a system to encourage the right behaviour through a combination of competition and performance management.

There has been some pressure on improving efficiency through the tariff deflator. Most providers have managed to meet the challenge and improve the quality of their service while reducing their unit costs. But this has been against a background of increased throughput to meet the risk in demographic demand and mainly to achieve a reduction in waiting times.

It has also been at a time when there has been an unprecedented increase in the level of funding in the NHS.

The global recession, which could potentially turn into a depression, will change the economic landscape fundamentally. The government and the public will still expect increasing quality levels and indeed the mantra is recited that improving quality costs less.

But what is the evidence for this? There are numerous seminal texts to support the hypothesis in other service industries but  very little evidence in place within the NHS.

In Plymouth Hospitals NHS Trust, we have set up a clinical systems engineering and service improvement team. Our work supports the view that it is possible to significantly cut costs and improve quality at the same time.

We reviewed the typical clinical pathways of non-elective patients through the hospital and divided these into three broad groups.

1. Short stay patients

The first group tends to be short stay patients and accounts for about 50% of our non-elective admissions. These patients are generally suffering from apparently serious symptoms but can either be treated very quickly or, in the case of about 15% of our throughput, don’t need any treatment at all. 

When we performed value stream mapping on these patients, however, the value added treatment they receive was reported as being less than 5% of their total time in hospital.  Figure 1 shows a typical case, with the green areas representing the value-added periods.  Some 30% of these patients who account for 50% of our non-elective admissions, don’t even need

to be admitted and most of the other 70% of these short stay cases can be turned around, treated, and discharged in 24 hours.

2. Patients needing intervention

The next stream of patients are those patients who do need significant medical intervention, tend to be suffering from single pathology

with no added complications and can normally be treated and discharged from hospital within seven days.

The early part of these patients’ stay, when value mapped, tends to look much like the short stay patients – a lot of time is spent waiting for diagnostics. If any change in their condition results, there is a similar delay.

In some specialties we now have a consultant in attendance on the ward – called an attending system – to ensure that correct treatment starts as near to admission as possible and that any change in patients’ condition or prognosis results in the appropriate change in treatment as quickly as possible. Figure 2 shows a run chart of consecutive days and bed occupancy levels – average occupancy for this specialty has reduced from 31 to 18 beds.

3. Patients with more complex needs

Finally, there is the cohort of patients who often have multi-pathology and complex social needs . This group of patients tend to have long lengths of stay and more complex discharge processes requiring assessments, nursing home placement packages of care and intermediate care reablement.

Although they represent only 5% of the elective admissions, they consume 45% of the non-elective bed stock. Our research has shown that many of these patients are staying weeks after becoming  medically fit for discharge. There are delays at every point in the process.

In most cases, patients can be identified as requiring more complex discharge pathways at the beginning of their stay. Notification to social services or the community’s onward care team is typically made either at, or close to the medically fit for discharge date.

The demand levels for the assessment for these patients to determine what is the right discharge pathway is reasonably constant, but capacity is only available five days a week and not on bank holiday or peak holiday times. That means there are delays in the notification for assessment and further delays from assessment to placing the individual patient or producing the right package of care where support at home is required.

We have calculated that about half of the bed availability used by these patients could be eliminated with better design of these pathways and improved communication between the various organisations involved.

In elective care there are many gains to be made in improving clinical pathways for elective inpatients. These include:

• Aiming for best practice both in day-case admission and day-of-surgery admission
• Discharge planning at the point of pre-operative assessment
• Smoothing discharge over seven days and using the option for non-consultant led discharge wherever possible.

There are, however, far greater gains in looking at theatre session and clinic productivity. Although our theatre system showed us as having in excess of 70% utilisation, this did not include any downtime between individual patients and took into account  start time and last patient finish time, and any theatre cancellations. When we calculated actual operating time divided by available operating time, we found that the average utilisation was 51%. The full details are shown in figure 3. Our review of outpatients shows a similar picture.

Radical changes

Our research has shown that we ought to be able to undertake our current workload on half the beds and two-thirds of the theatre capacity from our existing baseline. Although we have made some of these changes in some specialties, we have achieved nowhere near a level of savings that we believe is possible.

We will not get these changes without a radical change in the behaviour of clinical staff and in particular consultants. The change in ensuring there was an attending consultant in neurology, highlighted in figure 2, took nearly a year to organise and get agreement among those consultants. Making sure that every patient admitted acutely is seen within the first hour by a senior doctor will require a fundamental change to the way in which every consultant works.

It will require a massive renegotiation of job plans and will mean regular weekend working for senior doctors and other senior clinicians and some management staff.

However much we like to think we are different, the simple fact is people do not change the way they do things simply because it is the right thing to do. They will change because there is no alternative – a burning platform – or because they will improve their lives in some way if they do.

It is our duty as financial managers to use the current economic climate as a lever to create a burning platform story that is going to be sufficiently convincing to change the way people work.

High-level macro-economic arguments may well be sufficient to convince the average HFMA member, but they will certainly not be sufficient for consultants, senior nurses, healthcare scientists and other practitioners. We will need to assess their motivations at the micro level.

What is going to make them believe there is a problem? What will make them believe there is something they can do about it? And what in the final analysis will make them change?

We produced some theatre dashboards showing the throughput per session and cancelled sessions among other measures. After a few months we wondered why these were having no effect on individual specialties, improving their throughput per session.

After a number of discussions with leading surgeons it became apparent that even though these surgeons believed that the throughput per session in their specialty was unacceptable they saw this as being the result of a colleague’s action, not theirs. They argued that the type of cases they undertook personally took longer than average.

This sort of feedback forced us to change the way we reported. The dashboard is now available at individual consultant level showing whether their average income per session exceeds the target for their specialty – the target throughput per session multiplied by the specialty average healthcare resource group compared with the actual throughput in session at actual HRG tariff income.

The current economic crisis really is too good to waste. It will be our only opportunity for effecting significant behavioural change over the next couple of years.

We have, unlike many other public sector services, been given two years’ grace in which to plan and prepare for a massive rationalisation of services. It is our duty as financial managers to make sure that in the downturn we deliver the best value for money possible and try to maintain services at the volume and quality levels our patients now expect.

FIG 1: STROKE PATIENT -VALUE STREAM MAPPING

FIG 2: BENEFITS OF ADOPTING AN ATTENDING SYSTEM

 FIG 3: CURRENT THEATRE UTILISATION

To download a pdf of this article as it appeared in Healthcare Finance, click here