Quality should always be at the core

Recently I was able to attend an Intellect (intellect.co.uk) event held in Fleet Street, London with Jim Easton (National Director for productivity and efficiency) speaking. It was made clear that the NHS cannot sustain itself with current funding levels and £20Bn is the ‘qualified estimate’ of how much needs to be saved, recurrently, between now and 2015. It’s a huge task ahead and Jim Easton has to lead one of the toughest challenges to face the NHS in England – it was noted by Jim that mental health services have changed radically for the better in the past 30 years and acute trusts now have 4 years to achieve the same effort – a very valid point.

With that thought I have two observations to make:

Firstly,

It’s absolutely vital to note that quality should always be at the core. The statement “cutting costs puts services at risk of poor quality” – I don’t doubt it one bit. I think in projects it wrongly comes down to the separation of cost and quality – I think sometimes it’s easy for there to become a disconnect because a new cost improvement has been defined and although quality is always considered at the start it doesn't necessarily get discussed in project monitoring – if something starts late it’s the finances that suffer and they become more prominent. Quality metrics are challenging to define but they are needed to report on.

If a new project to improve the services offered by the Trust is delayed it:

1. Puts the financial plan at risk
2. Takes away the opportunity for the patient to receive a service of better quality during care/treatment. This may mean a shorter stay in hospital, one less visit to the phlebotomist or fast referral to the correct specialist.

Secondly,

I’ll start by pointing to page 4 of this article:

http://www.health.org.uk/public/cms/75/76/313/577/Rising%20to%20the%20challenge.pdf?realName=mcy7Hg.pdf

The article refers to evidence found by The Health Foundation on whether increasing quality saves money. It identifies that poor quality is common and costly but says complex organisational change offer great potential for savings but there is risk of failure. The reason for less evidence is obvious – its change which requires engagement of stakeholders from possibly multiple organisations, the risk of failure is high (as identified), it’s hard to meausre the improvement and it’s a tough project/programme management challenge. These are all factors that can be addressed with the right skills and this change is possible – pathology is an example area of where huge savings are possible.

Changes in areas which improve the clinical service also stop protesters on the street because of cuts to front-line services; questions like-

• Does the patient need that pathology test or MRI scan?
• Does the patient need to be in hospital this long (http://www.hsj.co.uk/news/primary-care/discharge-delays-questioned-after-patient-deaths/5025224.article)?
• Do we need to pay that much for this special drug?
• Can we improve the scheduling of this service to reduce cancellations?

Some of these ideas and more are mentioned here: http://www.bmj.com/content/341/bmj.c7239.full

Pathology continues to move up the agenda

At the beginning of the month I was at a launch event for a new approach to sending pathology samples between UK laboratories conceived by X-Lab, a service that will be hosted by the HIS (http://www.this.nhs.uk/npex). I worked for a medical reference laboratory (Pathology Associates Medical Laboratories (PAML) – www.paml.com) in Washington State that offered a very similar service – essentially a tool that translates the pathology request from one system into a readable and translatable form for any other system (and back again). The concept is similar to that of a telephone exchange.

I mention PAML because they offer a service to hospitals – using CRM to manage client services, using Fedex style logistics to manage pathology sample shipping, etc. Some features of the service could be very beneficial to the UK pathology service– however this will lead me into a comparison between business models that is for another time.

Pathology service savings – now is the time?

With the potential to save huge amounts of cost and increase the quality of service, it has taken a long time for pathology to move to the top of the agenda. We have all known the change is coming, presentations and whispers at two conferences I attended in late-2009 (SBK Pathology Toolkit – Service reconfiguration and implementing change) and late-2008 (Laboratory IT Strategy conference) predicted the change. We’ve all seen the two Carter reviews as well.

It’s one way of saving cost and improving productivity without closing front-end services which could ultimately result in protests and national newspapers front page headlines. At the minimum organisations are starting to pass ideas around about how pathology services can save cost locally (even if at Trust Chief Executive Level), if not already entering into a challenging process of change.

How NPEx and the advent of GP commissioning could impact this

NPEx is a concept that, if used widely enough, could change the shape of the pathology market. Two key examples:

1) Choosing an alternative reference laboratory for specialist reference testing. Laboratory X is charging the Trust £91 per test but the NPEx system states Laboratory Y can offer the same test for £68. This raises a number of interesting questions:

• Why is it cheaper?
•  Is the quality of testing going to be as robust as Laboratory X if I switch to Laboratory Y?

2) After the release of the new whitepaper could pathology rise to the top of the agenda for GPs, just as it is for Trust Chief Executives right now? GP work is typically automated and bulk accounting for a high volume at low cost.

• If information is realised about NHS Trusts cost per test compared to Quest, Serco or TDL how will GP consortia react?

The second point is one that is prominent and non-dependant on the X-Lab system. If private providers take all of the GP work then pathology services within NHS Trusts will not be able to sustain themselves performing the expensive specialist work.

Some key points...

• As a result NHS Trusts are under pressure to understand their true service costs and make the needed changes to increase quality and productivity throughout; otherwise they may find themselves fighting to keep the GP work from the hands of private providers.
• The model of delivery has to change. Using paediatric allergy testing as an example – within an SHA region it is most likely being performed in most DGHs and specialist centres. Such a service can be operated from one or two specialist paediatric centres across the region because the work is cold. This will result in:
• Decreased service cost for DGHs operating the service
• Reduced cost per test across the test repertoire
•  Increased service quality for allergy testing
•  Now only operating in one or two specialist centres
• A new process that has been implemented
• Achieving maximum productivity

Some key questions for thought...

• Can the logistics cope and will this be a telling point for enabling GPs or hospitals to choose where they order a test?
• If consolidation is to happen will the technology be a stumbling block?
• How will NHS Trusts actually react to a changing market? 

Planning is the only the beginning

“Efficiency is the ‘main game’ in the NHS” and “the eight ways to save cash and improve care” are just two headlines I’ve seen recently on one healthcare news website (HSJ) regarding cost and productivity improvement. On my twitter feed the word efficiency is always ‘popping’ up. It’s interesting that the way to address efficiency has, in one way or another, been wrapped inside an acronym, QIPP, which still remains somewhat mysterious to me. Kate Hall, a Health Leadership Fellow, recently blogged on HSJ (http://www.hsj.co.uk/a-pinch-of-qipp/5021132.blog) identifying that QIPP and national workstreams were published so long ago yet she states:

“I’m not sure why there is little or no information published on them nor why it is not available for people to look up and heaven forbid, see how they can support, help or get ideas “

The only website I’ve found is on NHS Evidence (http://www.library.nhs.uk/qipp/) but resources are still short of what they should be and examples are not updated regularly enough. The one problem I find with QIPP is that it’s been made into something apart from driving productivity and quality improvement that means it could easily viewed, quite dangerously, as a project or programme. In PRINCE 2 terms I’m talking here, as something that exists temporarily, when it should be instilled in the hearts and minds of NHS leaders throughout the country. Few NHS organisations are talking about QIPP, they’re talking about Cost Improvement Programmes which may be due to the lack of resources and a lack of understanding for what QIPP is really about.

The obvious action for Trust directors at the moment is to plan for big change, in anticipation of what may be 6% of budget savings. With QIPP in mind it's positive that such a concept will encourage more analysis around cost and productivity improvement, however the problem still remains that the output from this needs to driven. This is where the problem lies because only the ‘easy wins’ get a high profile and the real meaty cost saving ideas are left alone for fear of multiple reasons – before you know it CIP values are falling away and become at serious risk of under-achieving.

Perhaps this is too simple a view – I intended to summarise it but the hard fact remains that implementation is challenging. It requires tough project management with solid plans and well managed risks with an understanding of change management thrown in the mix– right now that’s what NHS organisations need to realise savings and looking to QIPP is only going to produce ideas for this process – at the very best.