The report, Can hospitals do more for less?, is the work of independent researchers commissioned by the Nuffield Trust as part of a two-year programme of research that aims to provide further evidence of how government policies and the activities of commissioners and providers can maintain and improve care at a time of severe financial constraint.
Citing length of stay and day surgery rates as examples of where there are still opportunities for efficiency to be improved, the report’s findings suggest the need for a concerted programme of efficiency initiatives across NHS hospitals as a whole.
An accompanying policy analysis written by the Nuffield Trust reviews the international evidence on how hospitals have increased their efficiency, before recommending several measures to help to close the gap between the worst and best performing NHS hospitals.
Dr Judith Smith, Head of Policy at the Nuffield Trust commented:
‘The main questions raised by this study are why, when so much is known about what drives and can improve hospital efficiency, has hospital productivity deteriorated across the board in recent years and so much variation persists across, and sometimes within, individual hospitals? The reasons are probably multiple.
‘In some areas these will include: the previous emphasis on growing capacity during a period of plenty, a lack of data and the capacity to analyse this at a very detailed operational level, conflicting incentives faced by the organisation, a lack of involvement of doctors and other clinical staff in determining and implementing programmes to improve efficiency, and insufficient priority given by managers to the tough business of changing long-standing working practices in hospitals.
‘It is very difficult to justify cuts if inefficiencies in areas such as rates of day case surgery, length of stay, and the purchasing of hospital supplies remain untackled. The financial challenge facing the NHS will concentrate minds, but much more needs to be done.’
Based on the findings of the main report, and the Nuffield Trust’s accompanying policy analysis, the Nuffield Trust recommends that:
• Clinical commissioning groups (CCGs) should establish with local providers clear goals in respect of day surgery rates and length of stay. At a national level the NHS Commissioning Board should investigate whether the next Outcomes Framework could be used to encourage commissioners to make a priority of this, building on the avoidable hospitalisation indicators for patients with long term conditions;
• The NHS Commissioning Board should strongly encourage CCGs to make the most of new technologies and NICE guidelines, particularly those around optimal practice, ‘do not do’ recommendations and cost savings technologies. This should be followed up with a national system of publicly monitoring clinical and administrative practice variation, by CCG area.
• When savings have to be made in staff costs, rather than opting for vacancy freezes, senior managers and clinicians should test the benefits of a higher ratio of qualified and senior staff, albeit with smaller numbers overall. This could be a powerful way of mitigating overall reductions in staff numbers, while increasing productivity and improving patient care.
• Hospital Boards should proceed cautiously when exploring organisational mergers. Mergers do not automatically lead to efficiency savings unless beds and services are closed. Diseconomies of scale can also emerge in organisations above 600 beds.
• Ways must be found to go beyond the crude measures of NHS productivity – more effort should be made to develop objective measures of quality and to identify where efforts have successfully reduced avoidable hospital admissions for patients, rather than just increased activity in hospitals.
• The report, which was prepared for the Nuffield Trust by Jeremy Hurst and Sally Williams, is based on two separate strands of investigation: a review of the British and international literature on the scale of hospital inefficiency, and ways to improve it; and fieldwork consisting of a survey of senior executive managers and clinicians in six hospital trusts which, following financial difficulties a few years ago, appear to have been ‘turned around’.
• These trusts were: Barnet and Chase Farm Hospitals NHS Trust; Mersey Care NHS Trust; North East London NHS Foundation Trust; Sandwell and West Birmingham Hospitals NHS Trust; St Helens & Knowsley Teaching Hospitals NHS Trust and The Royal Wolverhampton Hospitals NHS Trust.
• This report is part of The quest for efficiency in the English NHS, a two-year programme of research that aims to provide further evidence of how commissioners and providers can maintain and improve care at a time of severe financial constraint. Further details can be found here.