As we progress towards medium-term pandemic recovery, there is a renewed focus from central government and NHSE on delivering greater efficiencies, whilst continuing to improve quality of care and patient outcomes.
Unsurprisingly, Financial Improvement Plans remain a standing priority for NHS organisations, particularly in light of the recent NHSE announcement of up to 6% savings targets in FY23/24[1]. There is also additional pressure on ICBs to achieve financial balance, including those still carrying huge pre-pandemic deficits.
In light of this, the challenge is to address, achieve, and exceed previous performance, whilst sustainably offsetting inflation in the context of ever-increasing service demands, an over-burdened workforce, and ageing infrastructure.
Opportunities for Financial Improvement: ICBs and Collaboration
NHS leaders acknowledge that no single organisation can tackle the systemic and efficiency challenges facing the health and care sector alone[2]. Trusts and their system partners have been developing collaborative ways of working for several years as national policy has shifted away from competition to collaboration. However, workforce, funding, and investment barriers have been challenging to overcome. With the formalisation of ICBs, there is now a real opportunity to tackle the financial challenges with a collective effort, whilst acknowledging collaborative programmes can take longer to deliver to benefits and savings. Areas of focus for ICBs should include:
Akeso’s Approach:
Our series on financial improvement plans for the NHS will look at pragmatic and tangible opportunities over differing time horizons and objectives, whilst also achieving clinical, operational, and patient benefits.
Quick-win, short-term initiatives can realise benefits within a year, and tactical savings within as little as 3 to 6 months. Medium-term schemes are designed to deliver between one to two years, and longer-term opportunities look two years and beyond, with some strategic programmes (e.g., system-wide estates planning) spanning over five years.
While cost reduction has become byword for relentless programmes of marginal gains, in the current environment organisations should a) take a holistic approach – managing cost pressures (including inflation) is arguably as important as identifying savings; and b) recognise that delivering better outcomes with the same resource has significant value.
The next article in our Financial Improvement series will provide further detail on the proven methodologies to deliver savings in the short- and medium-term. We will then set out how Population Health Management can support ICBs in the long-term. For more details, please get in touch with Scott Healy, who leads our Financial Improvement offering.
Andrew is a results-driven transformation leader with experience spanning strategic planning, operational efficiency, and transformative change management for leading healthcare organisations in both the private and public sector.
After leaving the NHS, he spent 15 years with EY’s Consulting practice, overseeing large and strategically significant client projects across the health sector at front-line, regional and national level.
Akeso supported Moorfields Eye Hospital in the rapid deployment of a stand-alone ophthalmology remote diagnostic hub to increase capacity for diagnostic clinics for Glaucoma and Medical Retina Services
INSIGHT
Shortly following the onset of COVID-19 Moorfields Eye Hospital (MEH) looked to establish a first-of-kind ophthalmology remote diagnostic hub to support both short-term backlog clearance due to COVID-19 as well as a broader strategic objective to meet the medium to long term service delivery within MEH’s clinical model.
In implementing this site, MEH wanted to showcase an innovative model which could become a key exemplar for large scale ophthalmology services and further benefit planning for Oriel.
ACTION
We supported MEH with the rapid 3-month deployment of the remote diagnostic hub in Hoxton, North Central London through the following activities:
Defined strategic vision to inform the scope and operating model
Assessed patient need and identified the hub’s target patients to ensure that every aspect of the service model and patient pathway are built around this
Modelled patient activity and capacity across the whole patient pathway. Capacity within the CDH must align with the Trust’s internal capacity
Delivered robust planning from the outset, with involvement from multiple stakeholders, to capture dependencies at each stage and ensure delivery to budget
Reviewed service resilience to ensure the safety of patients and wider service resilience through reviewing patient flow and infection control
RESULTS
MEH successfully opening a six-lane remote diagnostic hub facility, providing Glaucoma and Medica Retina diagnostic services within a 3-month timeframe. The Hoxton remote diagnostic hub was able to increase capacity by up to 2,700 patients per month, addressing the immediate backlog as well as provide a COVID secure pathway.
Olivia is an experienced consultant in the private and public healthcare sector specialised in delivering tangible benefits to supply chain operations and strategic sourcing. Prior to joining Akeso, Olivia worked in the FMCG sector developing innovative products for global and market-leading healthcare brands.
Akeso supported Moorfields Eye Hospital in the implementation of a first of kind Research Diagnostic Hub to explore new ways of providing excellent patient care in the community
INSIGHT
Moorfields Biomedical Research Centre (MBRC), in partnership with UCL Institute of Ophthalmology, looked to establish a first-of-kind ophthalmology research diagnostic hub which would test methods to reduce patient visiting time and improve patient experience.
Funded through NIHR, the initiative aimed to set out the key principles for delivery of care in the community which would be applicable for any high-volume NHS outpatient setting, such as orthopaedics and cardiology.
ACTION
We supported MBRC to design, plan and build a research diagnostic hub at Brent Cross shopping centre in North London through the following activities:
Defined strategic vision to inform the scope and operating model
Delivered robust planning from the outset, with involvement from multiple stakeholders, to capture dependencies at each stage and ensure delivery to budget
Modelled demand and capacity through patient activity and workforce modelling across the whole patient pathway to plan and forecast patient flow
Designed, planned and implemented four phased operating models to test patient flow and enhance efficiencies in a controlled live environment
Explored various build environments and real-time tracking to assessment movement of staff and patient within the clinic.
RESULTS
Through the ‘one stop shop’, established in a major London shopping mall, MBRC were able to:
Reduce patient visiting time from nearly 2 hours to 45 minutes.
Reduce average ‘Did not attends’ to below 10% from historic levels of 15% – 20%.
Olivia is an experienced consultant in the private and public healthcare sector specialised in delivering tangible benefits to supply chain operations and strategic sourcing. Prior to joining Akeso, Olivia worked in the FMCG sector developing innovative products for global and market-leading healthcare brands.
We supported Homerton Healthcare Hospital Foundation Trust pro-bono to secure over £950k funding across three Trust charities in the North East London ICS, working in community partnerships to bring measurable health outcomes to communities negatively impacted by COVID-19.
The Challenge:
In 2020 when the coronavirus pandemic hit, Captain Tom Moore and many others raised £150m for NHS Charities Together (NHSCT) in response to their COVID-19 Urgent Appeal. This funding was split into various programmes, namely the Stage 2 Community Partnership Grant, where the funds are distributed to Integrated Care Systems (ICS) across the country.
We were engaged by Homerton Healthcare Hospital Foundation Trust (HUHFT) as a lead charity to support the North-East London (NEL) ICS, providing a governance and project management structure throughout the application process.
Some of the key challenges identified included:
Ensuring equal management of the funds across the 3 Trust charities applying under NEL ICS
Managing different processes across the ICS
Responding to changing requirements for proposals and applications due to the novel nature of this Grant
Demonstrating each charity’s programmes met the community partnership guidelines
Solution:
In response to the challenges identified at the beginning of the project, our first step was to set up weekly governance calls with representatives from all Trust charities within the NEL ICS. We used these meetings to agree and document terms of references for the group, how the money would be managed, and track each organisation’s progress.
Following this, we segmented both the proposal and application template from NHSCT into a clear and concise structure which could be used across the organisations applying within NEL.
We ensured each charity’s application clearly demonstrated the following:
Resulted in a measurable improvement in health outcomes for communities adversely affected by COVID-19
Involved a partnership with community organisations
Lead to a direct, positive impact on the NHS whilst responding to the COVID-19 pandemic
Results:
The full amount of over £950k (inclusive of an operational grant) was successfully awarded and shared equally across all 3 Trust charities.
Our governance meetings were particularly useful to bring all organisations together and share knowledge from their own applications, capturing lessons learnt for future Grants. They provided a platform for colleagues who carried out similar work to come together when they otherwise do not have many opportunities to.
Next Steps:
As the programmes go live, we will continue to provide governance and structure across the ICS, ensuring all organisations track the progress of their programmes in a standardised format. Interim reports are required to demonstrate the appropriate use of the funds in order to unlock future allocations of the Grant funds. As we did for the application process, we will provide a structure to the reports and build processes to easily demonstrate the organisation’s goals have been met to date.
Scott has dedicated his career to performance improvement in healthcare and life sciences working both within a multinational consulting firm, and for the last decade as a co-founder of Akeso.
As a Managing Partner of the company, he has led the development of Akeso as an established boutique consultancy committed to improvement in UK health. His project specialisms and areas of interest are systemwide performance improvement, the national and international healthcare supply chain and the use of data to drive tangible and actionable improvement insights.
His approach is flexible, warm and fact-based and he is proud to have delivered numerous collaborative/ICS projects being able to engage positively across multiple stakeholders, specialisms and styles to achieve outcomes around aligned goals.
Outside of work his passions are almost all sports (mainly watching nowadays although can be found trying to find his wayward golf balls in the woods / long grass / water) and spending time with family, including Rump the cocker spaniel who is also the honorary office dog.
As recent headlines have highlighted, the NHS backlog in routine operations and procedures has reached worrying heights during the pandemic. Data from NHS England shows that currently more than 5 million people in England are waiting for hospital treatment, with 3.63 million fewer elective surgeries carried out between April 2020 and May 2021. Meeting this backlog of care is going to be one of the key challenges for Trusts across the country over the coming months.
To achieve this, every element of a Trust’s service needs to be operating as effectively and efficiently as possible. One critical area that is often overlooked is decontamination and sterilisation services. Without effective surgical instrument sterilisation, even basic procedures cannot be carried out.
This insights article looks at some of the problems Trusts face when it comes to providing sterile services and how they can be addressed within integrated care systems (ICS) in a post-COVID world.
The current SSD landscape
There are more than 3,000 NHS hospital theatres across England, carrying out 10 million theatre operations each year, all of which are supported by sterile service departments at an estimated annual running cost of more than £200m.
Typically, sterile services are provided on-site on a Trust-by-Trust basis and are co-located adjacent to Theatres. The size and scope of this service provision is contingent upon both volume and type of a Trust’s elective caseload. The graphic below shows how this £200m spend breaks down by region and ICS, with percentages representing the proportion spent by each ICS within a region.
Figure 1 – ICS annual spend on sterile services across England by region
Disparities across NHS Trusts’ Sterile Services
Given the scale of these services, some variation in service performance and delivery is expected. However, digging deeper into NHS Digital data, Akeso & Co found significant disparities across Trusts that need to be addressed.
In fact, the total annual spend on sterile services per ICS, varies extensively in relation to the number of theatres in a Trust and the floorspace their sterile service department takes up. These variations are outlined in the graphic below which plots ICS spending driven by surgical activity and case type, against number of theatres and SSD floorspace.
Figure 2 – Unwarranted variation in sterile services performance in England, shown by the total annual spend of STPs/ICSs compared to the number of theatres and SSD floorspace (sqm)
There is significant variation in spend on sterile services by ICS and Trusts when accounting for a hospital’s number of theatres, volume and scope of surgical activity, and unit size. One major cause of this unwarranted variation, highlighted above, is the varying age and condition of sterilisation equipment and assets.
Because the service is capital intensive, with high-value complex assets and costly support facilities, this commonly results in the assets operating beyond their lifespan. Inevitably, this leads to high levels of breakdown, maintenance costs and downtime which impacts a theatre’s ability to operate. In a capital-limited environment, most Trusts do not have the funds to upgrade their sterilisation assets to a standard which would be optimal and compliant.
However, where there is variation in service performance and efficiency, and an increasing backlog of demand, there are clear opportunities for Trusts to improve how they run these services. Trusts should welcome the challenge of further ICS integration as a means of combatting these issues. This will also enable them to redefine operational processes within the entire peri-operative value chain, embrace novel technologies and explore a variety of commercial models.
Addressing the challenges
How Trusts transform sterilisation services to reduce inefficiencies and unwarranted variation will depend on a number of determining factors specific to each Trust. Addressing each one will enable Trusts to create efficient sterile services that allow theatres to function as effectively as possible, as they tackle the backlog of cases caused by Covid-19. Moreover, in reshaping the provision of sterile services, Trusts also have the opportunity to better manage their equipment and explore how they can optimise their floorspace, not least in the context of required theatre expansion programmes, where floorspace is at a premium.
We have identified several factors that will influence a Trust’s decisions, including:
Hospital site type, number of sites and location
Level of collaboration within an ICS / STP
Theatre case volume and type
State of assets and equipment
Financial position and capital availability
These all need to be taken into account when considering how to best prepare a Trust for the demands of a post-pandemic world.
To achieve this there are three steps we would recommend taking:
1.Understand the Trust’s requirements and activity
Theatre case volume, case type and surgical preference all impact decontamination activity. For example, orthopaedic surgeries require the greatest volume of associated surgical equipment and, in turn, sterilisation. Moreover, in larger Trusts, having a detailed understanding of the relationship between multi-site and multi-organisation environments is crucial. Only once the demand on sterile services has been accurately understood, can Trusts begin planning their bespoke sterilisation improvement strategies.
2. Tackle mismatches between theatre activity and decontamination volume
Through improved operational planning, Trusts will be able to manage surgical instrumentation to better meet peak demand and rapid turnarounds when necessary. Currently, the level of sterilisation activity does not always align with the volume of theatre cases, as illustrated in Figure 3 below.
Typically, cases and elective surgeries run throughout the working day, with sterile services running alongside them, often at max capacity. Trusts should look to adopt, where possible, a hybrid working model, whereby sterile service activity is better managed to align with demand and activity. This hybrid model would see the core volume of activity processed outside of the traditional elective window (also shown in Figure 3). This will improve their ability to respond to ad-hoc surgical demand and reduce pressure on already burdened capital assets, enabling crucial machine downtime.
Figure 3 – Misalignment in theatre cases and sterilisation activity
3. Adopt technological capabilities to maximise current operations
Alongside better planning, advances in technology can help ensure the instrument peri-operative value chain is as efficient and effective as possible. Track and trace technologies, such as Radio Frequency Identification (RFID), offer full visibility over surgical instrumentation from surgical use to decontamination and other movements. This enables workflow optimisation and full utilisation of the existing asset base. Work conducted by Akeso & Co discovered that a third of one leading Trust’s surgical instrumentation had not been used for three years, with instrument dormancy going as far back as 2004.
In situations like this, RFID can pinpoint where medical instruments are dormant. Although there are valid clinical reasons for not using certain instruments, a clearer oversight of assets gives Trusts the option to generate value by disposing of unnecessary equipment and freeing up hospital floorspace.
4. Explore a variety of commercial models
There are a number of different commercial models which Trusts should consider, such as joint ventures and managed services that can reduce the significant capital investments required. The graph below shows the range of commercial models currently available, and the different value propositions they offer depending on a Trust’s objectives.
Figure 4 – The range of commercial models available, including the level of service each offers and the advantages of a managed equipment service (MES)
Each commercial model comes with various advantages and opportunities. Depending on the selected model, Trusts have the possibility of further integration within the ICS to share capital and the option of taking sterilisation services off site if appropriate. Further to this, there is the opportunity to create revenue by acting as a lead partner in a commercial SSD network and offering services to the private sector.
Choosing the right model
There are benefits and risks to every solution and weighing up a Trust’s specific needs is an important part of the process when deciding which is the right route to take. We have worked with several Trusts over the years to identify the best direction for their SSD and build a business case to support this.
In transforming sterile services departments, Trusts will put themselves in a stronger position to deal with the fallout from the pandemic. Additionally, this will also increase theatre efficiency, improve infection control measures, generate space savings that enable theatre expansion programmes and potentially create much-needed income.
To discuss how Akeso & Co can help sterile service departments perform their critical role more effectively, get in touch.
Akeso & Co supported Homerton University Hospital Foundation Trust (HUHFT) in the design and implementation of a Scan4Safety Programme and Inventory Management System (IMS). Captured in a detailed business case, the initiative is set to drive significant operational efficiencies and improvements to patient safety and care.
Challenge
Homerton University Hospital Foundation Trust (HUHFT) is a major NHS provider of acute care in the London Borough of Hackney. With services spanning 75 locations across East London, including approximately 450 beds, 11 wards, three day-surgery theatres and six main operating theatres, HUHFT has a complex set of services and supporting supply chain.
Following a thorough opportunity assessment, a number of challenges were identified with regards to the current operations, accumulating in clinical time wasted, health and safety risks, as well as opportunities for cost improvements.
Some of the key challenges identified include:
Inefficient and inconsistent supply chain processes across wards and departments
Lack of visibility and control of inventory levels due to limited reporting capabilities
Segmented spending on products and consumables across wards and departments
Limited traceability of theatre implants through the supply chain to procedure due to manual processes
Strained working relationships between clinical and material management staff
Solution
To address the challenges identified, the project recommended HUHFT would benefit significantly from a Trust-wide IMS to improve inventory management and achieve patient-level costing. We supported HUHFT through a three-phased approach from business case development through to successful implementation.
Phase 1) Secure investment through a robust business case
With the support of key HUHFT clinical and operational stakeholders, we developed a compelling business case and secured the required backing to proceed to procurement. Through a detailed appraisal of the potential qualitative and quantitative benefits and risks, it was identified that implementation of a trust-wide IMS could deliver £1.4m in benefits over the next five years, from an initial £469k one-time investment.
Phase 2) Source and partner with the optimal provider
Following a route to market assessment, we facilitated a phased procurement process through a formalised ‘mini-competition’ to assist the Trust in their rigorous selection of a suitable IMS provider. Through taking this approach, we were able to secure an optimal solution balancing system capability and total five-year cost.
Phase 3) Implementation through rigorous PMO and change management
We project managed the implementation of the new IMS and change management of associated processes encompassed within the Scan4Safety programme, reporting to the patient safety board. From the outset, programme governance was implemented to ensure the new system and its related benefits were achievable and sustainable. This involved the recruitment and setup of a programme board of Trust directors, and the chairing of regular meetings and presenting programme updates at Trust-wide Scan4Safety engagement sessions.
Results
The full benefits of the IMS solution will be seen during the next five years but it is already delivering significant savings and process improvements.
The one-time investments equating to £469,000 and subsequent improved processes is expected to generate £1.4m in cost savings, including:
In addition to the projected quantitative benefits, implementation of a Trust-wide IMS is also expected to deliver number of qualitative benefits, including:
A reduction in the likelihood of ‘never events’ thanks to the patient level costing functionality which improves the traceability of implants, surgical instruments and medical equipment.
The release of up to six clinical WTEs, allowing them to re-focus on patient facing activities.
Automated processes, such as Barcode-driven ordering, that drive efficiencies in areas including procurement and recall.
Additional management information insights that enabled further efficiencies.
Increased clinical confidence in supply chain processes.
Compliance with GS1 and Scan4Safety.
What is next for HUHFT?
Following the success of the IMS and Scan4Safety pilot programme, HUHFT will continue to drive adoption of Scan4Safety to extended use cases, including potentially Blood Transfusion Scanning, Pathology samples, eMedicine, and many more.
Scott has dedicated his career to performance improvement in healthcare and life sciences working both within a multinational consulting firm, and for the last decade as a co-founder of Akeso.
As a Managing Partner of the company, he has led the development of Akeso as an established boutique consultancy committed to improvement in UK health. His project specialisms and areas of interest are systemwide performance improvement, the national and international healthcare supply chain and the use of data to drive tangible and actionable improvement insights.
His approach is flexible, warm and fact-based and he is proud to have delivered numerous collaborative/ICS projects being able to engage positively across multiple stakeholders, specialisms and styles to achieve outcomes around aligned goals.
Outside of work his passions are almost all sports (mainly watching nowadays although can be found trying to find his wayward golf balls in the woods / long grass / water) and spending time with family, including Rump the cocker spaniel who is also the honorary office dog.
For more details, please get in touch with Scott Healy, who leads our Financial Improvement offering.
