With NHS England predicting a £30bn ‘financial gap’ by 2021, everyone is talking about ways to save money. But is it possible to do this without compromising quality? Over three quarters of the Nuffield Trust’s Health Leaders Panel thought so, saying that productivity savings could be achieved without harming patient care.
While it’s clear it won’t be possible to meet the whole funding gap through productivity savings, there are certainly many ways for the NHS to become more efficient. This includes providing more coordinated care, offering more care outside hospitals, and a greater role for patients through self-management and shared decision-making.
Analysis by Monitor estimates that productivity gains along these lines could help achieve savings of £10.6–18bn over the next seven years. This represents an opportunity to ‘close’ 35–60% of the funding gap.
Here we provide eight examples of recent Health Foundation funded projects that have succeeded in demonstrating tangible cost savings while also improving quality. These are grouped into four areas, all of which have already been identified by Monitor, NHS England and other bodies as priority areas for achieving productivity gains over the next decade.
Reviewing care and medicines use in care homes
Monitor estimates that across NHS England, savings of £0.7–1.2bn could be made by 2021 through ‘better utilisation of drugs and stopping interventions of low clinical quality’. Two of our Shine projects illustrate the quality and productivity gains that can be achieved by focusing on care homes, particularly in relation to medicines optimisation and providing more integrated care.
Northumbria Healthcare NHS Foundation Trust’s project demonstrated that structured medicine reviews, involving residents and their families, can optimise medicines use and also deliver savings in terms of prescribing costs. As a result of introducing their new review process, almost 20% of medicines prescribed to residents were stopped, saving an average of £184 for every person reviewed. The data showed that for every £1 invested, £2.38 could be released from the medicines budget.
Manchester Community Health’s nursing home improvement programme succeeded in reducing admissions for nursing home patients admitted to Central Manchester University Hospitals NHS Trust by providing better and more integrated care in the home. They achieved a 40% decrease in the length of acute stays for patients admitted from homes, and a saving of almost £60,000 in phase 1 and £120,000 in phase 2 from reduced acute bed days.
National estimates show that providing more integrated care for ‘high-risk’ groups using approaches such as this could generate productivity gains of £1.2–2bn by 2021.
Improving the design and delivery of ambulatory care
Shifting urgent care admissions to ambulatory services – where patients are treated without the need for an overnight stay in hospital – is another area for potential productivity gains. Monitor reports that across England, approximately 20% of patients admitted as emergencies for more than a day could instead be treated by ambulatory emergency services and sent home the day they arrive. Two of our projects have succeeded in delivering savings by focusing on this area.
Sheffield Teaching Hospitals NHS Foundation Trust reduced inpatient stays for patients receiving chemotherapy treatment for haematological cancer. By making treatment accessible on a day case basis, they improved patient experience while achieving a 10% cost saving.
A team at University Hospital of North Staffordshire created an ambulatory outpatient clinic for people with heart failure who would previously have been admitted. Providing specialist care to enable people to manage their condition at home reduced annual acute admissions for heart failure and reduced annual bed days for that patient cohort by 1,000 days. Their work enabled nine beds to be removed from the acute trust at a cost reduction of approximately £980,000.
Redesign of acute services and departments
Monitor estimates that clinical redesign and process improvements in acute care could deliver productivity savings of between £1.1–2.3bn. It suggests that introducing new ways of working, redesigning job roles and applying ‘lean’ thinking to regular processes could allow hospitals to reduce their costs and/or absorb additional patient demand within their current resources.
Several projects funded through our Shine and Flow Cost Quality programmes have explored this theme.
Our Flow Cost Quality programme in Sheffield examined the flow of frail, older patients through the emergency care pathway with the aim of preventing queues and poor outcomes. By making changes which better matched capacity to demand, the team managed to reduce the assessment process for older patients by up to 20 hours.
The team also saw a 37% increase in the number of older patients now discharged on their day of admission or the following day – with no increase in the readmission rate. In-hospital mortality for geriatric medicine has reduced by approximately 15% and emergency care bed occupancy for older patients has been reduced – allowing two wards to be closed. The project has led to an estimated cost saving of around £3.2m per annum.
As part of our Shine 2010 programme, Great Western Hospitals NHS Foundation Trust worked to redesign antenatal care for all high risk pregnancies while also streamlining the service. Their work led to a 6% reduction in cost. It also reduced obstetric admissions – allowing the closure of 13 antenatal beds – and reduced avoidable inductions of labour by a third. Importantly, it also increased patient satisfaction, with over 90% of patients rating their experience as ‘good’ compared with just over half previously.
Another project at Charing Cross Hospital worked to improve access to urology outpatient services and deliver a more rational workflow. Imperial College Healthcare NHS Trust, who run the hospital, replaced a large weekly urology clinic with small daily clinics and introduced a ‘one stop’ service with diagnostic tests and outpatient appointments carried out on the same day. Patients now don’t have to wait for the weekly clinic, receive a same day diagnostics service and are less likely to need follow up appointments.
These changes have released vital clinic capacity and led to estimated savings of £116 per patient through reduced appointments and diagnostics. The trust has identified scope for potential annual savings of around £250,000 based on reducing overtime payments and other service costs.
Delivering a more efficient and person-centred acute discharge process
Royal Free London NHS Foundation Trust’s 'My discharge' project focused on improving the hospital discharge process for people with dementia. Timely discharge of patients is important both to ensure that the patient can recover in the most appropriate setting and that hospital beds can be used efficiently.
As well as receiving positive feedback from carers, the Royal Free’s new case-management model has reduced the average length of stay by 1.9 days for patients discharged home, while also delivering a 26% reduction in re-attendances to A&E.
During the project’s first nine months, a cost saving of just under £50,000 was predicted (based on the reduced length of stay). An estimated annual saving of £1.5m was also identified by enabling some patients to avoid residential care.
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