NHSScotland Chief Executive's Annual Report 2012/13

Chapter 5 Efficiency and Productivity

EFFICIENCY AND PRODUCTIVITY

'Resource constraints will undoubtedly continue in the NHS. There are two ways to deal with this reality. One is by simply cutting budgets and thereby placing the burden on staff of caring with fewer resources. The other, better, way is through improvement - introducing new models of care and new partnerships among clinicians, patients and carers that can produce better care at lower cost. Only a culture of learning and improvement can follow that better way.'^[56]

In 2012/13 the Cabinet Secretary for Finance, Employment and Sustainable Growth set an expectation that all public sector organisations will deliver minimum savings of 3 per cent. This meant that, based on baseline budgets, NHS Boards were required to deliver £264 million of savings in 2012/13. For the period April 2012 to March 2013, NHS Boards delivered efficiency savings of £270 million (over three quarters of which were recurring) - an overachievement of £6 million. Efficiency savings are retained by NHS Boards, helping to ensure ongoing financial balance and enabling reinvestment in patient care. National Procurement also secured an additional £39 million of savings, the benefit of which was seen across all NHS Boards.

NHS Boards delivered these efficiencies at the same time as making significant improvements to the quality of services as evidenced in the previous chapters of this report. NHSScotland's portfolio of work around efficiency and productivity seeks to maximise opportunities for quality improvement whilst ensuring sustainability of services now and in the future.

The NHSScotland Efficiency and Productivity: Framework for SR10* provides the overarching framework for the delivery of high quality, efficient healthcare through a number of national programmes:

• Outpatients, Primary and Community Care;
• Whole Systems Patient Flow (formerly Acute Flow and Capacity Management);
• Mental Health;
• Cancer Performance Support;
• Prescribing;
• Procurement; and
• Shared Services (Finance, HR, and Estates and Facilities).

A key priority for 2013/14 will be a refresh of this Framework to ensure that the national programmes continue to reflect the priorities for NHSScotland which are set out in A Route Map to the 2020 Vision for Health and Social Care*.

National programmes are led by an NHS Board Chief Executive sponsor and are delivered locally by NHS Boards in partnership with the Quality and Efficiency Support Team (QuEST), based within the Scottish Government.

QuEST provides support to NHS Boards to support delivery of key NHSScotland priorities with a particular focus on achieving these through actions that improve both the quality and the efficiency of services. QuEST works in partnership with NHS Boards to identify, test, sustain and spread innovative and best practice whilst also developing capacity and capability for continuous quality improvement. This unique approach was recognised by the team being short-listed for the UK Health Service Journal's Efficiency Awards.

In particular, QuEST supports delivery of the following priority areas:

• Efficiency and Productivity - the Efficiency Portfolio Office supports NHS Boards to achieve value and sustainability, for example by increasing shared services where appropriate to reduce waste, duplication and variation;
• Unscheduled and Emergency Care - the Whole Systems Patient Flow Programme will support NHS Boards to increase flow through the healthcare system;
• Primary Care - the Outpatients, Primary and Community Care Programme supports NHS Boards to shift the balance of care from acute to Primary Care and home to meet increasing demand; and
• Prevention - the Cancer Performance Support Team supports NHS Boards to improve survival for people with cancer in Scotland by diagnosing and treating the disease at an earlier stage.

NHS Boards delivered their efficiency savings through a wide range of programmes of work, which focus on improving the quality of patient care whilst also ensuring services are sustainable for the future. During 2012/13, 20 per cent of efficiency savings were delivered through improvements to clinical services. For example:

• NHS Lothian has developed an Outpatient Antimicrobial Therapy (OPAT) Service to treat patients requiring intravenous antimicrobial therapy in an outpatient facility instead of an inpatient setting wherever possible. Benefits include improved patient experience, avoidance of unnecessary admissions, decreased length of stay, and reduction in the risk of hospital associated infection (HAI). An efficiency gain through 'bed days saved' of £1.34 million has been achieved. Although this is not cash releasing it is a true efficiency gain. The capacity that has been released is being used to meet demand for inpatient beds on the acute sites.
• NHS National Waiting Times Centre Board has undertaken a review of patient flows which identified bottlenecks within the system, significant variation between surgical and anaesthetic job plans and an increasing number of additional theatre sessions at a premium cost. An efficiency saving of £0.2 million has been achieved by revising job plans to reduce bottlenecks, unnecessary admissions, theatre cancellations and premium rate theatre sessions. This has also resulted in improved patient experience.
• The Scottish National Blood Transfusion Service has implemented a programme to transform the donation experience through redesign and streamlining of the collection process, and improve efficiency by balancing workloads. A productive gain equivalent to £0.4 million has been achieved as a result of an additional 2,400 usable donations, a reduction in the number of donors attending sessions unnecessarily, and a reduced need to test donors following the introduction of home DSRs (Donor Session Record) and Health Check Questionnaires.
• NHS Tayside has shown a demonstrable improvement in waiting times for its Child and Adolescent Mental Health Service (CAMHS) and has also improved patient and carer experience following a redesign of the service. The service has introduced DCAQ (Demand, Capacity, Activity, Queue) through a CAMHS system flow management tool designed to reduce waiting lists and enable quicker response times for patients by improving patient flow, reducing DNAs (Did Not Attends) and optimising clinical time in patient facing activities.

Another clinical area where important gains have been made is prescribing which accounts for a quarter of efficiency savings realised by NHS Boards. The following example illustrates this achievement:

• NHS Fife has implemented the National Therapeutic Indicator guidance in relation to drugs to reduce cholesterol. This leads to more people receiving drugs with a strong evidence base, at lower cost. A saving of between £210 and £314 per patient per year has been identified, resulting in over £1 million being saved for NHS Fife.

In addition to the achievements led by clinical communities, support services have also played an important role in delivering high quality and efficient services. There has been an important move towards sharing services across NHS Board boundaries to reduce waste, duplication and variation. Within NHS Boards, technological solutions and new ways of working are being explored to enable staff to provide a quality service to those they support:

• NHS Orkney has contracted out its payroll services to NHS Grampian, achieving an efficiency saving of £23,500. This shared service model has benefited from commonality of systems and processes and has provided NHS Orkney with access to the full breadth of specialist HR services, demonstrating the benefits of exploiting economies of scale and adopting a 'centre of excellence' approach.
• NHS Lanarkshire has undertaken an administration improvement programme to improve processes, improve service levels and reduce waste. Significant improvements have been made to administration processes (typing, coding and case record management) through use of improvement techniques such as process mapping and implementation of technological solutions, for example, digital dictation and scanned patient records. As a result, recurring savings of £1.25 million have been achieved over two years.

The NHSScotland estate has been optimised to improve services to patients, enhancing services within the community and improving access for a larger number of patients.
The environments within which our staff work are fit-for-purpose and encourage effective communication and interaction:

• NHS Borders achieved recurring efficiency savings of £0.7 million following a review of its two inpatient facilities in Hawick. Facilities within the dementia inpatient setting in Hawick were redesigned to allow services to be provided in a community setting, enhancing the quality of services and increasing the number of clients that can be seen, helping to tackle the increased demand for services. In addition, acute inpatient services were reconfigured enabling inpatient care to be consolidated on one site, reducing the level of resource tied up in buildings.
• Healthcare Improvement Scotland has rationalised its estate by relocating the Edinburgh base from Elliott House to Gyle Square, which is held on a long lease and forms part of the NHSScotland estate, resulting in an annual saving of £0.1 million. The organisation is accommodated in a modern facility and the open plan design promotes easier and more effective communication and interaction.

Right across NHSScotland there are excellent examples of efficiency and productivity gains that are supporting the delivery of quality services. In addition to those highlighted in this chapter, many more can be found on the QuEST website^[57].

NHS Highland Story Delivering An Efficient and Person-Centred Microbiology Service^[58]

Timely access to the right test, with the right result, at the right time, are all essential to supporting high quality care for everyone and at the same time providing a cost-effective service.

With this in mind, a project was initiated in NHS Highland to develop a more personcentred and efficient service in relation to laboratory services. One of the key aims was to develop and deliver a repertoire around laboratory services that was more responsive, appropriate and clinically relevant.

Following a review, it was identified that the current service was an outlier in terms of cost, skill-mix and productivity. There was a need to update its repertoire in terms of methods and tests and to integrate management structures and staff arrangements.

In order to address this, and as part of the NHS Highland quality approach, a number of LEAN tools were implemented which included - the re-profiling of the skill-mix of staff, integrated management provided by one service manager, a reduction from five to three operational sections with integrated staff and a re-defined departmental structure based on methodology instead of historical discipline-based boundaries.

As a result of implementing these changes there has been a significant reduction in laboratory samples carried over and a more patient-focused service is now delivered. Staff satisfaction has also improved. There has also been a clear commitment by staff to make sure that best use is made of departmental resources, in turn freeing up resources for other services, to reduce costs or make savings.

The skill-mix redesign is underway and has already achieved pay savings of £200,000 per annum. An additional £250,000 is forecast once the skill-mix review and re-design is complete. It has also been identified that this work needs to be supported by new equipment and staff training.

Taking laboratory staff to meet patients, hearing patient stories and drawing fellow clinicians into the laboratory ensures the service is focused on patients.