THE B USINESS SERVICES ASSOCIATION
Lord Carter Review: BSA Response May 2016
ABOUT THE BSA The BSA is a policy and research organisation. It brings together all those who are interested in delivering efficient, flexible and cost‑effective service and infrastructure projects across the private and public sectors. Research conducted by Oxford Economics, commissioned by the BSA, shows that business service providers make a huge contribution to jobs and prosperity in every part of Britain. The sector accounts for over 9 per cent of gross value added to the economy and provides 3.3 million jobs, equivalent to over 10 per cent of all UK workforce jobs. More than two thirds of business services are provided for the private sector, with the remainder commissioned by the public sector.
Introduction BSA healthcare members work on the basis of supporting the NHS through collaboration and partnership. They offer services as diverse as catering, estates management, ICT, transportation, portering, back-office administration and more. We support many of the recommendations put forward in Lord Carter’s review. The private sector, with it’s involvement in other markets besides health, has the capability of adopting an integrated approach and avoiding working within silos. The Business Services Association 2nd Floor 130 Fleet Street London EC4A 2BH 020 7822 7420 www.bsa-org.com The Business Services Association Limited is registered in England No. 2834529 Registered office as above. Designed by Soapbox www.soapbox.co.uk
We believe that the best way private providers can contribute towards improving NHS efficiency is through further and deeper collaboration with hospital trusts. Savings targets provide a useful starting point to bring about the cultural and operational changes required to improve hospital efficiency. This note sets out the BSA’s response to the review and ideas for how efficiencies can be implemented.
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Estates The BSA recommends the establishment of a ring-fenced fund using money raised by individual trusts through property sales or leases. This money can help fund the transformation needed to deliver a trust’s care priorities. An additional benefit would be incentivising a commercial approach to estate management.
Money raised from a more efficient estate can help fund the transformations needed to deliver a trust’s care priorities
Currently, individual NHS trusts don’t retain money generated from the sale of buildings, offering little incentive to dispose of underused assets. The figures outlined in Lord Carter’s final report regarding space used by trusts for non-clinical purposes range from 12% - 69%. Research from elsewhere suggests the amount of unused and underused floor space in the NHS adds up to the equivalent of 14 hospital trusts. This clearly demonstrates the cost-saving potential of a more commercialised approach to estates management. Further to this, individual control of estates funding, combined with a commercial approach, would allow trusts to explore alternative revenue raising ideas, such as the leasing or hiring out of underused buildings. Partnering with private providers can help facilitate said commercial approach by improving access to finance and establishing joint ventures focused on estates management. BSA members are already delivering NHS estate improvements through such ventures.
Case study: Kier Construction & NHS Trusts Kier Construction has worked with a range of NHS trusts, helping them to reconfigure and redesign their estates. Such reconfigurations have helped the trusts involved apply improved operational efficiencies to underused or surplus parts of their estate. Tailored programmes have been introduced to transform both how patients are cared for and how the trust estate is managed. An example would be the use of underused buildings to house patients medically fit for discharge but require significant help with mobilisation before going home. Kier Construction found in this instance that adopting the trust estate in such a way helped reduce the length of a patient’s stay by 25%, with the figure projected to increase to 35 - 40% once performance gains are fully consolidated. Additionally, by treating patients in a focused clinical setting, costs were lowered through operational efficiencies not achievable when staying in higher acuity general surgical and medical wards.
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ICT and Technology ICT and digitisation offers the NHS a significant opportunity to transform how services are designed and delivered. Enhanced digital technology can allow data to be collated more comprehensively and geared towards reducing unnecessary expense. When harnessed effectively, technology can be used to significantly reduce unneeded admissions. Cost-savings associated with practical telehealth options used by patients can offer a ‘better of less’ scenario. Additionally, mobile technology offers the NHS a chance to become more efficient and improve patient experience. Simple measures such as allowing patients to order meals on computer tablets can improve their experience and save staff time.
When harnessed effectively, technology can be used to significantly reduce unnecessary admissions
Technology can also be harnessed to improve service quality by installing interactive screens at key points in the hospital, allowing patients to review facilities and alert staff to problems. Such a system could also allow (where appropriate) patients to rate services they receive, creating a data pool for hospitals to identify areas for improvement. This would provide real time data on patient experience allowing an effective targeting of resources. The ‘Happy Dubai’ initiative puts this dashboard principle into practice. Using screens placed around the city, authorities better understand how satisfied users are with municipal services. A similar NHS programme would allow patients to feel more involved in shaping the type and quality of service they receive.
Case study: Capita & Australia’s National Online Health Service Capita Healthcare Decisions worked with Healthdirect Australia to help people check symptoms online and receive personalised healthcare advice. With over 80% of Australians seeking health information online Healthdirect Australia recognised the importance of ensuring that the information they are accessing is safe, relevant and trustworthy. In response they developed the Healthdirect Symptom Checker – an online tool which allows people to check their symptoms and receive personalised advice on what healthcare action to take next. Healthdirect Australia chose Capita’s Decision Management Software (DMS) to power Symptom Checker. The DMS allows the organisation to aggregate its own verified content and present it to consumers online through Capita’s Application Programming Interface (API). Capita’s DMS and API significantly reduced the time taken to populate the Symptom Checker flows with verified clinical content, and changes and updates required are simple to undertake.
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Administrative NHS administration and back-office costs, as identified by Lord Carter, account for approximately ÂŁ4.3bn, nearly 4%, of total NHS spending. Carter points out that admin variation across NHS trusts ranges from 6% to 11%.
Strategic partnerships can allow providers to introduce a common set of services, processes and standards aimed at reducing variation
Strategic partnerships can allow providers to introduce a common set of services, processes and standards aimed at reducing variation. By adopting a partnership, rather than transactional approach, NHS organisations can learn from the prior experience, expertise and innovation of commercial providers. Performance improvement, in terms of cost and quality, can best be achieved through transformation of the way patient administration services are provided. This requires, for example, investment in appropriate technologies, including information systems and various forms of automation or self-service; introduction of lean operational processes; investment in workforce training; performance management and service leadership. To optimise the operational model also requires changes in working practices in the wider hospital system such as, for example, the way that consultants vet referrals. If you are going to exploit the significant advantages of digital workflow, then the role of hard copy and even faxes has to be “re-imagined�.
Case study: Serco & NHS Trusts Serco has worked with two innovative NHS trusts, one of them multi-site, to identify, quantify and plan to deliver transformational improvements in patient administration and are now working with a third. The core services addressed are typically: appointment booking, capacity scheduling, receptions, switchboard and help desk, post room and patient information (secretarial and medical records), patient experience and ward clerking. Despite concerns that such significant changes would be resisted, Serco found that by creating confidence in the alternative and demonstrating benefits to all parties the encountered enthusiasm for the smart use of technology and the release of time that can be better used, for example, for patient care.
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Workforce
E-Rostering offers a practical solution for improving staff efficiency and reducing dependence on agency workers
E-Rostering offers a practical and readily available solution for improving the efficiency of staff resources and reducing dependency on agency workers. It offers a potential small change that can ensure workforces are managed more efficiently. Establishing a clear and easy to understand system of electronic staff timetabling will allow managers and staff to quickly see the upcoming work schedule. This in turn has the potential to save man hours which can then be dedicated to the delivery of patient care. Such a system will also allow hospital managers to spot, in real time, where workforce inefficiencies are arising and help avoid the expensive last-resort of using agency staff. A number of BSA members offer and have already implemented e-rostering programmes at NHS trusts across the country.
Case study: Allocate & North Lincolnshire & Goole NHS Trust Allocate, using their software programme, helped improve the e-rostering system used by North Lincolnshire & Goole NHS Foundation Trust. The trust had been using e-rostering for a number of years previously, but hadn’t been able to effectively embed it into the hospital system. It was an add-on, rather than a replacement, for what roster creators were doing before. Incentives were created to get staff to use the system more effectively, such as moving the booking of requests for annual and study leave onto the system, helping influence when staff were able to take time off. Additionally, roster-managers were encouraged to use the ‘autoroster’ feature, significantly improving the efficiency of allocating frontline staff to the correct shifts. Regarding the improvements in e-rostering, Marcus Hassall from the Trust said ‘Across 10 wards we could evidence savings averaging £60,000 per ward. But we have also improved patient care by using our restricted resources better’.
Procurement
It is important procurement is conducted in an open and trusting manner from the start
It is important procurement is conducted in an open and trusting manner from the start. Too often the relationship between commissioners and providers can become rigid. A flexible relationship is essential to ensuring efficiency gains are made through strategic partnerships. Such flexibility will help both parties to adapt when circumstances change. Additionally, straighforward measures such as the introduction of a suitably responsible point person on both sides of a contract, coupled with regular meetings, will help to improve contract management. Other practices, such as a proper handover when relevant people move jobs, should be conducted as standard and contribute towards reducing inefficiency.
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Private providers can also play a significant role in helping trusts reorganise their procurement functions. BSA members have experience of becoming part of the trust’s procurement teams, combining their staff with NHS staff and working together as one unit for streamlining purchasing procedures. Innovative contracts, such as ones where the trust retains all associated savings, offer trusts an incentive to explore options for revamping their procurement.
Case study: Serco Group & District General Hospitals Serco worked with two NHS trusts, both mid-sized DGHs of over 1,000 and 800 beds respectively, tasked with redesigning the Trust procurement functions in order to deliver multi £m cost savings. The two contracts provided full service provisions of procurement, logistics and associated financial processes and had commitments baked into the commercial structure of contracts to deliver a long term reduction in the Trusts non-pay spend from the start. Flexible and mobile Serco category management and sourcing experts were inserted into the client’s existing team to create a single team managed by Serco, leveraging shared support services to maximise procurement savings. We reviewed supply chains for all goods which may deliver efficiencies in customers’ existing materials management activities. Serco used the TUPE transfer of existing staff to bring them into our procurement team. The additional resources, staff training, clear personal objectives, introduction of new procurement systems and access to shared service category management experts were vital to driving cost savings.
Pathology Transformation requires investment and expertise to deliver an efficient model on time and on budget
There is an evident need to reduce the number of inefficient laboratories, as outlined by Lord Carter’s report. This can be achieved by moving to networked pathology models – known as hubs and spokes – to improve quality of testing and cost effectiveness. There are examples of the private sector already successfully delivering pathology services across the country in partnership with the NHS. Such partnerships have demonstrated the potential for service improvement and efficiency savings to be made. Transformation requires investment and expertise to deliver an efficient model on time and on budget. Hub and spoke models in the UK and Europe have demonstrated improved quality and speed by separating urgent testing, which continues to be delivered close to patients on site at hospitals, from routine testing which is delivered from state-of-the-art, highly automated hub laboratories.
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Hub laboratories handle tests from primary care, as well as tests from hospitals that require same or next day turnaround. These large scale hub laboratories can handle testing volumes from many hospitals and also offer the service to general practice which can compete with NHS hospital labs to offer a faster, more cost effective service with improved quality. In order to realise the savings potential a hub and spoke model offers, investment is needed to design and build new laboratories, restructure existing processes and working practices and deliver new equipment. Guidance for hospital labs looking to calculate whether or not they are meeting the targets set out in Lord Carter’s reports is crucial for ensuring improvement. Many labs will not include the full costs of delivering pathology such as the hospital overheads and central costs which favourably skews the costs of pathology. The BSA recommends that a template is produced so that all hospital labs can be compared on a like-for-like basis to be able to fairly assess which are efficient and which require significant improvement to meet the deadline set by Lord Carter of April 2017.
Case study: Integrated Pathology Partnerships & Somerset Pathology Services Pathology services in Somerset were transformed with all ‘routine work,’ apart from histopathology, being delivered by a new state of the art, off-site, Hub laboratory. The hospital based laboratories were remodelled into essential service laboratories (ESL) to handle urgent testing requests requiring fast turnaround. This redesign was achieved by the original pathology staff working together with the IPP team to produce a more effective delivery model fit for the local health economy. Previously, GP work had been saturating the hospital laboratories during the early evening. Now, by splitting the ‘hospital in-patient’ work from the ‘cold work,’ turnaround times within the hospitals and for GPs has improved. Today, in excess of 95% of GP work is routinely reported by the following morning and there have been reductions of around 25% in average turnaround times for both urgent and routine blood tests within both hospitals. In addition, 95% of tests are now available within 74 and 124 minutes respectively (compared to 133 and 257 minutes previously). Within A&E, turnaround times in specific cases have reduced by 22% for urgent and 29% for non-urgent tests. Variation has also been reduced and the A&E doctors are now confident that they can expect to get critical tests back faster and more often with a positive impact on patient pathways.
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APPENDIX – LIST OF BSA MEMBERS
Full members
Associate members
Accenture plc AECOM Amey plc ARAMARK Ltd Atos Balfour Beatty plc Bellrock Ltd Berendsen plc Bouygues Energies and Services British Telecommunications plc Capita plc Carillion plc Compass Group plc Costain Group plc Elior UK Ltd ENGIE UK & Ireland Freidman FM G4S plc Ingeus UK Ltd Interserve plc ISS UK Ltd Kier Group plc Maximus UK Ltd Mitie Group plc MYFM Ltd NSL OCS Group UK Ltd Optum Health Solutions UK Ltd PeoplePlus Pinnacle Group Prospects Services Ltd Seetec Group Ltd Serco Group plc Sodexo Ltd Sopra Steria Ltd TerraQuest Solutions Ltd Veolia (UK) Ltd VINCI Facilities
Barclays Corporate Bevan Brittan LLP Clyde & Co LLP Deloitte DWF LLP ECI Partners Ernst & Young LLP Grant Thornton LLP Interim Partners KPMG LLP Metzger Ltd Nabarro LLP New Street PA Consulting Ltd Pinsent Masons LLP PricewaterhouseCoopers UK Reynolds Porter Chamberlain Royal Bank of Scotland Group Plc Sharpe Pritchard LLP Trowers & Hamlins LLP
W W W.B SA-OR G.COM
The Business Services Association 2nd Floor 130 Fleet Street London EC4A 2BH 020 7822 7420 www.bsa-org.com