NHSScotland Chief Executive's Annual Report 2011/12

CHAPTER 5 EFFICIENCY AND PRODUCTIVITY

NHS Boards delivered £313 million of Efficient Government Programme savings in 2011/12, equivalent to 3.6 per cent baseline funding made available to NHS Boards. In addition to this, Boards also delivered a further £6 million from other local savings. This exceeded the planned level of savings required and was the fourth year in a row that NHS Boards have exceeded their efficiency targets. Efficiency savings are retained and re-invested by Territorial NHS Boards, underpinning service developments and ensure ongoing financial balance. Crucially, NHS Boards have delivered these efficiencies primarily as recurring savings which means they are sustainable and will be reinvested in patient care.

NHS Boards delivered these efficiencies at the same time as continuing to make significant improvements to the quality of services and therefore the outcomes for patients and carers. It is this commitment both to delivering improvements in quality and making the best possible use of public money that drives NHSScotland's programme of work around Efficiency and Productivity.

EFFICIENCY AND PRODUCTIVITY FRAMEWORK

In February 2011, the Efficiency and Productivity Framework for NHSScotland* was published, which identified three overarching themes that would increase efficiency and support the delivery of the Quality Strategy. These are:

• Support - supporting our workforce (including ensuring that staff are appropriately skilled to deliver the necessary change);
• Enablers - identifying, sharing and sustaining good practice (including benchmarking and data, and efficient use of technology); and
• Cost reduction - reducing variation, waste and harm.

* All publications referred to within this document can be found in the publications section of the appendices.

These themes are expressed in a number of key workstreams, chosen in partnership with a range of stakeholders across NHS Boards, where we identified there were further potential gains in efficiency and productivity. These are:

• Preventative and Early Intervention;
• Outpatients, Primary and Community Care;
• Acute Flow and Capacity Management;
• Prescribing;
• Procurement; and
• Shared Services - Finance, HR and Estates and Facilities.

Each workstream is led by an NHS Board Chief Executive but projects are delivered by NHS Boards themselves, as any efficiency and productivity gains will be reinvested locally. The workstreams are supported by an Efficiency and Productivity Portfolio Office, based within the Scottish Government's Quality and Efficiency Support Team (QuEST) that ensures consistency and coherence in approaches and maintains an oversight of delivery and benefits realised. Assurance and scrutiny of the whole enterprise is undertaken by the Efficiency Portfolio Board which reports to the NHS Chief Executive's group and the Scottish Government Health and Social Care Management Board.

NHS Boards delivered their efficiency savings through a wide range of programmes of work. Crucial to this success has been an overarching commitment to ensuring that quality is at least maintained but ideally improved. Clinical leadership has been key to this and over a quarter of the 2011/12 savings were delivered through clinical service improvements. The following examples illustrate this achievement:

• The Scottish Ambulance Service has redesigned its Patient Transport Service (PTS) with the primary aim of making it more professional, efficient and responsive for patients. This has included implementing a single telephone number for the whole country, the development of integrated transport hubs and ensuring patients spend less time in vehicles.
• NHS Borders, using 'Lean' quality improvement approaches, changed the way patients are managed after they have had Total Joint Arthroplasty to improve patient outcomes and ensure that they are working as efficiently as possible. Outcomes have included: a 90 per cent fall in rates of blood transfusion after hip arthroplasty; a 93 per cent fall in catheterisation rates; and a reduction in average length of stay from seven to four days.
• NHS Ayrshire and Arran also used 'Lean' to redesign the way they managed theatre supplies. The process allowed the team to identify a number of key areas where substantial improvements could be made, such as ensuring obsolete stock was removed, managing procurement of items more effectively and tracking spend more proactively. Primarily, this will free up valuable clinical time that had been spent dealing with supplies.

Another clinical area where important gains have been made is in Prescribing. NHSScotland spends around 14 per cent of its budget every year on drugs in both hospital and community settings, with the vast majority of this being GP prescribing. The effective management of this resource is crucial and NHS Boards have, with the support of the prescribing workstream and excellent work from their own pharmacy teams, delivered some significant achievements over the year. For example:

• NHS Greater Glasgow and Clyde's prescribing support teams helped GPs to achieve their Quality Outcomes Framework (QoF) targets for cholesterol lowering drugs in Cardiovascular Disease leading to overall savings of £1.5 million.
• NHS Forth Valley also engaged with their GP community and supported them to deliver a saving of £3.4 million during 2011/12.
• NHS Tayside implemented an IT solution that provides advice to GPs and other prescribers at the point of generating a prescription offering more cost-effective alternatives.

As well as these important achievements led by our clinical communities, support services have played an important role in delivering greater efficiency while ensuring quality is prioritised. It is sometimes easy to forget the important role that the people who provide our food, laundry supplies and IT equipment play in ensuring that our hospital and community facilities are safe, efficient and fit for purpose. Equally, those who provide important back office services such as HR, finance and procurement - the services that allow clinical staff to do their jobs - have an important contribution to make to improving the efficiency of our services.

These services have begun to deliver significant savings, in part due to the shared understanding of everyone working in NHSScotland that every opportunity to make savings in these critical but supporting areas results in more cash to reinvest in improving clinical quality outcomes. Special NHS Boards and Healthcare Improvement Scotland are leading on a number of these efficiency areas. Some of the highlights of 2011/12 are:

• Healthcare Improvement Scotland (HIS) and NHS Education for Scotland (NES) delivered £0.2 million and £0.3 million in efficiency savings respectively by reviewing their entire approach to procurement; reducing costs by standardising supplies, managing orders more closely and, for example, moving to paper-free meetings.
• NHS National Services Scotland (NSS) works with external partners to increase savings, maximise supply chain effectiveness and procurement capability. This year, it secured savings to NHSScotland of £41 million, taking the total since 2006 to over £200 million. In 2011/12, it negotiated national contracts on everything from telecoms to blood tubes. Based at the National Distribution Centre, it also delivered 4.5 million order lines to hospitals, equating to 45 million items, with 98.6 per cent of orders delivered on time and in full.

Right across NHSScotland, there are excellent examples of efficiency and productivity gains that are supporting the delivery of improved quality services. For example, as part of improving patient flow through the system, the average length of stay for emergency inpatients has fallen by 24 per cent, from 4.2 days in 2006/07 to 3.2 days in 2011/12. There were over 43,000 more hospital day cases episodes in 2011/12 than 2006/07^[44].

NHS Board Story:

NHS Lothian

IMPROVING ORTHOTICS SERVICES IN NHS LOTHIAN†

NHS Lothian had been delivering its orthotics services as multiple autonomous services with independent budgets and was operating from multiple locations resulting in little equity of access or standardisation of the service.

The decision to transfer the hub of the orthotics service from an industrial estate on the outskirts of Edinburgh, which was no longer fit for purpose, to the SMART centre on the Astley Ainsley hospital site provided an opportunity to review and redesign orthotics service delivery across Lothian.

As part of the review, the project team used a number of tools in the project's pre-work stage which included stakeholder interviews; data collection and analysis; value stream mapping; circle of work; time value analysis; voice of the customer; and critical to quality trees. A three-day Kaizen event was also held in August 2011 with 23 members of the multidisciplinary team and private contractor representatives.

As a result, the Orthotics Service has now moved from 30-minute to 20-minute appointment slots, creating 3,036 additional clinic slots annually. Three privately contracted clinics were absorbed in-house (saving £81,129), bringing the service within budget - simultaneously reducing cost while improving quality. Three management teams also moved to one centralised structure, allowing tighter control of contracts and referrals. New prescribing guidelines were developed and new waiting areas and additional clinic rooms have improved patient experience.

Under a single management structure and due to efficiencies achieved, the service now plans further improvements, including developing one-stop clinics and further reductions in privately contracted activity.

Orthotic patients in NHS Lothian now receive a more streamlined service, with their experience at clinics enhanced through reduced waits and improved environments.

† This work was presented as a poster at the 2012 NHSScotland Event and won first prize in the 'Efficient' poster category. To view the poster visit: www.nhsscotlandevent.com/posters/Posters-2012/