We can't hide from the huge financial challenge facing the NHS. The well-documented numbers are staggering - productivity improvements are needed immediately to meet a predicted £30bn annual funding gap by 2021. To put this into perspective, £30bn would pay for over 130,000 nurses, which accounted for 35% of England's nursing workforce in 2014.
In times of such austerity, hospital providers are looking at transformation programmes that can include drastic measures such as reducing staff numbers and selling land to create desperately needed savings. This approach requires hospital managers to perform a constant balancing act to ensure that any organisational cutbacks do not impact the quality of patient care. Savings in one area can have a detrimental impact on another; resources to support care provision need to be agile, responsive, and cover more than one care setting, especially as we move to more integrated care.
The challenge is to translate this into changes at the frontline. During my time as a paediatric surgeon I saw that while doctors were encouraged to reduce the ‘down time’ between operations in order to treat as many patients as possible, the NHS’ waiting list initiative rewarded consultants with overtime payments for meeting demand in evenings or at the weekend - potentially discouraging productivity during normal opening hours.
Such examples illustrate the reactive nature of recent attempts to meet the increasing demands on our hospitals. Neither of these scenarios are the answer to improving productivity and saving money - in fact, I think short-term actions like this are holding the NHS back from long-term sustainability.
Long-term efficiency is not easy
NHS frontline staff members understand that inefficient care impacts the quality of care delivery. Staff members are championing and sharing examples of good, efficient care in campaigns such as the Health Service Journal’s Challenge Top-Down Change, the Academy of Fabulous NHS Stuff, @WeNurses tweetchats, and even NHS Change Day. These campaigns reinforce the truth that people who work in the NHS do so because they want to make a difference, and their enthusiasm for long-term efficiency improvements is clear. Demand for change also comes from many other parts of the healthcare system. For example, delivering hospital efficiencies, such as reducing ALOS (average length of stay), is high on the Government's healthcare agenda. Likewise, NHS England is launching a clinical utilisation review Commissioning for Quality and Innovation (CQUIN) payment, whereby providers of specialised services will be rewarded for demonstrating that "patients are cared for in the optimal setting and to address barriers to optimal patient flow."
Such incentives can be blunt instruments in changing organisational behaviour, but they can work by making the topic a priority from the boardroom down. These types of measures create perverse incentives that reward activity over outcome. Aligning incentives across health and social providers to deliver integrated care is likely to prove challenging for years.
Even when we all want to do the right thing, in the right way, however, change is not always easy. As I saw when working with the NHS, addressing cultural issues is one of the biggest challenges for change management programmes – as such initiatives are often met with scepticism.
Why is this? Often management consultants lead the drive for change, but without the support for staff to make the necessary change. This can disempower those most capable of delivering sustainable, patient-led change.
Caregivers need the right tools to help them deliver change. For nursing staff, this could mean providing the status and location of each patient, and delivering information about them to manage and prioritise care in a timely manner. For social care staff, this may mean speeding up discharge processes and making sure the right services are notified. For carers and relatives, this could mean ensuring their loved ones are cared for by the right staff, who have the time to show the right standards of care. We need to help NHS staff progress patients through the hospital and back into the community in a safe, compassionate and efficient way. Such tools do exist.
Can technology make the difference?
Data is an important tool to help support change. When I worked in the NHS, I recall receiving management data that was a week or a month old, and using it to try and make changes to the way we worked. In a few instances, this kind of data is useful, but the majority of the time, such data is too retrospective to make a significant impact. Caregivers require technology that generates real-time data which allows them to adjust or react to current situations and make forward plans. They need the ability to make clinical and management decisions at the frontline, using real-time data to inform and support changes in working practices.
Although a considerable portion of available budget across frontline healthcare is being invested in electronic patient records (EPRs) and associated modules, these solutions do not in themselves fully support workflow. Rather, they digitise patient data and, by recording everything a clinician may want to know about a patient, provide an essential resource for maintaining and improving quality of care. But even with the data in an EPR, a trust may be no closer to effectively managing the in- and out- flow of patients, and moving them through the hospital system efficiently. Maintaining and improving the delivery of care is just as important; EPRs help power the engine, but they are often a cumbersome steering wheel.
Hospitals that truly want to streamline and manage care workflows require technology that can capture information and pull relevant data about patients, staff and assets in real-time. A nurse on a ward will want to get the right doctor to the right patient. The right equipment needs to be in the right place, and not take half an hour of a nurse's time to locate. When emergency departments are under extreme pressure because of hospital capacity issues, vacant beds need to be cleaned and made available in the most rapid way possible.
Operational systems are an essential part of making this happen. Using such systems gives busy hospitals the ability to see where capacity issues are arising. Visual dashboards on the ward can show nurses when beds are likely to be free, and show which doctors are available. Porters can bring the right equipment to the ward, and take the right patient to theatre at the right time. Care can be made more efficient both by managers and by frontline staff. In addition to improving the delivery of care, such technology can also generate significant, long-term cost savings.
The effectiveness of such operational platforms is the subject of numerous success stories in the US. Health First, a Florida-based healthcare provider, is benefiting from the "immense amount of data available" by driving operational efficiency from their operational platform. Bill Griffith, the organisation's executive director of operational excellence, says data is important to identify bottlenecks and gaps, and this data helps the provider to plan ahead and manage patient flow more effectively.
Logistical excellence underpinned by technology has empowered frontline staff, helped to deliver the necessary culture change that supports cost-effective, compassionate care, and has done so over the long-term.
Such change is not simple. But Bill's example will show that the effective use of technology for healthcare provision and healthcare delivery can deliver efficient, sustainable care. Rather than continuing to work around unsustainable, shortsighted cuts, hospitals can create meaningful long-term change by putting the right technology in the right hands.