Well, I can’t shy away from answering this question anymore! Two weeks ago, in his first major speech since becoming Secretary of State, Andrew Lansley said quite plainly, “the Health Foundation has said in a recent report, that better quality can save money”. So for me it is no longer a question, it is a fact and a well reported one at that. What is it that convinces me of this? Quite simply, it is what the academic evidence tells us. It is also the practical experience of many of those in the service that the Health Foundation supports.
But there are many caveats, many issues that also make me state quite plainly that improving quality will only make a relatively modest contribution to the savings that the NHS will need to make in the difficult years ahead. Last year I warned against over claiming and I do so again today.
So first let’s look at the evidence.
Twelve months ago, when it was clear that we were going to face tougher times ahead, and when we all began to add the “P” word to our thinking, the Foundation commissioned one of the leading researchers in the field, Professor John øvretveit from the Karolinska Institute in Sweden to help us answer the question: 'does improving quality save money?' It was a big ask from the start, hampered by multiple definitions, heterogeneous and sometimes disputed methodologies and complex outcomes. He looked at the published evidence and despite these challenges, produced a carefully nuanced piece of work.
Firstly he proved without doubt that unsafe care is expensive.
Common adverse events such as healthcare acquired infections, adverse drug events, falls and pressure ulcers lead to additional treatment, extended length of stay, costs of investigation and possible litigation and damages.
Then he proved that poor quality care is also expensive: duplicated tests, poor patient experience, delays in transfer and poor coordination of services.
More importantly, the report suggested that although the scientific evidence is not strong, improvement initiatives can reduce costs to service providers. In summary he says, improving quality can make an important, if limited, contribution to addressing financial pressures.
However, to achieve this requires the kind of attention to detail and sustained implementation from management that has rarely been possible in the NHS:
It especially requires a sustained and relentless focus on high-quality implementation.
At a national level, the evidence suggests that the Department of Health and strategic health authorities could improve the chances of success by providing NHS organisations with expert support, enabling the development of a skilled cadre of improvers and by addressing the barriers created by the financial and performance management systems.
This is a particularly pertinent comment in the light of the current ALB review. I hold no brief for any of the organisations caught up in this review. I do know just how important the leadership and technical support provided by the National Institute across its various programme initiatives and that of the NPSA in connection with the Safety First Campaign have been. I also know of the value added by the four SHAs with whom the Foundation has worked on quality and safety. I say to Andrew Lansley, cut the quangos all you like but lose this capacity at your peril.
So far so good, but what is the experience of those the Foundation is supporting to do work of this kind in the NHS?
In asking this question I want to draw on two of our programmes. Firstly, our award scheme, Shine.
This aims to stimulate thinking and activity among staff at a clinical micro system level to develop new approaches to improve quality and save money.
Earlier this year, 18 teams from across the health services of the UK took up this Shine challenge. At the end of the first quarter we estimated each award holders’ potential to make savings. Savings from reduced bed use are reported most frequently (38% of sites), then out-patient activity (27%), with workforce and consumables each reported by 22% of sites.
Examples include:
A team at NHS Stoke on Trent is running a project to manage the demand for pathology tests from general practice. They are on track to make real cost savings through reducing the number of unnecessary tests ordered and the use of alternative tests. They anticipate savings of c£150,000 pa.
A team from University Hospital of Wales is running a project to conduct outpatient operative hysteroscopy with conventional re-useable equipment with anticipated savings of £15-20,000 pa.
We will launch a second round of Shine early this summer with the focus remaining on looking for ideas that reduce costs while improving, or at least maintaining quality. If you would like to know when these awards are open for applications, visit the Health Foundation’s stand here at the Conference.
John øvertveit in his research showed that improvement programmes of the sort I have just described have a high chance of success if undertaken in the way described. However, he also made the point that it is interventions at a much larger scale that have the greatest potential to make a significant difference, yet the greatest potential to fail.
It is in this higher risk territory that my second example fits – our work on flow, cost and quality.
The aim of this programme is to understand the relationship between patient flow, cost and quality in an acute hospital setting. It posits that the root cause of the many delays and queues built up in a hospital’s system lies in the capacity planning process. Traditional capacity plans are based on average levels of past activity (patients seen), not on the demand (requests for care). The mismatches between the daily variations in demand on the one hand and staff capacity on the other result in queues and waiting lists at every stage along the patient’s pathway of care.
This is a three-year programme due to finish in 2012. The participating organisations are South Warwickshire NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust. Dr Kate Silvester is providing dedicated clinical systems improvement expertise to both organisations. Some of you will have heard her speak yesterday about this work, much more authoritatively than me.
What are we learning?
Some very troubling findings. In both of the healthcare systems where we are working, as emergency flow slows, as measured by A&E performance, there is a corresponding increase in the crude death rate and HSMR and salary costs increase at the same time.
Patient flow slows as a consequence of changes we make to our capacity rather than changes in demand. In general, too much demand is not the problem, the way we deploy our capacity is. That daily volume of demand is different but predictable at both hospitals.
The way we deploy our capacity causes a persistent mismatch between the predictable variations in emergency demand (8am to midnight, Monday to Sunday) and the availability of the manpower capacity (9am to 5pm, Monday to Friday, with an ‘on call’ service at weekends).
As a result, two thirds of the daily demand has to be ‘stored’ overnight during weekdays and reworked on subsequent days, thereby wasting resources and stressing staff and patients. At weekends, two days worth of patients have to be ‘stored’ before their care is progressed on Monday of the following week.
These mismatches between the predictable variations in demand and the way we deploy our capacity are accentuated during weekend and public holidays – especially over Christmas and New Year. This results in massive sudden fluctuations in backlogs of patients causing stress to the few permanent staff on duty and the agency staff employed at this time. The consequences of five day working and the impact of public and school holidays on staff capacity probably create more safety issues than we are aware of.
This analysis shows how very much more difficult improvement interventions of this sort can be. They confront implicit assumptions, norms and behaviours and challenge vested interest.
Try telling a busy staff in a busy emergency care system that we have enough resources to meet demand.
Try telling managers that the data we need to diagnose the problems with patient flow is available from our information systems but the problem lies in their inability to extract it and analyse it.
Try telling those who sit in judgement of a hospital’s performance – be that internally or by external regulators - that the way they do this leads to misinterpretation of the measures and no statistically significant change in system performance. There are still those who think the problem of breaches of the four hour A&E target is due to a problem in A&E not a problem of a mismatch of demand and capacity elsewhere in the system.
Finally try telling the BMA that the major implication of matching capacity to demand will be to rip up existing consultant job plans across the NHS.
This leads me to wonder whether, from Ministers to clinical and managerial leaders on the ground, we have the collective appetite for the kind of radical change that will be necessary if quality improvement is to be able to maximise its contribution to productivity. Will the wake-up call of this week’s budget enable us to create the burning platform necessary for radical change? Or, for all their promise and potential, will those improvement plans flounder as a result of political cowardice, the power of vicious vested interest or the inadequacy of local leadership?
This has led others to suggest that in other sectors of the service economy, the greatest productivity gains are made by new entrants to a market never by the incumbents. Those incumbents in turn only make their own productivity improvements as a result of the consequent competitive market pressure. But we have no such market in healthcare. Even if we did, just as the banks have become too big to fail so hospitals have become too politically popular to fail.
So I come full circle. It is down to us. Even given the relative paucity of true research evidence, there is a sufficiently plausible case, experiential evidence and good enough documentation and measurement for NHS provider organisations to act and to act now to implement tested quality improvement interventions. With focused attention on skilful implementation QI can make an important if limited contribution to the cost efficiency of healthcare. The NHS should proceed but with care and not over claim.
