Scrutiny of the Budget Proposals 2011/12

Appendix 5D

SCRUTINY OF THE BUDGET PROPOSALS 2011/12:

The service and financial challenge for the local NHS over the next four years

KEY QUESTIONS

Group 4 – EFFICIENCY & TRANSFORMATION

4.1Which other trusts have a reputation for innovation and what lessons might you learn from them for the Trust?

East and North Hertfordshire NHS Trust

There are a number of mechanisms for the Trust to learn from others and to benchmark itself to ensure it moves towards upper quartile/decile performance in key performance areas:

• McKinsey and Co have provided all acute Trusts in East of England with an ‘outside in’ analysis illustrating where there are opportunities for improvement. The analysis benchmarks Trusts against each other in areas ie. finance, operations, workforce and quality

• The NHS Institute for Innovation and Improvement provides all organisations with the Better Care, Better Value indicators. These illustrate the differences in performance in key clinical areas such as length of stay, day case rates, outpatient DNAs. They provide details of ‘best in class’.

NHS Hertfordshire

NHS Hertfordshire used the Commissioning Intentions published by East of England SHA and we have been highlighted as a PCT that adopted the recommendations, eg. payment of day cases as outpatient treatment. The PCT continues to benchmark against other organisations to adopt efficiency gains, e.g. the use of the NHS Institute for Improvement benchmarking tool. For 2010/11 the PCT is looking to implement the efficiency changes in A&E as adopted by NHS Suffolk in 2009/10.

Hertfordshire Partnership Foundation Trust

The Trust has researched in depth, organisations which have or are implementing similar service models to those developed through the Leading By Design programme.

Our proposals in relation to the development of a Coordinated Access and Assessment Service, Care Pathways and Acute Inpatient Reprovision draw upon international, national and local models which exhibit recognised best practice and the Trust is working with experts who have been involved in similar developments to support the process locally

WestHertfordshireHospital Trust

We are in constant contact with other Trusts and health and provider organisations and though benchmarking we are able to identify excellence and use their learning to innovate locally.

These include:

Foundation Trust Network (FTN)

East of England Quality, Improvement, Prevention and Performance (QIPP)

Chief Executives and Chairs meetings

Other National Forum

Hertfordshire Community NHS Trust

• Joint early intervention and prevention services – Croydon, Lancashire and City of Westminster. We have proposals to enhance our enablement services using observations from Croydon’s assessment processes.

Trusts are beginning to utilise “Lean” methodologies. We are leading on the introduction of such to our intermediate care processes.

4.2Do efficiency and transformation savings reflect Value for Money / Benchmarking analysis?

East and North Hertfordshire NHS Trust

See 4.1 above.

NHS Hertfordshire

Yes. A variety of benchmarking analysis is undertaken. The PCT’s strategic plan used work from the NHS Institute for Innovation to assess the opportunities for improved productivity, reducing ineffective treatments and alternative responses to demand. Another source is the NHS Primary Care Commissioning (NHS PCC) benchmarkingtool which highlights variations in primary care spend across the country. A number of initiatives are also planned which adopt best practice from elsewhere. For example, Scriptswitch (UnitedHealth UK) is a computer software package for GP systems which highlights “bespoke” prescribing recommendations at the point of prescribing. Experience has demonstrated that this is effective in influencing GP prescribing as it provides prescribers with thechoice of the most cost-effective medication option at the point of prescribing.

Building on performance scorecards developed elsewhere in the country, the PCT has developed and introduced local practice specific scorecards for every practice. This utilises a wide range of outcome measures from numerous data sources.

Hertfordshire Partnership Foundation Trust

The Trust uses benchmarking evidence from a number of recognised authorities e.g. MH Strategies, Audit Commission, NHS Confederation, etc to periodically evaluate efficiency indicators against national and local comparators. Current benchmarking against comparable Trusts for indicators of quality are favourable in terms of safety and serious untoward incidents and the Trust has been successful in pursuing accreditation in relation to safety issues over a number of years. The Trust already compares favourably when benchmarked nationally on the basis of efficiency and cost, being ‘excellent’ in its use of resources and significantly below the average national reference cost index (approximately 10% better than average cost).

Areas of work being pursued through our transformation plans which include a focus on delivering efficiencies include:

• In Specialist Learning Disability services the unit cost is higher than services where there is less reliance on inpatient beds, and neither does this provide the best quality in terms of model of care. There is an ongoing project to reduce reliance on an inpatient service model by reinvesting efficiencies in enhancing community based bed services, and developing community teams to provide early intervention to prevent admission and to work with people in their own homes.

• An independent review of adult mental health inpatient services has been undertaken. This has benchmarked indicators such as number of beds available, occupancy, level of stay, number of admissions etc against other similar Trusts across the country, providing population based statistics which confirm previous studies and affirm that for Hertfordshire there are further opportunities to reduce the overall number of inpatient mental health beds through appropriate management of admissions, building upon the significant work already taking place through coordinated discharge planning, and supporting people to stay in their own homes wherever possible.

• A value for money for study of mental health services showed that the funding contributed to the pooled arrangements for joint commissioning, whilst not dissimilar in total to cluster group comparators, under benchmarking was not contributed in similar proportions by partners compared to similar organisations. As a result of this, Adult Care Services have demanded very challenging efficiency savings from the Trust over the next three years in order to address this issue from the local authority position. In response to this, the Trust has developed a programme of re-providing accommodation, repatriating out-of-county placements, more flexible day opportunities and community services and is rolling-out the self-directed support agenda across the organisation. These will contribute significantly to achieving the 22% savings requirement.

WestHertfordshireHospital Trust

The Trust is benchmarked against a peer group of over a dozen similar Trusts. The efficiency and transformation data is measured against these organisations and allows learning from excellence.

Hertfordshire Community NHS Trust

We are determined to address the above average costs of our estate and similarly to preserve investment in front line services.

4.3Which are the high(er) cost services? Are high cost services identifying proportionately greater savings?

East and North Hertfordshire NHS Trust

The higher cost services (per patient) in acute hospital care tend to be the specialist services such as cancer, renal and neonatal intensive care. These services are not required to generate proportionately more savings than other more general services.

NHS Hertfordshire

Benchmarking analysis shows the highest cost services compared with other PCTs are planned care, both admitted care and outpatients, because of higher than average volumes. A large proportion of the workstreams are therefore focussed on these areas.

The PCT also uses commissioner level programme budgeting data, which is published annually in the form of a benchmarking tool. It enables us to identify how we spend our allocation over 23 disease groups, and how this compares with other commissioners nationally, locally or with similar characteristics.

Hertfordshire Partnership Foundation Trust

Through Leading By Design, the Trust is planning to provide services locally to natural communities to reflect needs within the local area. As part of this focus and building upon Investing in Your Mental Health there is also a shift away from reliance on bed-based services, which whilst benchmarked nationally as delivery cost efficiency, remain a significant element of the Trust’s cost profile and are relatively ‘resource hungry’.

Bed-based services tend to be higher cost and provide the least flexibility in terms of cost savings given the higher proportion of fixed and semi-fixed costs associated with delivery, particularly around estate. The ongoing programme across services is to move away from the need for admission; developing community based capacity and more responsive services that enable people to maintain as much independence as possible in their own homes or through supported living. The recovery based care principle is being ingrained across all services to facilitate and normalisation and the ability of people to move through the care pathway, resulting in discharge from services where appropriate in terms of individual need and timing. A key element of the budget proposals, underpinned by the Leading By Design programme, is to free up resources tied up in estate and high cost services to deliver efficiency gains and to provide opportunities for reinvestment.

WestHertfordshireHospital Trust

The Trust is progressing the development of SLR to enable a greater understanding of the relative contribution of services by specialty, thus contributing to the Trust’s strategic decisions and identifying savings plans, which will be proportionately distributed.

Hertfordshire Community NHS Trust

Service performance is assessed before efficiency schemes are approved by the Executive Team, and authorisation is only given if the ET is satisfied that the risk to performance can be tolerated.

4.4Are savings classified as “efficiencies” genuine efficiencies, or will service performance reduce?

East and North Hertfordshire NHS Trust

All our cost improvement programme schemes are considered and risk assessed by clinicians to ensure that they do not jeopardise patient safety.

NHS Hertfordshire

The efficiency savings described above do not result in service reduced performance. An example is a falls project pilot in West Hertfordshire with the East of England Ambulance Service NHS Trust (EEAST). To help maintain independence and prevent future falls in older people the EEAST worked with the PCT and Hertfordshire County Council to deliver a pilot which provided an alternative to conveyance to hospital for older people who had fallen. The results show an increased admission avoidance rate, faster access to social care and a likely possible impact on preventing future falls. Due to the positive evaluation in terms of patient experience and reduction in conveyance to hospital and direct referral into services, this intervention will continue in West Hertfordshire and be rolled out to include East and North Hertfordshire within the comprehensive clinical pathway for falls management.

Hertfordshire Partnership Foundation Trust

The Leading By Design programme incorporates the elements of QIPP to ensure that significant service transformation is accompanied by the maintenance of quality through the delivery of efficiency and productivity. The focus of plans is on areas that do not add value and where we can eliminate waste, reducing duplication and improving performance and efficiency by reducing variation. These initiatives therefore support service performance and sustainability by delivering real efficiency gains.

The development of a single coordinated assessment service will enable expertise to be drawn to the front of the care pathway, identifying the best value services based on individual need. Clear articulation of the care pathway, both community and 24/7 services, will help to eliminate costly variation and focus care provision on clear outcomes with efficacy of treatment and effective resource utilisation.

WestHertfordshireHospital Trust

The Trust will not compromise patient safety to achieve financial savings. The Trust brought in a patient experience expert from the World Health Organisation (WHO) to oversee the design and early implementation of the Cost Improvement Programme. Their role was to ensure that all clinical cost improvement schemes were driven by a need to improve quality first and foremost. If schemes compromise patient care they were rejected. This robust process continues.

Hertfordshire Community NHS Trust

Service performance is assessed before efficiency schemes are approved by the Executive Team, and authorisation is only given if the ET is satisfied that the risk to performance can be tolerated.

4.5What is potential for increased efficiency

• … from partnerships? e.g. joint arrangements with local authorities,
• Police, etc
• … from procurement? e.g. commissioning, negotiating, outsourcing, etc

East and North Hertfordshire NHS Trust

The Trust would like to explore the potential for partnership working across the local public sector with a particular focus on back office functions.

The Trust is part of the Hertfordshire Supplies consortium and the Procurement Hub which operates across the East of England. There is almost always scope for further improvement but the Trust is collaborating significantly already to achieve best value in procurement across a wide NHS patch.

NHS Hertfordshire

The PCT’s intermediate care strategy will lead to the development of more integrated services with ACS. Improved community based services and more flexible bed based procurement will reduce bed capacity required.

For mental health services, Hertfordshire Partnership Foundation Trust has recently agreed a 3 year contract with the Hertfordshire Joint Commissioning Partnership Board. This contract provides HPfT with some security over future income but also requires HPfT to make significant efficiency savings for both NHS Hertfordshire and the County Council, whilst continuing to maintain existing service levers and to improve the quality of its services.

• … from procurement? e.g. commissioning, negotiating, outsourcing, etc

The PCTs’ proposed Contracting Framework currently being finalised will lead to an integrated and improved procurement process ensuring effective commissioning through negotiation and utilisation of capacity.

Hertfordshire Partnership Foundation Trust

The Trust works with a number of different partners to deliver either joint services or to improve the journey for people through services. There is ongoing work to increase efficiency by sharing estate and back-office functions where feasible so that savings are focussed on support functions as far as possible.

The main partnership arrangement is with the local authority where the Trust provides a breadth of integrated mental health services across the full age, and specialist learning disability services through jointly commissioned arrangements, underpinned by a three year contract through to 2013 which details expectations around performance, efficiency and quality of service delivery.

Arrangements for the provision of substance misuse services are being reviewed by the Joint Commissioning Team and the Trust is negotiating partnership arrangements with a 3rd sector provider in order to respond fully to future requirements, building upon the strengths of different organisation to bring improvements to care and broadening delivery towards a less medicalised model of care.

A similar process is taking place to explore the potential of delivering day service opportunities through new and improved partnership arrangements.

Discussions are at the explorative stage, but it is expected that efficiencies will be delivered from the sharing of ‘back office’ services across Hertfordshire health bodies.

• from procurement? e.g. commissioning, negotiating, outsourcing, etc

The East of England Collaborative Procurement Hub delivers annual efficiency savings to member organisations through targeted programmes which utilise the combined volumes to drive down prices and deliver quality improvements by suppliers. For the East of England, the Finance Directors group meets regularly and as part of the regional QIPP programme is specifically focussing on procurement efficiency opportunities. Areas being explored are e.g. multi-functional devices to provide printing efficiencies, negotiation with soft ware suppliers, telephonics and nationally, energy contracts.

The Trust’s placement service negotiates placement contracts with providers, restricting annual inflationary uplift and reviewing each placement on an individual basis to ensure that these meet needs.

An independent review of back office services is planned, with the potential to outsource further services being explored.

WestHertfordshireHospital Trust

The Trust has a detailed list of CIPs for increased efficiency including working with Hertfordshire Supplies Management Confederation (HSMC) to deliver savings across clinical and non clinical spend, negotiation of a lower service charge to the Trust, implementation of a product selection committee and use of internet auctions.

The Trust will also explore other options to further develop savings from shared services, such as HR and payroll.

Going forward the Trust will seek to gain further efficiencies from the re-organisation of services (better use of St Albans site, reducing operating inefficiency caused by providing the same services on 3 sites).

Hertfordshire Community NHS Trust

HCT is keen to extend scope for joint working with HCC, especially around procurement. We currently procure collaboratively at two levels, with the other Hertfordshire NHS Trusts, and across the East of England region through the procurement hub. Brining other public sector bodies into these at present exclusively NHS consortia would extend the scope for savings.

1