Case Study

ICS Procurement Collaborative

We supported the design, development, and implementation of a collaborative procurement function across North East London, including the delivery of over £1m in savings on non-pay spend, service specific ICS category strategies, and standardised processes

INSIGHT

North East London (NEL) are one of the largest integrated care systems across England, formed of five Trusts, with a total third-party, non-pay spend over £1.2bn.

Akeso were engaged to analyse this spend and deliver £1m in cost savings efficiencies through the collaborative model, in addition to designing a new operating model for procurement services, develop collaborative category strategies, and transform singular service provisions into integrated delivery models.

ACTION

  • Akeso developed an initial opportunity assessment analysing the ICS’s total £1.2bn non-pay spend (60% non-clinical products and services; 19% clinical products and services; and 21% on drugs)
  • From this, Akeso delivered a series of collaborative opportunity recommendations, which ranged from 3rd-party spend cost reduction initiatives to yield ‘hard’ benefits, to ‘softer’ service enhancement and capability development initiatives
  • We developed an overarching governance and reporting structure to track opportunities and value delivery and designed a detailed workstream and category management structure and supported value-delivery projects including; CIPs, procurement exercises, strategy design, and business case development across clinical products and services, estates and facilities, corporate services, and IT, data, and systems

RESULTS

Across the programme we developed and implementation a new collaborative operating model, including an overarching collaborative governance structure, delivered over £1m in collaborative annual savings, developed approved service specific business cases, consistent ways of working, processes, standardised templates, and the upskilling of NEL team members

NEL team

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Peter Marshall

Peter Marshall

Associate Director
Insight

Financial Improvement Plans: Schemes to Target Outcomes

In the first article of Akeso’s financial improvement series, we set the scene on the financial challenge faced by NHS organisations and Integrated Care Boards (ICBs) and outlined the opportunities to leverage tangible savings within differing time horizons.

In this article, we share examples of the proven efficiency and savings schemes that Akeso have supported our clients to implement, which also address clinical, operational, and patient challenges.

Short-term

Quick-win initiatives with in-year benefits realisation, and tactical savings in as little as 3 to 6 months:

Controlling costs by reducing the use of inappropriate products and services, whilst finding feasible ways to change spend patterns throughout the organisation is key to managing demand. Additionally, implementation of robust stock management principles reduces excess stock and releases clinical time to care, whilst ensuring staff have the correct type and number of items at the correct time for safe and effective care delivery.

Conducting detailed reviews with budget holder input to identify all types of discretionary spend. Outputs from reviews support data-informed decisions to implement the necessary controls, governance, and tracking across organisations. For example, highlighting inflated contract spend for renegotiation, and non-essential ad-hoc spend.

Clinicians should also be engaged to develop an exclusion list to protect budgets, where necessary

At a provider level, implementing process improvement to focus on reducing agency spend. At a system level, partners working collaboratively to operate joint banks, aligning agency rates across the system, and sharing specialised clinical resource, rather than competing to recruit from the same pool.

Reducing expenditure on non-clinical staffing should be a priority.

Medium-term

Schemes delivering within one to two years:

Use of data, technology, and digitalisation to automate processes, reduce administrative burden, and provide care closer to home, whilst releasing staff time and resources through:

  • Robotic Process Automation (RPA) for both front office activities, for example patient administration, and corporate services, for example Finance and HR systems.
  • Inventory Management and Point of Care solutions. A recent NHS Supply Chain (NHSSC)review found ‘improved inventory management represents the most significant cash-releasing saving and operational efficiency available in supply chain management within the NHS’[1].

Implementing best practice initiatives, such as improved discharge planning, to reduce length of stay, release of escalation beds, and increase income through delivery of more elective operations.

Akeso have a Discharge to Assess (D2A) and community support maturity matrix that helps acute Trusts, local authorities and ICBs to understand the fundamental requirements for D2A to be a success[2].

Out-of-hospital programmes, including virtual wards and remote monitoring, enable release of bed days and improve patient outcomes through admission avoidance and delayed discharges, supported by a well-defined benefits framework[3].

Virtual ward schemes are essential if we are to meet the national target of 50 Virtual Wards per 100,000 population.

At a provider level, informed by Getting it Right First Time (GIRFT) benchmarking, the focus is on improving productivity through booking procedures, scheduling, and improving staff skill mix.

At a system level, supporting providers in moving procedures to the most appropriate setting, e.g., from traditional theatres to community and outpatient settings, as well maximising the use of digital tools for virtual care, where appropriate.

Long-term

Opportunities to realise savings after two years, with strategic programmes delivering five years and beyond.

Population Health Management analytics and benchmarking support optimisation of resources and best-practice clinically led care across pathways. Examples include:

  • Innovative cross-pathway workforce models such as use of advanced practitioners and nursing staff in the community and acute settings, recognising current recruitment constraints.
  • Improving workforce productivity and elective recovery by using analytical tools to understand, predict and plan for system-wide capacity and demand.

Self-management of chronic conditions such as asthma, COPD, and diabetes. Recent evidence also suggests prehabilitation is cost effective in reducing the need for surgery, reducing complications by 50% and improving recovery[4].

Establishing Shared Support and Collaborative Functions in clinical support services for systems such as:

  • Regional pathology networks to deliver the recommendations of the Carter report[5] – recognising the capital funding challenge. One in three pathology networks are still running at Trust-level, despite the roadmap to service consolidation published over five years ago[6].
  • Developing innovative pharmacy supply chain functions at an organisation and provider collaborative level, delivering benefits of inventory reduction, net operating cost savings and release of clinical time to care.
  • Implementing collaborative procurement functions to leverage the of economies of scale and switching to evidence based lower priced products.
  • Centralising sterile service functions across providers to promote standardisation and reduce operating costs.

Detailed, system-wide estate planning allows organisations to work together to use their combined estate to share workloads, improve efficiencies, and reduce costs.

Examples of using a shared estate are Integrated Care Centres, to allow co-location of GP surgeries alongside other primary care facilities such as pharmacy and dental services.

Savings can also come from a system approach to the disposal of surplus properties, running costs, and backlog maintenance.

If you would like to find out more information on how Akeso can support you in delivering financial improvement schemes, please get in touch with Scott Healy, who leads our Financial Improvement offering.

The next article in our financial improvement series will focus on one of the longer-term opportunities, which is also a hot topic in public health: the role of ICBs in Population Health Management.

 

References

[1] National rollout of crucial systems will reach just 20 trusts in two years [online]. Available at: https://www.nhsprocurement.org.uk/news/national-rollout-crucial-systems-will-reach-just-20-trusts-two-years

[2] Akeso. I’m a patient get me out of here. 2022. [Online] Available at: https://akeso.co.uk/insights/im-a-patient-get-me-out-of-here/

[3] Akeso. Technology-enabled virtual wards the future of healthcare. 2022. [online] Available at: akeso.co.uk/insights/technology-enabled-virtual-wards-the-future-of-healthcare/

[4] Centre for Perioperative Care (CPOC). 2020. [Online] Available at: https://www.cpoc.org.uk/cpoc-publishes-major-evidence-review-impact-perioperative-care

[5] Carter, P.R. Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles. 2016. Department of Health.

[6] HSJ.  Dozens of Trusts still not sharing single Pathology Service. 2022. [online] Available at: https://www.hsj.co.uk/service-design/dozens-of-trusts-still-not-sharing-single-pathology-service/7033372.article

 

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Scott Healy

Scott Healy

Director
Case studies – newspapers
Case Study

Optometry / Ophthalmology Digitalisation PMO

Akeso were engaged by a London ICS to provide programme management expertise for a NHSx national pilot programme supporting the delivery of an Electronic Eyecare Referral System between community optometry and secondary care ophthalmology

INSIGHT

The Electronic Eyecare Referral System (EeRS) pilot, jointly commissioned by NHS England and NHS Improvement and NHSx in November 2020 was a pilot programme that sought to achieve:

  • Electronic referral management between primary and secondary care
  • The ability to share complex diagnostic images (e.g., Optical Coherence Tomography Scan (OCT scan)

ACTIONS

With EeRS being procured and managed on a regional basis, Akeso were engaged by a London ICS to support the roll-out of EeRS within the region.

Responsible for Programme Management, Akeso were responsible for end-to-end programme implementation accountable to the Programme Board and reporting back into NHSx.z

The Akeso project team were responsible for maintaining oversight of the budget, supplier and contract compliance, and working with a diverse stakeholder group from independent, private and NHS sectors.

With 6 workstreams including Information Governance, Communications, Clinical Safety, Digital Integration, Commissioning and Evaluation, Akeso ensured the project progressed to timeline, with the London region being a national exemplar, with the highest level of optometry engagement as well as being first-movers in implementing a technical integration into secondary care and resolving IG issues.

RESULTS

Owing to Akeso’s programme management support, the proof-of-concept EeRS programme in London was successfully evaluated at the end of Year 1, with a board decision to continue the programme.

The Akeso team facilitated an efficient project roll-off following a short-term extension into Year 2, with the Programme Management moving into BAU activity.

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Olivia Jeffery

Olivia Jeffery

Manager
Case studies – newspapers
Case Study

Bristol Pharmacy Technical Services

Following on from similar work completed with the West Yorkshire Association of Acute Trusts (WYAAT), Akeso were invited to complete and options appraisal and business justification case regarding the future of two Bristol based NHS Trusts and their combined Pharmacy and Technical Services.

INSIGHT

Following Lord Carter of Coles’ 2020 Transforming Aseptic Care in England report, several trusts have been conducting options appraisals with the aim of  investing to modernise facilities, cope with expected demand growth and reduce reliance on non-NHS medication suppliers.

Following work completed with WYAAT, Akeso were tasked with conducting an options appraisal to review the future of a combined pharmacy technical services for University Hospital Bristol and Weston and the North Bristol Trust.

ACTION

We completed an options appraisal starting with site visits, interviews with clinical leads and data gathering sessions to understand the current operational activity.  Following workshop sessions, we defined project specific critical success factors and explored what the options for appraisal could look like.

Through extrapolation of baseline data, we were able to build modelled scenarios for each option over a 25-year period starting with the do nothing and do minimum options which reflected shut down of operations and continuation of as-is operations, respectively.

Modelled scenarios reviewed potential refurbishment of a new on-site facility on the UHBW Trust site and leasing of a new facility off site.  Cost elements were considered from the baseline data and assumptions made following discussions with clinical lead, estate and facilities colleagues, financial colleagues and wider NHS experts.  The preferred option was selected based on CSF and VfM scoring.

RESULTS

Akeso successfully demonstrated that the preferred option will be for a new off site hub facility.

Akeso completed a short form business case in full in line with HMT Five Case Methodology for the preferred option which require initial capital investment of c. £24.5m but result in lifecycle savings of approximately £200m (relative to the do minimum).

Insight

Integrated Care Strategies: Turning rhetoric into reality

Thirty-six draft Integrated Care System (ICS) strategies have now been released with the final 5-year forward plans due to be completed by the early summer.

So, what can we learn from the strategies?

As to be expected, they reflect different levels of maturity and development of systems, which are impacted by current operational pressures.

Common themes across all the strategies are the focus on improving population health using collective resources, reducing health inequalities, as well as the emphasis on longer-term prevention, integration, and personalised care.  The biggest gap in describing key priorities is around how the NHS can support wider social and economic development, perhaps because of the limited definition of what this entails.

Whilst there are nuances in how ICSs define Population Health Management (PHM) it is refreshing to see commonality in how the term is referenced. In general, it is described as using data to allocate resources optimally to population cohorts with the greatest need, and to interventions that add most value. There is also the emphasis on predicting the health and care needs of local people in the future.

Although the strategies tick the box of ‘what’ should be included in an integrated strategy the ‘how’ of implementation has still not been defined.

Akeso have outlined four key challenges that need to be overcome to turn rhetoric to reality.

  1. ICSs capacity to progress longer term objectives such as preventing ill health is at risk from shorter term pressures: There is a risk that ICSs will struggle to make progress on local or longer-term priorities such as increasing healthy life expectancy and reducing avoidable ill-health given the national focus on shorter-term challenges such as the elective care backlogs and A&E waiting times. The recent National Audit Office (NAO) report outlines while 77% of senior ICS staff consider their ICSs intend to invest in preventative measures, only 31% feel they currently have the capacity to.

ICSs need to have the capacity and headspace to focus on prevention, and a framework to develop well defined business cases or evaluations, which set out the timeframe to achieve benefits and the required investment. The DHSC also need publish to its response to its consultation; Advancing our health: prevention in the 2020s.

  1. The NHS and social care continue to maintain separate budgets despite the ambition of integrating services through these new reforms. Therefore, a key priority is to remove system, organisation and workforce barriers so the NHS can work more closely with local government and other partnersto tackle the wider social determinants of health, and the broader issue of health inequalities. It also needs to be clear which improvements ICSs will be specifically accountable for, which are the responsibility of NHS England, and which are wider government responsibilities. This should be helped by the DHSC’s guidance on the scope of pooled and aligned budgets, which is due be released imminently.
  2. Significant workforce challenges across health and care: It is well documented there are critical shortages across the NHS and social care workforce, for example the number of people working in social care fell in 2021/22 for the first time in the least 10 years. The NHS Long Term Plan committed to producing a Workforce Implementation plan by September 2020, this now needs be an urgent priority to set the blueprint for workforce planning at a local level. This should include integrating workforce across health and adult social care, developing new cross-system ways of working, as well as exploring opportunities for system-wide recruitment and deployment, informed by joined-up workforce planning and skills development.
  3. What will be measured is likely to drive ICS direction and focus: Key system metrics and KPIs have yet to be set for most Integrated Care Systems. A system wide balanced scorecard will need to be agreed by system partners, which is inclusive of domains such as health inequalities, quality, workforce, and finance. The balanced scorecard will need reflect the short, medium, and longer strategy of the ICS, and include carefully selected metrics so reporting is not too onerous. Success measures outlined in the strategies will also need to be turned into ‘SMART’ goals so integrated care partnerships can track and report progress to local people.

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Peter Marshall

Peter Marshall

Associate Director
Case studies – newspapers
Case Study

NHSE South-West Community Diagnostic Hubs

Akeso supported NHSE SW to design and procure a regional CDC service for the South West., built in partnership with the independent sector. Key aspects of our support spanned Commercial Model & Business Case development as well as the full end-to-end procurement delivery to secure the provider partner

INSIGHT

Driven by the recommendations of Professor Sir Mike Richards’ report, Diagnostics: Recovery and Renewal, NHS England South-West (NHSE SW) engaged Akeso as an operational delivery partner to support in the regional roll-out of Community Diagnostic Centres, in partnership with the Independent Sector. The programme aimed to rapidly expand capacity and transform diagnostic provision for the local populations across the seven ICS systems, whilst maintaining ownership of the service.

ACTION

Through our deep understanding of the community diagnostic landscape and procurement expertise, our delivery team supported NHSE SW in the following:

Commercial Model: Akeso developed critical CDC-related business, organisational and operational requirement solutions from the perspective of an “intelligent customer” in order to secure best value-for-money. These included development of optimal clinical service model, integrated workforce strategy, approach to integration of diagnostic technology and digital connectivity with local healthcare providers and an appropriate financial model

Procurement Preparations & Delivery: Akeso managed the end-to-end procurement strategy including facilitation of supply market engagement, development of service specification defining key requirements and mapping CDC processes based on programme vision and objectives, ICS demographic and patient needs and delivered a full and compliant procurement tender and contract award process.

RESULTS

Akeso successfully developed the Commercial Model and procured the Independent Sector provider to form the foundations for joint service delivery with NHS across a ten-year fixed CDC site contract and three-year mobile CDC site contract, with a total worth of £250 million.

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Chris Robson

Chris Robson

Managing Director
Insight

Delivering improvements to discharge practices

At Akeso, we are extremely saddened by the current healthcare crisis caused by the unprecedented NHS capacity constraints which is threatening the lives of so many of us this winter.

According to the latest discussions at No10, the Government’s response to this challenge is an improved discharge to medically fit patients that is enabled by solutions such as virtual wards.

Although programmes such as discharge to assess (D2A) and virtual wards are not new, we welcome the recognition that doing the same but (slightly) better is not going to solve the problem this winter, or in fact any winter going forward.

According to the NHS, there are 12,809 patients fit for discharge who are occupying beds which could be available to save lives. In an analysis by HSJ, 7,000 virtual ward beds exist, but only half of them are occupied.

So, what is causing this disconnect and why aren’t virtual wards that are in place delivering results?

We believe that the system is struggling with uptake due to the lack of mechanisms that offer a partnership platform between healthcare professionals, who must continue to care for patients uninterruptedly, and specialist partners that can facilitate discharge programmes and implement functional virtual wards.

Akeso can offer such a mechanism and work with Trusts to deliver improvements to discharge practices and implement technology enable virtual wards. We can enable this by offering:

  • Demand and capacity analysis to enable care pathway remodelling.
  • Workforce optimisation and empowerment to support discharge and remote care.
  • Project management to ensure programmes and solutions offer evidenced results.
  • Comprehensive guide and methodology which takes a Trust ‘step-by-step’ through business case, implementation, effective management and scaling of virtual wards.

A medically graded virtual ward technology which offers proven discharge results by reducing length of stay of medically fit patients.

We are here to talk and help Trusts and ICSs with a free assessment and actionable plan that can offer results right now!

Together with HSJ and Masimo we’ll be hosting a roundtable which will focus on Virtual Wards and Discharge in March. Watch this space for updates!

Insight

Discharge to Assess: Where the rubber hits the road

There are seven key steps to generating traction and improving the discharge-to-assess pathways. These are a mix of technical development in respect of discharge-to-assess (such as the establishment of agreed patient strata) and the generic challenges of change management (such as engagement, communication, and skills building). The first 3 phases (which are the planning phases) will be broadly sequential but the delivery phases can be run in parallel, as the figure below indicates:

  1. Establish a core guiding coalition: build a small group with representation from the acute, community, and social care teams who will act as the core accountable team.  This team will guide the program to ensure time and resources are well spent.
  2. Understand where you are and why, in order to build the local case for change, including:
    1. Maturity model completion:  complete the self-assessment complete the self-assessment of the Akeso discharge-to-assess maturity model to show where the current system is already fit-for-purpose and where changes need to be made
    2. Internal analysis on “no right to reside” and other key metrics (such as risk adjected length of stay, and elective and cancer waitlist variation) to give additional local relevance
  3. Define the overall model of discharge-to-assess which best suits your location, given the NHS England guidance, known exemplar case studies, and the results from the maturity assessment, including:
    1. Patient stratification: be clear on which patients fall under the category of relevant for discharge-to-assess and how/when they are highlighted
    2. Workforce models: with community and social care partners, develop a sustainable workforce model which meets local population health needs and is achievable with local resources
    3. High-level process: agree what the high-level discharge-to-assess process is which balances discharge efficacy with clinical risk
    4. Technology aspirations: be clear on where technology will help (with both current and potential future systems)
  4. Launch the program of change: take the time to engage with a broad range of stakeholders to lay out the overall aims of the discharge-to-assess program and how it contributes to the aims of the organisation, including:
    1. Vision expected outcomes, and expected timelines: establish what success looks like from an outcome perspective (for example, number of patients remaining in the acute setting with no right to reside; 7-day re-admission rate
    2. Leadership team & resource: ensure that there is sufficient resource ring-fenced to deliver and manage the work, and that senior leaders are actively supportive
    3. Govern and track effectively: embed discharge-to-assess governance within the existing board and directorate mechanisms to ensure its visibility
    4. Communicate plans and progress
      Healthcare team working
    5. Establish portfolio of work: the maturity matrix and case study examples will suggest a wide range of work to be done. It’s important that any portfolio and phasing is chosen which reflects the need and resources available, including:
      1. Pilot and refine: choose 1-2 specific patient groups or services on which to pilot the design where there is both a clear need and support for discharge-to-assess; learn from these pilots and moderate the initial designs as necessary and remember that “getting it right first time” doesn’t apply in this situation! Learning and adapting is part of the process. To aid this, you may want to instigate regular learning cycles (such as Plan-Do-Study-Act) and daily management meetings
      2. Embed and roll-out: broaden the scope of patients and services for whom discharge-to-assess is available, building on the learnings from the pilots (in 1 or 2 further phases)
      3. Business case development: when investment is necessary, put together a robust business case (using recognised approaches such as the HM Treasury 5-case model)N.B. when engaging in technology-driven change, it is very important to ensure that practices are “digital-ready” before they become digitised so take the time to improve ways of working before the technology is available. It is value destroying to embed poor current practice within a new system. Many organisations, therefore, go through two phases of transformation: pre-tech and post-tech availability
    6. Train, support and reward those involved in delivering this new way of working. The pilots will establish local standard methods and learnings. These should be documented and shared with groups involved in subsequent phases of roll-out. The pioneers who drive the change should be given the reward and profile that it deserves.
    7. Communication progress, learnings, and successes, including regular broad updates and particular highlights. Appreciation of the efforts of everyone involved could be included within monthly and annual recognition systems. 

Keeping people healthy and returning them to their usual home after a hospital spell is a key ambition for all those involved in health and social care. There is an even greater imperative to do so given the pressures on the system now (be they workforce, elective backlog or capacity constraints). Discharge-to-assess, enabled by technology is one of the ways in which we can work together to ease this problem. Many organisations are already making this work. We hope that these four articles can encourage more progress for the benefit of citizens and health and social care workers alike.

For a free Discharge-to-assess consultation, please contact us for an initial conversation with our consultants.

Insight

I’m a patient get me out of here

As the first article in this series highlighted, too many people are spending too long in an acute setting, well beyond the point of clinical need.  One in six beds in these hospitals are occupied by patients who would be much better served in their usual place of residence. 

Furthermore, with an elective backlog of almost seven million, one in eight people across England are currently waiting for operations and other types of care, and ambulance response times are at an all-time worse. Unprecedented operational challenges are anticipated for the winter period.

Therefore, it is imperative that post-discharge short-term health and care services increase in capacity, improve in quality and effectiveness, and can support system flow for both urgent and emergency care and elective recovery. Indeed, the new Prime Minister Rishi Sunak has made tackling delayed discharges a key priority and ensuring there is an available workforce in the community to deliver timely care.

To support the safe and timely discharge of patients from hospital and to ensure that people continue to receive the care and support they need after they leave, a wide range of supportive material has been produced grounded in research and practical learnings of existing Discharge to Assess (D2A) models.  The Department of Health and Social Care (DHSC), Local Government Association and the Association of Directors of Adult Social Services (ADASS) have all released guidance for organisations and local systems on implementing best practice Discharge to Assess and community support. These include:

  • Managing transfers of care – A High Impact Change model: Local Government Association (2020)
  • Hospital discharge and community support guidance: Department of Health and Social Care (2022)
  • Quick Guide: Discharge to Assess:  ADASS (2021)

The most recent guidance was outlined in July 2022 by The National Health and Social Care Discharge Taskforce. Based on their learnings from NHS and Social Care pilots, 10 best practice initiatives have been identified. 100-day discharge challenge – Improvement – NHS Transformation Directorate (england.nhs.uk).

Maturity Matrix

From the various national guidelines, alongside discussions working with a number of organisations and systems around D2A, Akeso has developed a D2A and community support maturity matrix. This helps organisations (for example, acute trusts, local authorities and ICSs) to understand what needs to be in place for D2A to work well.  There are 36 factors across 7 different domains which all need to be in place,

The 7 domains, as part of a high-level D2A operating system are set out below:

Figure 1 – D2A operating system
Figure 1 D2A operating system

Key ‘essential’ D2A priorities we recommend organisations focus on, which can be delivered in a phased approach to implementation include:

  • Short term (0-2 months) Discharge Planning: Setting up consistent processes, ensuring early multi-disciplinary engagement and planning for discharge on admission.  This is something that organisations could be progression before winter.
  • Medium/longer term (2-6+) Integrated Team Working: Potentially has the biggest impact for patients and covers 25% of D2A best practice initiatives.  Includes systems optimising workforce capacity acute, community and social care settings, for example from joint team working and a pooled workforce
  • Medium/Longer term (2-6months+): Virtual Wards:  Implementation of a tech enabled virtual ward, would require the appropriate infrastructure, funding and resources to be in place, which has shown to improve patient experience and nursing and clinical workforce productivity

As set out in the D2A operating model, D2A priorities would need to be underpinned by robust leadership and governance, and vitally, the appropriate D2A system-wide culture.

Using this framework, we have also developed a more detailed assessment matrix which allows any organisation to assess their current level of maturity against these factors. Details of what “best practice” looks like across these different factors are shown below.

D2A and Community Support leading practice

Table 1: D2A and Community Support leading practice
Table 1: D2A and Community Support leading practice (text in blue represents the 10 best-practice D2A initiatives identified by the Health and Social Care Taskforce).

We recommend that, as an organisation continues to develop its D2A capability, it uses this D2A maturity matrix to inform the programme of work that is required.  To request Akeso’s D2A maturity matrix, and if your organisation requires any support in implementing D2A best practice initiatives, please contact Mike Meredith.

In addition, based on the D2A maturity matrix, Akeso have put together a short D2A survey for D2A leaders, Organisations and system leaders.  Organisations and systems completing the survey will receive a tailored benchmarking report against their peers.

The next article in this series will focus on how technical innovations, for example tech enabled virtual wards, can improve patient experience and discharge effectiveness, followed by a D2A implementation guide.

Contact our experts

Martin Shiderov

Martin Shiderov

Associate Director
Insight

Discharge to Assess: What You Need to Know

When the new Health Secretary, Therese Coffey, was appointed she detailed her priorities for the NHS. These were A, B, C, D, or in other words, ambulances, backlogs, care, and doctors and dentists.

Critical to the current challenges facing the health system is the ability to create and ensure bed capacity. Currently, one out of every six beds are taken up by a patient who no longer requires it. Furthermore, without this bed capacity, it will be impossible to deliver the ambitions of NHS England’s CEO Amanda Pritchard’s around recovery, reform, resilience, and respect (her “4 Rs”).

With an elective backlog of almost seven million, one in eight people across England are currently waiting for operations and other types of care, and ambulance response times at an all-time worse. Unprecedented operational challenges are anticipated for the winter period.

One of the Government’s responses to this problem is the new Discharge to Assess (D2A) programme. This aims to discharge a greater proportion of patients when they no longer require the direct support of an acute bed. They may require further care but can have their longer-term care and support needs undertaken in a more appropriate setting. Four pathways have been established within this D2A programme. They are summarised below.

Overview Discharge to access model
Figure 1 – Overview Discharge to access model

As in any production flow environment, effective and efficient flow of D2A requires a balance of push and pull on the Hospital and Local Care Organisations respectively.

Discharge Performance

Reasons Behind Delayed Transfers of Care

Before looking to implement solutions to enable the D2A programme, it is imperative to understand the current and historic blockers to discharge. Analysis of delayed transfers of care data highlights these blockers as well as historic performance. Since 2010, there has been a 75% increase discharge delays measured by the increase in volume of additional hospital days resulting from delayed transfers of care.

Figure 2: Delayed transfers of care in hospital days by cause since 2010/11
Figure 2: Delayed transfers of care in hospital days by cause since 2010/11

Due to COVID, and the subsequent operational pressures, DTOC data is no longer published by NHS Digital. In 2019/20, there were 1,600,000 additional hospital days generated by delayed transfers of care.

The most common reason for these delays was the lack of capacity within the residential or nursing care home setting (ARNHP) accounting for a quarter of all delays. The two next greatest discharge blockers were the need to wait for a care package (ACP, 21%) and the need to wait for further non-acute care (AFNAC, 18%). Both of these blockers can be theoretically readily addressed by the discharge to assess programme. However, the ability for systems to combat the greatest blocker, a lack of capacity within the residential or nursing care home setting, in regard to D2A programmes should be carefully considered.

Current Discharge Performance

National data shows that current discharge performance across England varies widely and is significantly below NHSE’s target of discharging half of those with no right to reside, with an average discharge performance rate of 43%.[2] This equates to almost 3,000,000 instances over nine months where a patient was eligible for a discharge but remained in hospital. Or, in other words, 12,000 patients everyday remain in hospital when they should be discharged.

Figure 3: Regional discharge performance overview, from Nov-21 to Jul-22
Figure 3: Regional discharge performance overview, from Nov-21 to Jul-22

Furthermore, London is the only region achieving a discharge rate of half of patients who are eligible at 53%. All other regions are below this threshold. The South West and North West regions have both been operating at an average discharge rate of 34%. In fact, London is the only region performing stronger now than in winter 2021.

Analysis at an ICB-level portrays a similar message; performance is widely variable. On one hand, the highest performing ICS, Northumberland, Tyne, and Wear achieved an average discharge of 73%, whereas the lowest performing ICS, Birmingham and Solihull, achieved 17%.

Only 14 of the 44 ICS’s achieved an average performance rate of above 50% (full details of discharge performance by ICS can be seen within the appendix). Moreover, the South West region were the only region not to have an ICS currently meeting this target.

Figure 4: Average discharge performance by ICS and region based on percentage discharged of eligible patients, from Nov-21 to Jul-22
Figure 4: Average discharge performance by ICS and region based on percentage discharged of eligible patients, from Nov-21 to Jul-22

We further analysed discharge performance in terms of acute trust type which identified no significant trend. With exception for multi specialist trusts, performance follows the same profile. Regarding the scale or of Trust, suggesting that the economies of scale for large acute trusts, or the localised focus of smaller trusts, are not factors in discharge performance.

Figure 5 - Discharge perf
Figure 5: Discharge performance by acute trust type based on percentage discharged of eligible patients, from Nov-21 to Jul-22 (week 54 corresponds to 26/12/21 to 01/01/22

When looked at Trust level, there is again wide performance variation. The top-5 performing Trusts average ~78% discharge performance, whereas the bottom-5 Trusts average ~16%.

Figure 6: Discharge performance of the top and bottom-5 trusts, from Nov-21 to Jul-22
Figure 6: Discharge performance of the top and bottom-5 trusts, from Nov-21 to Jul-22

Responding to the discharge problem

Analysing the top and bottom-5 trusts in greater detail, it is apparent that Trust from all regions and types feature at both ends of the spectrum. The question, therefore, is what does this tell us about how providers can better respond to their discharge problems?

In answering this question, it is important to acknowledge that the analysis clearly points to this issue being universal. That is to say that discharge performance is not seemingly affected by geography, locality, Trust type or provision, or indeed by system, evidenced by wide ranging variation with ICS’s. The responses to the problem can therefore not be generic in line with the above factors. They must be organisational specific, in line with providers individual caseloads, models of care, and local leadership.

Appendix: D2A Performance by ICB
Appendix: D2A Performance by ICB

Various supportive materials, based on research and practical learnings from existing discharge-to-assess models, have been produced to encourage the adoption of discharge-to-assess principles in health and social care settings, in an effort to reduce the number of patients in acute settings with no right to stay.

All of this material has been summarized by Akeso into one useful framework. The next article in this series will focus on this framework designed to help ICSs and other organizations better understand what D2A requires in order to be successful.

References

[1] Akeso analysis of NHSE reported Delayed Transfers of Care, 2010-11 to 2019-20 – Number of Delayed Days during the reporting period, Acute and Non-Acute, for NHS Organisations in England by the type of care that the patient was receiving. https://www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/delayed-transfers-of-care-data-2019-20/

[2] Akeso analysis of NHSE reported Covid-19 Daily Discharge Situation Report – All patients for 29 November 2021 – 30 July 2022. This data contains all inpatients 18 and over, including critical care and COVID-19 positive patients, but excluding paediatrics, maternity, and deceased patients. This includes data for acute trusts with a type 1 A&E department. Mental Health Trusts, specialised Trusts (including Children’s and Women’s Trusts) are not in scope of this collection.

Insight

Technology-enabled Virtual Wards

How hospital grade remote monitoring technology can enable the delivery of high-impact patient outcomes.

Technology-enabled Virtual Wards have arrived, are you ready?

The NHS must establish 24,000 Virtual Ward beds by December 2023 to support a targeted increase of 30% in elective care procedures by 2025. The delivery of effective ‘in-hospital’ patient care depends on reliable communication, monitoring, and alerts. Maintaining this level of care efficiently and effectively in a Virtual Ward, outside of the hospital, requires reliable, trusted, proven and privacy-compliant solutions for timely detection, prevention, and treatment. Masimo SafetyNet® is a Digital Health platform from Masimo, whose innovative monitoring products have been in use across the NHS for over 15 years, with a proven track record of success.

Masimo SafetyNet is an example of Virtual Ward enabling technology

Virtual ward chart

For Patients: Technology-enabled Virtual Wards help assure higher-acuity patients that they remain under the watchful eye of clinicians even following discharge to their own home.​

For Acute Care Providers: Masimo SafetyNet offers advanced automation features so institutions can more easily deploy home monitoring, track patient compliance, identify when intervention may be required, and prioritise patient needs whilst maintaining the ability to scale up to meet patient demand.​

For NHS Leaders: Masimo SafetyNet is an effective, easily deployed turnkey solution designed to address the challenge of rapidly establishing and operating Virtual Wards whilst optimising use of clinical resources.

​For an average sized2 NHS Trust, a robust technology-enabled Virtual Ward could…

Tech enabled ward example
The above figures are estimates, for further detail on inputs for the analysis, please see the references below 3, 4.​

Masimo offers an end-to-end approach to help NHS providers implement Virtual Wards with the Masimo SafetyNet app currently available at no charge for NHS Trusts. ​

Deployment launched across the NHS; contact Masimo to activate your site!

uksales@masimo.com | + 44 (0)1256 479988

Case studies – newspapers
Case Study

Development of Business Cases for Scan4Safety Demonstrator Sites

In 2014, the Department of Health (DH) commenced an ambitious program, Scan4Safety, to transform the way that the NHS manages the numerous interventions that take place in NHS Providers at all points of care delivery everyday, both internally and externally with suppliers. The DH invited outline business case applications from NHS Provider Trusts interested in being one of six NHS demonstrator sites, who would be awarded investment of up to £2m to act as early adopters and communicate the benefits of Scan4Safety.
Working with a large top-tier Consultancy, we were engaged as a subject matter expert to deliver four of the final 12 Outline Business Cases, leveraging our direct experience of delivering transformational projects in the NHS involving technologies and solutions covered by Scan4Safety. We worked with a number of leading academic NHS Trusts around their process maturity and eProcurement capabilities. Our directors have presented on the topic at a number of events in the UK and the US, on behalf of GS1 and other organisations.

INSIGHT

The benefits of Scan4Safety adoption are significant: improved transactional efficiency, improved traceability and risk reduction, inventory and wastage reduction, released clinical time to patient care – all of which lead to improved patient outcomes and safety.
We have extensive experience of Scan4Safety relevant technologies including a number of Use and Enabler cases. We brought a number of methodologies and tools, including Hospital Supply Chain Maturity Framework and Diagnostics Tools, Financial Modelling and Market Studies of Healthcare Inventory Management and Procure-to-Pay systems.

ACTION

We analysed submissions from applicant NHS Providers. We engaged key stakeholders in organisations at all levels up to an including Executive, to validate the ambition levels within each of the four Trusts.
We developed a comprehensive business case framework for the final applications, based on the HM Treasury Blue Book methodology. We worked closely with applicant Trusts to complete the comprehensive business cases This included engagement with external suppliers, modelling of solution options as well as development and costing of implementation plans to take forward if successful.
We then developed four final recommendations and business case applications for DH Board approval.

RESULTS

Three of the four applications validated by us were successful in securing investment of up to £2m, as part of the six NHS providers selected as Scan4Safety demonstrator sites.

Contact our experts

Peter Marshall

Peter Marshall

Associate Director
Insight

Creating more effective Estates and Facilities strategies through the Integrated Care Systems model

Estates and facilities (E&F) management plays a critical role in the delivery of all healthcare services. Every department or location depends on E&F services, with each facing unique challenges. These challenges have been significantly exacerbated by recent events such as the COVID-19 pandemic and Brexit, which have placed even greater pressures on supply chains and staff.

That is why overcoming these challenges and developing robust facilities management (FM) strategies, which ensure spaces are clinically safe, fit for purpose and able to flexibly meet patient demand, is increasingly becoming a key priority for Trusts.

In this article, we will look at the opportunities the shift to an integrated care system (ICS), presents and how your Trust can leverage them.

The key Estates and Facilities challenges Trusts are facing

Before examining the potential of an ICS to transform E&F provision, it is worth taking a closer look at some of the common pressures and challenges that are impacting Trusts across the NHS.

Perhaps most stark, is the current level of backlog maintenance. At the end of the last financial year the total cost to eradicate backlog maintenance stood at more than £9bn. This is around 20% more than the NHS’s entire capital budget of £7bn, with acute settings requiring 85% greater expenditure per square metre than community settings.

Creating more effective estates graph

Impacting a Trust’s ability to address this issue is a lack of capital and labour. There has been no long-term capital commitment from the government for E&F and there was no reference to the NHS estate in the November spending review, other than what had previously been outlined in the Long-Term Plan (LTP) and Health Infrastructure Plan (HIP). The emphasis remains on ambitious building projects rather than how to meet the maintenance needs.

On the labour side, the sector is struggling with the same supply issues as many others in the wake of COVID-19 and Brexit, making it harder to complete necessary tasks. But failing to maintain E&F correctly, will present risks to patient safety. Indeed, analysis by The King’s Fund suggests more than 5,000 clinical service incidents are caused by E&F failures each year.

Looking ahead, the function and form of E&F is changing. For the past 20 to 30 years estates have been constructed for a particular purpose, but it has become clear flexibility needs to be embedded in the design to allow Healthcare settings to adapt to shifting patient demand. Alongside this, net zero is now a core principle.

Developing an ICS model to address these challenges

Into this mix of challenges, the ICS model brings complexity. Formations of ICS’s as legal entities will become a statutory requirement from the 1st of July 2022 and understanding the different service provisions and settings that come under the umbrella of an ICS, will be critical to successfully adapting to this new landscape.

But with this complexity comes a number of advantages associated with having control over an entire ICS estate, and being able to make decisions that benefit the whole ICS.

Historically speaking, Trusts have arranged the delivery of their E&F services in one of four models, which must be understood in the context of an ICS:

  • Bundled services – Several single services contracted directly with the same supplier. One of the benefits here is improving negotiating power and potentially reducing the number of suppliers needed.
  • Fully integrated services – A service provider self-delivers all services, with some limited subcontracting. The key benefit is economies of scale and the ability to provide consistent service specifications and performance standards across an entire ICS.
  • Agent model – Management functions are carried out by an agent allowing them to focus on cost reduction and management excellence.
  • Total property outsourcing – A complete outsourcing of an ICS’s property needs to be done in a consortium of, for example, private sector finance groups.

The first two models are the most common, but the circumstances of individual ICSs will determine which is the most appropriate path to follow. In each case, a joined-up ICS-wide approach will enable Trust’s to seize opportunities that are emerging across hard FM, soft FM and utilities.

For example, the recent increases in virtual care and working will enable an ICS to re-examine their entire portfolio of sites and optimise for the requirements of the future.

There will also be numerous opportunities to create synergies and efficiencies, including:

  • Re-distributing service lines according to new organisational, geographic and category types.
  • Unifying maintenance contracts across sites.
  • Strategic sourcing and economies of scale throughout the supply chain.
  • Performance tracking and relationship management.
  • Greater career opportunities for the workforce.

Similarly, utilities consumption will be able to be monitored across different settings and supply consolidated where it makes sense to do so. Moreover, the ICS model will also enable larger group purchasing, which will strengthen the ability to weather the significant sector and price instability currently being experienced.

Understanding the opportunities of an ICS

To take the E&F opportunities available to them, Trusts must first be able to identify how effective their current E&F provision is within the context of their ICS.

Akeso & Co’s E&F dashboard has been developed to provide this capability. Its data-driven insights will support Trusts to devise an E&F strategy in several ways, including:

  • The ability to focus on key areas of E&F management to provide a clearer view of how each compares to NHS E&F management across England.
  • The ability to target analysis of a specific Trust or group level to identify organisations that can provide transformational advice.
  • The ability to benchmark within an ICS or on a national level to understand where best performance is and to develop new strategies.
  • The ability to filter information and drill down into it to understand a range of cost profiles at different organisational levels and identify opportunities for improvement.
  • The capacity to evaluate key metrics to understand potential future regional or organisational challenges.

As the ICS model becomes fully embedded in the NHS, Trusts must actively engage with the potential benefits on offer to realise them.

Tools such as Akeso & Co’s dashboard bring visibility and understanding to the complexities involved, enabling them to identify opportunities and take them.

If you would like a demonstration, please do get in touch with Debora Salvado at debora.salvado@akeso.co.ukdebora.salvado@akeso.co.uk.

A door to redesigning a one of a kind NHS shared service facility
Case Study

Redesigning a one-of-a-kind NHS shared service facility

We’ve helped shape the NHS Wales Shared Services Partnership (NWSSP)’s long-term use and vision of a one-of-a-kind NHS physical shared service facility.

NHS Wales Shared Services Partnership – Potential

Challenge

In 2018, Welsh Government acquired a 275,000 sq.ft. warehouse in Newport to store core medical supplies as part of the EU Exit preparations. Longer term, the Welsh Government intended that the warehouse would be a strategic investment for Wales. NWSSP were responsible for defining the future shared service opportunity and asked us to develop a strategic outline case, demonstrating that the facility could generate broad benefit to Wales and be financially sustainable in the future.

NHS Wales Shared Services Partnership – Opportunities

Solution

We understood the importance of maximising the warehouse’s potential to contribute towards NHS Wales and broader government strategic priorities. We broke the project into four phases to determine how best to respond to the opportunity.

The first was to engage with key stakeholders to identify how everyone might benefit from the warehouse. The second was to evaluate service options that could deliver clinical, social, operational, and financial benefits for the Welsh Healthcare system. The third was to outline how the warehouse space could be best configured to support different functions and balance a range of benefit opportunities. And the final phase was to draft the strategic outline case and recommend the preferred future option for the Welsh government’s approval.

NHS Wales Shared Services Partnership – ROI

Results

The NWSSP Executive approved the preferred option and ring-fenced ongoing funding, with the adopted approach estimated to generate over £8m in benefits over the next 10 years. The recommended configuration will serve as a cornerstone for key Welsh strategies including the Wellbeing of Future Generations Act, Taking Wales Forwards and A Healthier Wales. It also provides an opportunity to fast track and accommodate initiatives already underway, including the Transforming Access to Medicines Programme.

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Peter Marshall

Peter Marshall

Associate Director
Guys and St Thomas Hospital
Case Study

Facilities Management Cost Reduction

Guy’s & St Thomas NHS Foundation Trust (GSTT) comprises two of London’s best known teaching hospitals, St Thomas’ Hospital and Guy’s Hospital, providing a full range of hospital services to the local community and specialist services nationally. GSTT is one of the largest Trusts in the UK with a turnover of almost £1.5bn and 15k staff, treating over 2.4m patients per year, including 88k inpatients,103k day cases, 1.2m outpatients and 800k patients in community services.
GSTT operates a wholly owned subsidiary, Essentia, which provides Facilities Management (FM) for GSTT. Essentia was challenged to deliver cost savings, improve service quality and manage an aging asset base to maintain uptime through a blend of in-house and externally contracted services. Akeso&Co were engaged by Essentia to complete a total cost review of the Hard Facilities Management service (Engineering and Building Maintenance) to identify near term and long-term cost reduction and operational efficiency opportunities in 3rd party spend and the internal service.

Insight

Essentia was challenged to deliver cost savings in addition to assuring service quality and maintaining an aging and diverse asset base, with very limited funds for investment. We brought a number of methodologies, tools and experiences to support the client through each stage of the project including a proven Opportunity Assessment approach, Capability Development (People & Organisation, Process and Systems) and Hard Facilities Management-relevant Category and Market Intelligence.

Action

In Phase 1, our consultants led the process to identify the value through benchmarking GSTT to peer Trusts in terms of scale/ size and location using latest Estates Return data from NHS Digital. We completed in depth reviews and analysis for a number of key product and service contracts with the client and incumbent providers to evaluate fulfilment of requirements and to develop strategies to improve performance and leverage benefits where suppliers were failing to meet performance standards. We then prepared a Board level recommendation for a Programme Delivery setting out a range of tactical and strategic options.

In Phase 2, we designed and led a joint Consultant:Client delivery program to implement the recommendations. We developed and ran multiple Tenders, which included soft supplier market engagement, the development of output based specifications and the design of contract models that would permit the involvement of local SME providers. We finally designed and costed a detailed process improvement plan to transform the end-to-end Hard FM Callout process handling 50k callouts per year.

Results

We established and mobilised a structured Trust-wide improvement programme which delivered savings and improvements across all areas of Engineering and Building Maintenance to improve customer service and regulatory compliance and reduce cost to serve.

Contact our experts

Scott Healy

Scott Healy

Director