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

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.