LZbudgetvm

6UnwarrantedvariationsExecutivesummary;OL5/:PZL_WLJ[LK[VKLSP]LYLJPLUJPLZVMWLY`LHYLLJ[P]LS`ZL[[PUNHYLHS2termscostreductiontargetforachievementbyApril2021.
WhilsttheNHSranksasthebestvaluehealthcaresystemintheworld1,weknowmorecouldbedonetoimprovequalityandLJPLUJ`PUVYOVZWP[HSZZV[OL`JHUTLL[[OPZL_WLJ[H[PVU;OPZYL]PL^SVVRLKH[WYVKJ[P]P[`HUKLJPLUJ`PU,UNSPZOUVUZWLJPHSPZ[HJ[LOVZWP[HSZ^OPJOaccountforhalfofthetotalhealthbudget,usingaseriesofmetricsandbenchmarkstoenableJVTWHYPZVU>LJVUJSKL[OH[[OLYLPZZPNUPJHU[U^HYYHU[LK]HYPH[PVUHJYVZZHSSVM[OLTHPUresourceareas,andalthoughwefoundmanyexamplesofgoodpractice,noonehospitalisgoodateverything.
>LLZ[PTH[L[OPZU^HYYHU[LK]HYPH[PVUPZ^VY[OIUPU[LYTZVMLJPLUJ`VWWVY[UP[`HWV[LU[PHSJVU[YPI[PVUVMH[SLHZ[VU[OLIUZWLU[I`VYHJ[LOVZWP[HSZ;OLYLWVY[makes15recommendationsdesignedtotacklethisvariationandhelptrustsimprovetheirperformancetomatchthebest.
Unwarrantedvariation>LSVVRLKH[[OLRL`YLZVYJLHYLHZVMJSPUPJHSZ[HWOHYTHJ`HUKTLKPJPULZKPHNUVZ[PJZHUKPTHNPUNWYVJYLTLU[IHJRVJLMUJ[PVUZHUKLZ[H[LZHUKMHJPSP[PLZ>LHSZVSVVRLKH[XHSP[`HUKLJPLUJ`[OYVNO[OLSLUZVMJSPUPJHSZWLJPHS[PLZ,_HTWSLZVM[OL]HYPH[PVU^LMVUKPUJSKL!
Overallnon-specialistacuteKRVSLWDOFRVWV(]LYHNLJVZ[VMHUPUWH[PLU[[YLH[TLU[PZI[[OLYLPZ]HYPH[PVUIL[^LLU[OLTVZ[expensivetrusts(3,850)andtheleastexpensive(3,150)2QWKHZDUGAverage9.
1hoursofcareprovidedbyregisterednursesandhealthcaresupportworkersperpatientdaybutvariationfrom6.
33to15.
48hours,althoughweshouldbemindfulofJVTWHYPUNKPLYLU[[`WLZVM^HYKZHUK[Y[Z,QWKHRSHUDWLQJWKHDWUH2UWKRSDHGLFV+LLW^VUKPUMLJ[PVUYH[LZMVYWYPTHY`OPWHUKRULLYLWSHJLTLU[ZJYYLU[S`YHUNLMYVT[V0MHSSOVZWP[HSZHJOPL]LK[OPZ^VSK[YHUZMVYT[OLSP]LZVMWH[PLU[ZHUKZH]LtheNHS300mperyearProcurementAveragepricepaidforhipprosthesisvariesfrom788to1590,andtrustsbuyingthemostarenotpayingthelowestprice,QWKHSDWKRORJODEPathologyprovidersareconsideredproductiveifthecostofpathologytothetrustPZSLZZ[OHUVMVWLYH[PUNL_WLUKP[YL+H[HNH[OLYLKZNNLZ[ZH[^VMVSK]HYPH[PVUPU[OLJYYLU[JVZ[MYVT[V,QWKHPHGLFLQHFDELQHWStockholdingvariesfrom11to36days,andifeveryoneachieved15daysthiswouldsave50mHRDepartment:PJRULZZHUKHIZLUJLYH[LZ]HY`MYVT[V;OPZPZH]HYPH[PVUVM2QWKHKRVSLWDOestateTotalestatesandfacilitiesrunningcostsperarea(/m2)–trustsareconsideredgoodiftheirmetricislowerthan320,thecurrentvariationisbetween105and970;Ifeveryoneachieved[OLTLKPHU[OPZ^VSKZH]LIUWLY`LHY5VUJSPUPJHSZWHJLVMVVYHYLH[Y[ZHYLJVUZPKLYLKNVVKPM[OLPYTL[YPJPZSV^LY[OHU[OLJYYLU[]HYPH[PVUPZIL[^LLUHUK1CommonwealthFundreport,MirrorMirrorontheWall,20147UnwarrantedvariationsOptimisingresourcesProfessionalswithbackgroundsinareassuchasnursing,pharmacy,diagnostics,procurementandestatesmanagement,engagedwiththeircounterpartsinacohortof32truststodiscussperformancedata,andtoidentifyandcodifywhatgoodlookslike.
Thisledtoasetofbenchmarksandindicatorstoenablecomparison,andinsomecasescreationofnewmetricssuchasCareHoursperPatientDay(CHPPD),allofwhichformthebasisofamodelhospital.
-VYJSPUPJHSZ[H^LVIZLY]LK]HYPH[PVUPUHYHUNLVMPUKPJH[VYZZJOHZZPJRULZZYH[LZHUKturnover,andinpoliciesandpracticessuchasrosteringandspecialling.
WealsobecameH^HYLVM]HYPHUJLZPU[OLLVMTLKPJHSZ[HQVIWSHUUPUNHUK[OLKLWSV`TLU[VM(SSPLK/LHS[OProfessionals.
Wealsofoundvariationintheuseofmoderndigitalsystemssuchase-Rostering,athemethatisconstantthroughouttheareaswelookedat.
Evenwheretrustshaveinvestedinsuchtechnologywefoundtrustswerenotgettingfullmeaningfuluseofit.
6W[PTPZPUNVYZ[HYLZVYJLPZUV[Q[HIV[WVSPJPLZHUKWYHJ[PJLZ0[PZHWWHYLU[[OH[ZVTL5/:Z[HOH]LUV[ILLUMSS`LUNHNLKPU[OLWYVKJ[P]P[`HUKLJPLUJ`HNLUKHHUK^LRUV^[OH[[OLSPURIL[^LLUZ[HLUNHNLTLU[HUKXHSP[`V[JVTLZPZ^LSSUKLYZ[VVKHUKL]PKLUJLKHJYVZZOPNOWLYMVYTPUNVYNHUPZH[PVUZ>LULLK[VKVTVYL[VPTWYV]LZ[HLUNHNLTLU[^OPJOiswhywearerecommendingNHSImprovementdevelopanationalpeoplestrategy.
InhospitalpharmacyweknowthatthemoretimepharmacistsspendonclinicalservicesYH[OLY[OHUPUMYHZ[YJ[YLVYIHJRVJLZLY]PJLZ[OLTVYLSPRLS`TLKPJPULZLPZVW[PTPZLKOV^L]LY^LMVUKZPNUPJHU[]HYPH[PVUVMPU[OLYH[LZVMWYLZJYPIPUNWOHYTHJPZ[ZHZaproportionoftotalhospitalpharmacists.
SimilarlyinpathologyserviceswefoundthemixofXHSPLK[VUXHSPLKZ[H]HYPLKMYVT[Y[[V[Y[HUK^HZPUJVUZPZ[LU[^P[O[Y[HJ[P]P[`InprocurementwefoundastonishingvarietyinthenumbersofproductsandsuppliersusedHJYVZZHUK^P[OPU[Y[Z(ZHTWSLVM[Y[ZLZWWSPLYZKPLYLU[WYVKJ[brands,over400,000manufacturerproductscodesandmorethan7,000peopleareabletoWSHJLVYKLYZ(UHS`ZPZVM[OL5/:LZ[H[LPKLU[PLK]HYPH[PVUPU[OLLVMZWHJL^P[OJSPUPJHSZWHJLVJJWH[PVUYHUNPUNMYVT[V"HUKZPNUPJHU[]HYPH[PVUPUMHJPSP[PLZTHUHNLTLU[JVZ[Z*VYWVYH[LHUKHKTPUPZ[YH[PVUJVZ[Z]HYPLKIL[^LLU[Y[ZH[VMPUJVTL^P[O[Y[ZMHPSPUN[VJHW[YL[OLILUL[ZVMZJHSL8HSP[`LJPLUJ`HUKWLYMVYTHUJLThereisstronginternationalevidencethatgoodhospitalmanagementpracticescandeliverbothimprovedclinicaloutcomesandproductivity.
Duringourworkwecameacrossanumberoftruststhathadastronggriponthemanagementoftheirresources,whilealsodoingwellintheirCQCratings,however,wealsofoundthathospitalsandcommissionerswereoftenlookingatKPLYLU[KH[HZL[ZHUKMYVTKPLYLU[WLYZWLJ[P]LZ^P[OPUL]P[HISLKPZHNYLLTLU[Z;VVW[PTPZLXHSP[`HUKLJPLUJ`HJYVZZ[OLLU[PYLJHYLWH[O^H`HZPUNSL]LYZPVUVM[OL[Y[OHUKanintegratedperformanceframeworkiscritical.
Wearethereforerecommendingthatorganisationsshouldadoptasingleintegratedperformanceframeworkforperformance,centredaroundJ[VTLYZ^VYRMVYJLHUKUHUJLZ;OPZZOVSKPUJVYWVYH[L[OLLZ[HISPZOLK*8*YLNSH[VY`MYHTL^VYRVM]LHYLHZ^P[OKL]LSVWTLU[VM[OL^LSSSLKXLZ[PVUZHUKHUL^ZP_[OHYLHSuchaframeworkalsorequireshospitalstoimprovetheiruseofmoderndigitaltechnology.
Thebestperforminghospitalsystemsaroundtheworldhavereal-timemonitoringandYLWVY[PUNH[[OLPYUNLY[PWZLUHISPUN[OLT[VTHRLKLJPZPVUZVUHKHPS`^LLRS`TVU[OS`IHZPZ8Unwarrantedvariations[VPTWYV]LXHSP[`HUKLJPLUJ`WLYMVYTHUJL>L^LYLZ[YJRI`[OLPTTH[YP[`VM[Y[ZLofsuchtechnologyfrome-Rosteringsystems,e-Prescribingandbasicelectroniccataloguesforprocurement,sowerecommendNHSImprovementneedstoincentivisetruststofullyutilisetheirexistingdigitalsystems,andwherenecessary,enablethemtoaccesssomeoftheSpendingReviewcommitmenttoinvestindigitaltechnologies.
WearealsorecommendingthatnationalclinicalprogrammesdesignedtoimprovequalityandLJPLUJ`HJYVZZJHYLWH[O^H`ZHYLJVVYKPUH[LKUKLYHZPUNSLNV]LYUHUJLMYHTL^VYRSLKI`NHSImprovementtoensuretheyalignwiththeperformanceframework.
Inourdiscussionswithtrustswerepeatedlyheardthechallengestheyfacewithtwowidersystemissues;delayedtransfersofcareandbarrierstogreatercollaboration,cooperationandLJVUVTPLZVMZJHSL;OLZLJOHSSLUNLZPUOPIP[[Y[ZHIPSP[`[VPTWYV]LWLYMVYTHUJLHUKYLZS[PUZIVW[PTHSJSPUPJHSXHSP[`HUKLJPLUJ`HJYVZZ[OLSVJHSOLHS[OLJVUVT`>OPSZ[^LMVUKgoodexamplesofwheretrustshavetakenmattersintotheirownhandstoaddressthem,thereisnodoubttheyneedhelpandsupportatanationallevel,sorecommendDH,NHSEnglandandNHSImprovementdevelopastrategyforaddressingtheseissues.
ThemodelhospitalHighlightingvariationrequirestherightmetricswithdetailedguidanceonwhatgoodlookslike.
;OLHKQ[LK[YLH[TLU[JVZ[(;*PZVUL^H`MVY[Y[Z[VZLLOV^[OL`]HY`PU[OLPYJVZ[ZMVYagivenoutput.
Theweightedactivityunit(WAU)canalsobeusedtocompareperformanceandproductivityacrosstrusts.
Thesemetricsshouldbeusedtocreateamodelhospital,whichwithassociatedbestpracticeguidancewillgivetrustsasingleversionofthetruthonwhatgoodlookslikefromboardtoward,tohelptrustsunderstandwhatgoodlookslike.
NHSImprovementshouldcontinuetodevelopthemodelhospitalanditsunderlyingmetrics,sothatthereisonesourceofdata,benchmarksandgoodpractice.
Engagementwithtrustsandimplementation9LHSPZPUN[OLMSSWYVKJ[P]P[`HUKLJPLUJ`VWWVY[UP[PLZZL[V[PU[OPZYL]PL^^PSSILchallenging.
Wehavelearntfromourconversationswithtruststhatcloseengagementandcollaborationareessentialandthatthissupportiveapproachneedstobemaintained.
;OLYLPZHULLKMVYUH[PVUHSJHWHIPSP[`HUKJHWHJP[`[VOLSW[Y[ZPKLU[PM`HUKZLPaL[OLVWWVY[UP[PLZ[VHJOPL]LWYVKJ[P]P[`HUKLJPLUJ`NHPUZPUN[OLHUHS`ZPZWYVMLZZPVUHSPUZPNO[andengagementapproachweadoptedthroughoutthecourseofthisreview.
WehavethereforeplacedaheavyresponsibilityonNHSImprovementtomanagethedeliveryofthesesavings,butitisimperativethatallofthenationalorganisationsworktogetherandwewanttomakeitabsolutelyclearthattrustboardsshouldbeheldtoaccount.
Inourdiscussionswithtrustswefoundthattypicallytheyrecognisedathirdofthesavingsopportunitiesweputinfrontofthemandalreadyhadplansinplacefordeliveringthem,aMY[OLY[OPYK[OL`^LYLH^HYLVMI[OHKUVWSHUZPUWSHJLHUK[OLUHS[OPYK^LYLJVTWSL[LS`newtothem.
Nearlyalltrustsrecognisedtheurgencyfordeliveringtheopportunitiesandweregratefulforthehelpandsupporttheyreceivedfromthereviewteam.