Carter Review demands NHS becomes more transparent and trusts work together to enhance services

Long-awaited report calls for standardised procedures, improved benchmarking, more transparency, and better financial control

Hospitals are being urged to standardise procedures, be more transparent, and work more closely with neighbouring health trusts. <.p>

In his final report to the Department of Health, Lord Carter of Coles claims that implementing this vision will help to end significant variations in the quality and cost of care that currently exist both locally and nationally.

Giving hospitals the tools and support to better manage resources will make it easier for boards to follow the example of the best trusts and means that every patient can receive the same world-class care

His long-awaited review found unwarranted variation in running costs, sickness absence, infection rates, and prices paid for supplies and services among NHS trusts. Even trusts in the same area were found to be paying different amounts for the same products or services.

As part of the review, a ‘model hospital’ has now been developed that will advise NHS trusts on the most-efficient allocation of resources and allow hospitals to measure their performance against others.

Following the model hospital examples could save hospitals £5billion a year by 2020/2021 and put an end to the variations the review uncovered across the NHS, including:

  • Average running costs for a hospital (£ per square metre) vary from £105 at one trust to as high as £970 for another
  • Infection rates for hip and knee replacements vary from 0.5 to 4%
  • Prices paid by different hospitals for hip replacements range from £788 to £1,590
  • The use of floor space - one trust uses 12% for non-clinical purposes and another uses as much as 69%
  • Sickness absence rates differ from 3.1% to 5%

As well as reviewing hospitals across England, Lord Carter’s review looked at healthcare systems abroad, including in the US, Germany, Australia, Italy and France, where hospitals have a greater focus on efficiency because they have established the clear link it has with patient care.

Lord Carter said: “My experience of the NHS and hospitals internationally is that high-quality patient care and sound financial management go hand in hand. To improve the quality of care hospitals must grasp resources more effectively, especially staff, who account for more than 60p of every pound hospitals spend.

To improve the quality of care hospitals must grasp resources more effectively, especially staff, who account for more than 60p of every pound hospitals spend

“Giving hospitals the tools and support to better manage resources will make it easier for boards to follow the example of the best trusts and means that every patient can receive the same world-class care and taxpayers will also receive a fairer return on their significant investment in the NHS.”

Acute NHS trusts spend £55.6billion every year, £33.9billion of which goes on staffing. Lord Carter estimates a 1% improvement in staff productivity will save the NHS £280million a year, which equates to hospitals using new working methods that would save every member of staff five minutes on an eight-hour shift.”

Other areas covered by the report include:

  • Staffing: the review calls for an improvement in the way the NHS deploys its staff, ending the use of outdated and inefficient paper rosters
  • Procurement: as part of the review, from April 2016 trusts will publish their receipts on a monthly basis for the top 100 items bought by the NHS such as bandages, needles and rubber gloves
  • Use of floor space: trusts’ unused floor space should not exceed 2.5%, and floor space used for non-clinical purposes should not exceed 35%
  • Administration costs: these should not exceed 7% by 2018 and 6% by 2020
  • Delayed transfers of care: Lord Carter has called for action to be taken on the ‘major problem’ of delayed transfers of care, which affects hospitals and trusts’ earning and spending capacity
  • Working with neighbouring hospitals: Lord Carter advises trusts to work closely with their neighbouring hospitals, sharing services and resources to improve efficiency and reduce costs
  • Lord Carter was asked to carry out the review by Health Secretary, Jeremy Hunt, as part of his aim to make the NHS the safest and most-efficient healthcare system in the world. The efficiency expert has spent the last 18 months visiting hospitals across the country and reviewing productivity to ensure the NHS gets the best value from its £102billion annual budget and help the NHS to implement a seven-day service.

    This ground-breaking review will help hospitals care for patients, making sure every penny possible is spent on frontline patient care and bureaucracy is slashed so doctors and nurses can concentrate on caring

    Hunt said: “I want to make the NHS the safest healthcare system in the world, capable of providing the same world-class care every day of the week, powered by a culture of transparency and learning. This ground-breaking review will help hospitals care for patients, making sure every penny possible is spent on frontline patient care and bureaucracy is slashed so doctors and nurses can concentrate on caring.”

    Lord Carter will continue to engage with and support trusts to achieve the efficiency improvements they can make over the coming months.

    NHS Improvement (NHSI) will lead the implementation of the recommendations and Lord Carter will become a non-executive director of the regulator in April.

    Lord Carter has also called for trusts to have closer support and management from NHSI, both locally and nationally, to ensure the review is fully implemented.

    Commenting on the problem of delayed transfers, Nicola Burgess, an associate professor of operations management at Warwick Business School, told BBH: “Bed-blocking is a back-door problem that inevitably leads to a front-door problem.

    “If patients cannot leave the hospital then queues of people build within the system, physical capacity becomes breached, care becomes compromised, staff become overburdened and eventually the hospital has to close its doors and turn patients away.

    “We have seen this happen in many of our hospitals in recent weeks. The fault does not lie with the individual hospitals, but with the system and the lack of synchronisation between care providers.

    Hospitals do not and cannot operate in isolation. They are part of a wider care network and as such need to integrate systems and processes to allow patients to flow both in and out of hospitals

    "Many patients experience delayed discharge because of difficulties in synchronising services across care providers. As patients become fit for discharge they are effectively 'pushed' to the next stage of the care pathway. Unfortunately, community-based care providers may not be in a position to accept the patient at this point, meaning the patient has to wait, resulting in delayed discharge.

    "A 'pull approach', on the other hand, would see care providers identifying patients in need of their services ahead of discharge and then planning their resources accordingly to allow for a smooth transition from the hospital to another place of care safely and without delay. Such an approach, though, requires improved communication and enhanced transparency between care providers.

    Hospitals do not and cannot operate in isolation. They are part of a wider care network and as such need to integrate systems and processes to allow patients to flow both in and out of hospitals."

    And Paul Briddock, director of policy at Healthcare Financial Management Association (HFMA), said: "Directors of finance welcome any kind of benchmarking which helps support and guide them in delivering the unprecedented efficiency savings required of the NHS.

    “HFMA is working closely with them to review and consider the review’s recommendations and how these can and should be implemented so we can get maximum value out of each pound spent in the NHS.

    “Efficiency and productivity are top of our members’ agendas and they are very open to finding better, sustainable ways of working that lead to cost reductions.

    “In our most recent NHS Financial Temperature Check survey of over 200 finance directors they expressed scepticism about Lord Carter’s savings plans with the majority saying they didn’t know if the savings could be achieved. They wanted more clarity on aspects such as where exactly the savings could be made and how feasible the plans were. Today’s report brings us one step closer to getting some answers.

    Ensuring the process of implementing Lord Carter’s recommendations is collaborative and open, rather than top down, with the entire healthcare system working together will be vital

    “However, all parties must be mindful of the immense pressure finance directors in the NHS, and their teams, are under. The review and its recommendations must not be used as a stick to further beat them with. We can only bring about change if they are kept engaged.”

    “Ensuring the process of implementing Lord Carter’s recommendations is collaborative and open, rather than top down, with the entire healthcare system working together will be vital to this.

    “While the current review focuses on hospital efficiencies, there are other hugely significant problems – like the delayed discharge of patients – which continue to be a costly drain on resources and cannot be solved unless the whole of the health and social care system works effectively together. Transforming service provision is key to a fit-for-the-future NHS.”

    Commenting on the need to embrace technology to meet the demands of the review; Paul O’Hanlan, managing director of systems manufacturer, Omnicell, said: “We are pleased to see the report highlight the need for a greater use of technology such as electronic systems to automate ordering, storage and tracking of medicines and supplies.

    “By using technology in this way, hospitals can access an accurate breakdown of treatment costs at patient level and free up clinicians’ time so it can be redirected back into face to face patient care.”

    An example of where this approach has worked is Omnicell’s work with Guy’s and St Thomas’ NHS Foundation Trust in London, which was visited by Lord Carter as part of his review.

    In a day and age where we use technology in nearly everything we do, isn’t it time we started to embrace technology in the same way across the NHS?

    The trust initially installed over 100 Omnicell automated dispensing cabinet system across wards, theatres and the A&E department. It now has more than 300 Omnicell systems across three hospitals - the largest implementation of its kind in Europe.

    O’Hanlan said: “Through this installation they identified millions of pounds of excess stock, as well as over 10% reduction in spend. In addition, the average transaction time for accessing medications and supplies has been reduced and new automated processes have released thousands of hours of clinical time which can now be spent on patient care.

    “Stock is secure and benefits from an automated re-ordering system, together with an interface that feeds patients names from the patient administration system right through to the cabinet.

    “The Omnicell system is also integrated with the hospital Electronic Prescribing and Medicines Administration (EPMA) system, further improving efficiency and patient safety.” He added: “We recognise that there is a long-way to go, but we look forward to working with more trusts to drive up efficiency through innovative technological solutions.

    “In a day and age where we use technology in nearly everything we do, isn’t it time we started to embrace technology in the same way across the NHS?”