NHSScotland Efficiency and Productivity: Framework for SR10

4 Driving cost reductions and Improving Quality

Reducing Variation, Waste and Harm

The following section provides detail on the workstreams and areas which have identified productive opportunities. Priority areas for initial focus are detailed in Annex 1.

The workstreams build on existing quality and service improvement approaches and incorporate the lessons learned from the current available literature. The overall benefits realisation is the culmination of benefits across all workstreams leading to the redesign of service delivery models.

The whole systems approach to unwarranted variation, waste and harm builds on the early work of the IST, the Efficiency and Productivity Programme, Audit Scotland and the SPSP. Figure 2 illustrates the workstreams vertically with the whole systems approach to address unwarranted variation running across all workstreams, leading ultimately to the service redesign.

Figure 2: The Efficiency and Productivity Framework Overview

The whole systems approach will focus on service areas of high volume and high cost. This will allow variation to be identified in all aspects of the service, including clinical variation, variations in outcomes, workforce, procurement spend, prescribing and support services, and the effective use of eHealth and new technologies.

Initial areas under proposal for the whole systems work approach include: older people's services (under the Quality Strategy and the 'effective' ambition), cancer and orthopaedic services. In orthopaedics, for example, there is significant data and information available from the current 18 weeks Referral to Treatment ( RTT) Improvement Programme, the Musculoskeletal Audit, enhanced recovery, National Procurement and the Audit Scotland report on Orthopaedic Services. Taken together, this information will provide a robust foundation for the whole system approach to be piloted.

In addition to the whole systems approach work, a number of workstream-specific projects and programmes will be identified to provide short-, medium- and long-term efficiencies. The following provides further detail on the potential areas that will be scoped within each workstream.

4.1 Evidence Based Care - Potential Savings Opportunity - MEDIUM

NHS Boards are supported in the delivery of care by a series of clinical standards and guidelines which reflect clinical evidence and best practice, including: SIGN guidelines, NICE clinical standards and patient pathways. However, significant variation in the implementation and adherence to these guidelines result in inconsistent services and outcomes.

Comprehensive service specifications and the robust implementation of evidence based standards are entirely consistent with improved quality. Healthcare Improvement Scotland ( HIS) and the National Planning Forum are best placed to lead a programme that quantifies the benefits and financial return of taking a more focussed and consistent approach to service specifications. Future activity will need to demonstrate the economic impact of implementing guidance and the potential for decommissioning out-of-date approaches.

The National Planning Forum will oversee the governance of decisions around disinvestment. Robust information on costs and comparative patient outcomes is at the heart of consideration of disinvestment. The forum's focus will be on identifying where resources can be saved from reducing spending or disinvesting in low-value interventions, whilst ensuring careful integration across all service areas to avoid fragmentation and inequity. There is also a requirement to identify the evidence for thresholds for treatment and take a consistent approach to their application. There will be a need to consider long-term gains, ensure quality of service and improved outcomes. Working closely with the professions will be fundamental to agreeing how to progress this new approach to specification, investment/disinvestment and service thresholds.

4.2 Preventative and Early Intervention - Potential Saving Opportunity - HIGH

There are three key areas that will be focussed on initially within the workstream:

• the large-scale change required to make sustainable improvements in the long term for the population, Getting it Right for Every Child ( GIRFEC)
• public health interventions, including smoking cessation and alcohol awareness, and
• more targeted work such as the prevention of falls in the elderly.

4.2.1 Large-scale Population Change

GIRFEC is a Scotland-wide programme to improve outcomes for all children and young people, and applies to all services and agencies working with children and families. It provides a common framework, practice model and language to deliver a coordinated approach which is appropriate, proportionate and timely and has the child at the centre.

Research published in November 2010 by the Scottish Government into the financial impact of GIRFEC estimates long-term savings of over £100m a year. By contrast, failure to effectively intervene to address the complex needs of a child in early life could result in a ninefold increase in costs to the public purse.

4.2.2 Public Health

There are a wide number of initiatives already well established, such as smoking cessation and alcohol awareness programmes. These programmes will continue but there will be a need to have a clearer understanding, coupled with evidence, on the potential benefits realisation from these interventions whether this is short, medium or long term.

4.2.3 Targeted Work - Falls

During 2010 the Scottish Ambulance Service responded to over 35,000 incidents of falls in the over 65 population; over 31,000 of these patients were taken to hospital. Over the same period NHS 24 handled between 960-1460 calls per month where the patient reported that the principal reason for calling was a fall.

During financial year 2009/10, 17,499 patients in the over 65 population were admitted to hospital with the diagnostic code for falls being recorded as one of the reasons for admission. Of these, over 5,000 were admitted with a hip fracture, at an average hospital cost of £14,200 (not including subsequent costs incurred in primary care for post-operative care and rehabilitation services).

NHS Boards have a range of services in place locally aimed at preventing both primary and secondary falls in the over 65 population. The award-winning service in NHS Greater Glasgow and Clyde has been recognised by independent researchers as the best in the UK. There has been a 3.6% decrease in repeat admissions for emergency hip surgery between 1998 and 2008, compared to a rise of 5.1% across Scotland as a whole and a rise of 16.2% throughout England over the same period.

4.3 Outpatients, Primary and Community Care - Potential Saving Opportunity - HIGH

Shifting the balance of care from acute to primary care locations is critical to allow the health service to increase quality, reduce cost and meet the increasing demand of an ageing population profile. In addition, shifting the balance of care allowing greater self-management especially for chronic diseases will not only provide greater control to individuals of their own disease but will allow resources to be utilised for those most in need. Successful change requires knowledge of alternative proven models, and further work on demand and capacity management, flow and pathways will be necessary within this workstream.

4.3.1 Releasing Time to Care in the Community

Releasing Time to Care ( RTC) in the Community is a lean work-based improvement programme that will improve scheduling, team work and prioritisation in community teams. Coupled with a more robust approach to measurement across integrated, multidisciplinary teams, the implementation of RTC in the Community is intended to reduce variation and improve the quality of care. NHS Boards have already evidenced that the use of lean improvement methods within district nursing teams has improved patient care, increased productivity and consequently costs as illustrated in Box 3. A similar programme, Productive Community Hospital, is being implemented across 29 community hospital wards across Scotland.

Box 3: NHS Forth Valley - Community Nursing Team

Following implementation of lean improvement methods within the district nursing team, caseload management and planning were re-organised, which allowed bank nurse expenditure in the pilot site to be eliminated over 3 months. As a result, the 10% vacancy rate was absorbed across Forth Valley without compromising service delivery. In addition, the team was able to increase its anticipatory care planning and early assisted discharge.

4.3.2 Mental Health

The Mental Health Improvement Collaborative and mental health benchmarking have identified scope for efficiency gains from better management of demand and capacity and continuing to focus on reducing inpatient bed usage through provision of better community/crisis care. It has identified opportunities for improved management of demand, including referral management, reducing did not attend rates and better caseload management. RTC in the Community will also be adapted and implemented across mental health teams. Box 4 provides an indication of potential within the system:

Box 4: Mental Health Productive Opportunities
Improvement within one service in NHS Lothian released 312 hours (over 8 weeks) of clinical time per year just by reviewing referral allocation processes. The introduction of a more patient-focussed booking system in a psychology service reduced DNAs from 21% to 7.5%.

The national dementia demonstrator sites commenced in January 2011 and will focus on whole system pathway redesign, including an economic analysis of the savings delivered across both health and social care. Additional areas that will be scoped for potential improvements and efficiencies include:

• drugs and prescribing (addressing variation through benchmarking)
• workforce productivity (new to review and caseload management)
• psychological Interventions (options for delivery), and
• out-of-area placements and private sector usage.

4.3.3 Reshaping Care for Older People and Long Term Conditions

Implementation of Reshaping Care for Older People will be undertaken under the 'effective' programme of the Quality Strategy, and will build on the work of the Long Term Conditions Collaborative. Improvements made in managing long-term conditions and care of older people in Scotland have demonstrated reductions in emergency admissions, bed days, and GP and A&E attendances.

There is potential for reducing emergency admissions by around 35% by proactively managing the care for people with COPD or heart failure in care homes. Targets agreed with NHS Boards for the reduction in emergency admissions in people with four long-term conditions ( HEAT T6) between 2006/07 and 2010/11 range from 3% to 20%. Implementation of the Reshaping Care for Older People will be supported by close working between the Joint Improvement Team and QEST to identify unwarranted variation.

4.3.4 Releasing Time to Care: GP Practice

The NHS Institute for Innovation and Improvement is currently developing an improvement product for GP practices. NHSScotland is involved in the development of this UK-wide demonstrator and will have a GP practice piloting the new product. Similar to the other NHS Institute products in the productive series, the tool would then be offered to NHS Boards for implementation.

The potential to use the Integrated Resource Framework ( IRF) as an enabler for this workstream, while identifying variation and outcomes, will be investigated further. This provides a clearer understanding of cost and quality implications of local decision-making about care across both health and social care.

4.3.5 Outpatient and GP/ GDP Referral Redesign

It is essential that primary care teams have access to data to identify unwarranted variation but also to provide easy access to specialty advice from the acute sector. This could reduce the demand placed on acute services and avoid unnecessary hospital visits.

One area of potential savings is decreasing the demand on outpatient services. The number of new outpatient appointments across NHSScotland in 2009 was 1.4m, with increases year on year. Evidence from work with long-term conditions indicates that there are a number of patient referrals that could be dealt with more effectively in a primary/community care setting rather than hospital. Box 5 highlights one such example where GP practices have come together to make successful changes locally.

Work is underway on the enhanced service for primary care (2011/12), which focusses on reducing:

• costs and improving quality in prescribing
• inappropriate variation and supporting development of pathways for outpatient referrals, and
• variation and preventing avoidable emergency admissions through the development of an anticipatory care approach supported by the development and adoption of effective pathways to enable older people and those living with long-term conditions to remain at home.

Box 5: NHS Highland: The 70% Group - A New Federation of General Practices

The development of a corporate body of GPs in South East Highland CHP and Mid-Highland CHP is providing an exciting and innovative framework for shifting the balance of care in high volume specialty areas, influencing the quality of prescribing, and delivering improvements in unscheduled care. The introduction of a system to manage referrals from a corporate body of practices was deemed a critical success factor. The group's first project commenced in January 2010 and contracted GPs to care for the majority of benign skin excisions within the new community-based dermatology service.

4.4 Acute Services Flow and Capacity Management - Potential Savings Opportunity - HIGH

Through the 18 Weeks RTT Programme and the focus on pathway development, NHS Boards are identifying and challenging waste, variation and duplication in care and the supporting administrative processes. The 18 weeks programme will continue until March 2012 with a focus on reducing variation, removing waste and improving flow across elective pathways. Additional work on unscheduled pathways will also be taken forward.

Box 6 illustrates the improvement potential within the acute services.

Box 6: NHS Lanarkshire - Lean within Acute Services

The Board has implemented lean methodology across general surgery and theatres with the following improvements: Ten per cent increase in orthopaedic procedures in-house Fifteen per cent increase in cataract procedures in-house Earlier theatre starts and faster change over times Same day admission in orthopaedics and ophthalmology now 92% (from 50% baseline), saving 1,000 bed days a year Medicines now dispensed within 2 hours to 87% of patients (from 36% baseline), and Monklands theatre cancellations in general surgery down from 13% to 7%.

There are a number of areas that require sustained effort and focus not only to shift the balance of care to community but also to release efficiencies within acute settings. A number of these areas are evidence based and will not only improve quality of patient outcomes but also release efficiencies within the system and include:

4.4.1 Operating Theatres

There are over 300 operating theatres within Scotland with an average running cost per theatre of £1.4m per annum. An early priority, therefore, will be a focus on streamlining current initiatives, including: the National Theatres Implementation Group ( NTIG) benchmarking, the development of an IT system for operating theatres, the SPSP peri-operative checklist and the implementation of Productive Theatres.

4.4.2 Lean Pathways and Acute Capacity

Further support is required within the acute setting to ensure that NHS Boards are fully equipped to support the efficient flow of patients through all services while sustaining access targets. Box 7 illustrates an example of using lean methods to improve pathways.

Box 7: NHS Lothian Colorectal Cancer Programme

Attaining the 62 day cancer target for colorectal cancer has risen from 57% in January 2007 to consistently above the 95% goal throughout 2008/09. The first phase addressed long waits for colonoscopy and the slow outpatient administration processes. Diagnosis to treatment issues were tackled in phase 2; case management was introduced and greater control over this part of the patient journey was achieved. The most recent information flow project has tightened up all referral and tracking processes utilising the patient management system, and ensuring that all patients are seen at the correct time.

The Better Quality, Better Value ( BQBV) Toolkit and Audit Scotland's efficiency study on orthopaedics highlight significant variation in the average length of stay across specialties and NHS Boards. The chart in Figure 3 illustrates the variation in average length of stay for NHS Boards in Scotland in general surgery (quarter 2, 2009/10). There is a potential (annualised) efficiency gain of approximately £2.5m if all NHS Boards can achieve performance equal to the Scottish mean and £12m by achieving upper quartile performance in general surgery.

Figure 3: Average Length of Stay - Inpatient beds

4.4.3 Enhanced Recovery

Enhanced recovery provides a way of managing care and rehabilitation that improves patient outcomes and speeds up a patient's recovery after surgery. It focusses on patients as active participants in their own recovery process and is based on evidence-based care. It has been shown to significantly reduce the length of time for a joint replacement, for example from 6.5 to 3.5 days for hip replacements in one NHS Board. Work is already underway through the 18 Weeks RTT Improvement Programme to roll-out enhanced recovery in orthopaedic services, and rapid analysis will be undertaken on the broader benefit realisation of implementing enhanced recovery across other specialties in NHSScotland.

4.4.4 Same Day Surgery

Based on guidance from the British Association of Day Surgery ( BADS), same day surgery for a wide number of surgical procedures should now be regarded as the norm. The HEAT target for same day surgery is on track for 80% across NHSScotland by March 2011. Reducing length of stay results in a range of benefits to patients, including less time in hospital, improved safety and patients' preferred option while increasing overall efficiency. NHS Boards will be expected to sustain these improvements and to continue to benchmark local performance against the aspirational rates within the BADS Directory.

4.4.5 Emergency Ambulatory Care

As part of the BQBV Toolkit, benchmarking data has been made available to NHS Boards to highlight areas for improvement in the management of patients who present with common symptoms where care could be provided on an ambulatory basis without admission to hospital. The BQBV Toolkit contains evidence-based guidance to provide patients with quality care while preventing unnecessary admissions. There is potential for a minimum of £18m to be saved through implementing this guidance.

4.5 Workforce Productivity - Potential Productive Opportunity - HIGH

NHSScotland is a major employer and has a pay bill accounting for 69% of running costs. As the greatest cost and resource, an efficient and productive workforce will be essential to our drive for quality improvement and efficiency. Staff numbers and activity have increased over recent years. Analysis of the change in aggregate outputs, aggregate inputs and productivity in NHSScotland is underway. We have developed a measure of the change in the crude volume of output over time, and are working to develop a measure of the change in the volume of inputs. Later this year, when this work has been sufficiently refined and quality assured we plan to be able to publish a measure of the change in productivity across NHSScotland.

Following identification of variation there a review of management structures, administrative services and support functions will be carried out to ensure efficiency and a focus on supporting frontline service delivery. Identifying and promoting the most innovative approaches to making appropriate skill-mix changes, tackling staff absence, reducing reliance on locum/agency staff and consistent use of staff contracts will also be included. For example, if NHSScotland permanently reduced staff absence by 0.25% a minimum saving of £4m could be made.

Workforce engagement in the context and implementation of NHS Boards' quality and efficiency strategies is vital. Taking quality improvement principles to the ward or team setting through the implementation of lean-based workplace improvement toolkits is one of the resources that can be used to facilitate workforce engagement and improve productivity. QEST will continue its sponsorship of these approaches.

There is already a commitment to reduce senior management headcount within NHSScotland by 25% over the period of the next spending review, highlighting that while managers are valued, when budgets are tight it is important to ensure that resources for direct patient care are optimised.

The National Scrutiny Group, comprising both union and employee representation, has been established to maximise staff engagement in the process and to ensure that the quality of healthcare services is maintained. The group is developing a mechanism to ensure feedback from local area partnership forums.

4.6 Prescribing, Procurement and Shared / Support Services - Potential Productive Opportunity between - HIGH

4.6.1 Prescribing

Prescribing accounts for approximately £1.3 billion on prescription drugs in NHSScotland per annum, representing 14.2% of the total NHS spend. Whilst a number of important reforms have been implemented, such as the Community Pharmacy Contract, e-prescribing and pharmacy robotics in major sites to optimise efficiency and efficacy of prescribing, continued focus will be required to optimise efficiency in such a large area of NHS spend.

In previous work, the Efficiency and Productivity Programme supported the West of Scotland Prescribing Group to progress a menu of improvements to identify variation and reduce costs. The programme has also supported the piloting of decision support software for primary care.

The key areas to address in the future workstream include polypharmacy and addressing thresholds for prescribing. For example, a recent review of statin prescribing indicates a wide variation between NHS Boards in respect of the cost and volume of statins prescribed. Figure 4 highlights the percentage of low cost statin prescribing compared to all statin prescribing. If all NHS Boards reached upper quartile performance, the productive opportunities for NHSScotland would be approximately £8.5m.

Figure 4: Low Cost Statin Prescribing

Source: ISD, Scotland (Prescribing Information System) and epact.
Notes: Low cost statins (Pravastatin and Simvastatin).
All statins: Atorvastatin, Fluvastatin, Pravastatin, Rosuvastatin and Simvastatin.

4.6.2 Procurement

NHSScotland procured just over £2bn of goods and services from suppliers for the acute sector in 2009/10. Currently around £1bn is subject to some form of national contracting framework - with £700m of this through National Procurement contracts - while the remaining £1bn spend is subject to local arrangements. Procurement is focussed on driving increased value from this spend through reductions in price, improved product and service output and delivery, supporting appropriate reductions in demand and assisting with process improvements where procurement can have an impact.

The focus over the next year will be in the following areas:

• ensuring a higher percentage of total spend is covered by an appropriate procurement process, including increasing the level of national contracting activity
• improving current contract conformance and compliance levels
• driving further savings from existing national and local contracts
• continued development of eProcurement systems and management information
• improving procurement capability, and
• reducing the variation of products and services across NHSScotland.

The process is being led by National Procurement and local NHS Board procurement teams through the Accelerated Procurement Savings Group, which is tasked with supporting current activity and driving the wider agenda across NHSScotland. Box 8 highlights the potential for savings with NHS Boards.

Box 8: NHS Grampian - Procurement Improvement
By applying improvement methods and establishing a category management process, NHS Grampian has achieved £2.4m annualised savings and identified a further £2.6m by applying improvement methods within local procurement by establishing a category management process and ensuring over 70% of procurement through formal contract arrangements.

Ensuring that maximum efficiency is derived from estates and facilities will form part of the procurement workstream and include effective asset management, energy consumption, use of existing estates/ NHS footprint and the support services within this area. The NHSScotland Estates and Facilities Benchmarking Programme will continue to support the delivery of the Framework.

4.6.3 Shared and Support Services

The NHSScotland Shared Support Services Programme is tasked with ensuring shared working for finance and payroll to drive economic and qualitative benefits across NHS Boards. The new ways of working that the programme has delivered enhance overall financial governance and stewardship, and include:

• automated processes to lessen human error and system-driven control processes
• increased compliance, for example through the eExpenses system, and
• enhanced management information by adopting common finance codes and improved reporting tools.

The programme has delivered savings of £5.5m recurring per annum and £2.7m non-recurring and will continue to identify opportunities within shared/support services and management/ administrative costs to improve quality while reducing overall cost. This ensures that maximum resources are directed to patient care. In addition, the workstream will sponsor and promote innovations and benefits realisation, such as the effective use of voice recognition software, automation and modernisation of laboratories and capacity within diagnostics services.

4.7 Service Redesign, Transformation and Innovation - Potential Savings Opportunity - HIGH

Health services are constantly adapting and evolving to meet the challenges of rapid innovation, changes in demand driven by demography, disease, evidence and lifestyles, and changes in available capacity as workforce supply, capability, regulation and expectations change. The National Service Framework (2005) set the strategic context for service redesign and Better Health, Better Care and subsequent guidance on service change set the parameters for progressing major service change.

The Quality Strategy is the next stage of implementing Better Health, Better Care and the Spending Review is the context for its implementation. In order to provide a high quality, cost-effective and sustainable service designed for the twenty-first century, the Quality Strategy's three delivery programmes and all of the workstreams detailed above will provide a focus on the areas for short- and medium-term change.

Ensuring that NHS Boards' clinical strategies and capital planning processes reflect the momentum of the drive to quality and efficiency will be important if costs are to be released. The aim is to redesign care from traditional secondary care models to community-based models which will provide improved care and outcomes for patients while ensuring the acute service is redesigned to meet the long term needs of the population. Tackling unwarranted variation, exploiting the potential to shift the balance of care, optimising technology and implementing evidence-based care will have a material impact on service redesign:

There will be a need for all involved to demonstrate strong leadership skills and creativity in scoping and implementing the necessary redesign of services. The Scottish Government will also keep under review the policy frameworks around service change including lessons learned from engagement and scrutiny and the need to ensure that care is delivered as locally as possible.

The whole systems approach proposed for high-volume, high-cost services will feed directly into this workstream which will work closely with HIS and the National Planning Forum, where appropriate, to support successful delivery of change and benefits, including the effective use of technology.

Innovation within NHSScotland must be encouraged to allow individuals to come up with creative solutions, to be given the space to test these potential solutions and also to be allowed to prove that these are feasible or not. Ultimately, learning from failures should be as important as learning from success.

Box 9: NHS Tayside - Whole System Strategic Programme

NHS Tayside has implemented a whole system strategic programme, Steps to Better Healthcare, built around continuous improvement and focussed on delivering two parallel outcomes: delivery of high quality care and reduction of costs through minimising waste and variation. Delivering older people's services was a key project. The healthcare system engaged with key stakeholders to fully understand the current state of service delivery, appropriate data analysis to identify best practice and areas for improvement, design and implementation of 'test of change' demonstrators with clearly identified benefits and outcomes. There was a strong focus on collaborative working with the right resource delivering high quality integrated care at the point of individual need. The project has and will continue to realise significant improvements, both qualitative and financial. By focussing on the patient and removing waste, NHS Tayside is delivering: reduced inappropriate admissions reduced length of stay through focus on patient goal setting and partnership working (from 27 to 18 days) lower readmissions by shifting the balance of care capacity and capability in staff to proactively manage and support more effective and efficient patient pathways, and potential to save £1.4m per annum in net savings from service reconfiguration.