The NHS financial crisis: E-QIPP-ing the nursing workforce with the skills to drive quality and efficiency improvements
Tuesday 3 February 2015By:
- Chih Hoong Sin
It seems that not a week goes by without some form of media headline trumpeting the scale of the financial crisis confronting the NHS. NHS finances is a major issue requiring urgent and sustainable solutions. In the past few years, the National Audit Office repeatedly questioned the sustainability of savings made to date. The easiest savings have been made – through a pay freeze for public sector staff, reductions in the prices paid for healthcare, and cutting back-office costs. Yet these savings have yet to be driven by fundamental service transformations at scale. The latest report by the Public Accounts Committee underlines the depth of the problem, pointing out that the proportion of NHS trusts and foundation trusts in deficit increased from 10% in 2012-13 to 26% in 2013-14. According to the regulator Monitor, the problems are particularly bad for hospitals, with 80% of acute foundation trusts reporting a deficit half way through the current financial year.
More worryingly, there is evidence that ‘cuts’ may be conflated with ‘savings’. This reflects the lack of a whole system approach in looking at how we make decisions about resource allocation. After all, the Mid Staffordshire NHS Foundation Trust Public Inquiry has shown how the Trust Board’s focus on short term cost control contributed to a range of adverse impacts on the quality and safety of care, that have longer term financial (and other) implications.
In relation to nursing, a study published in the British Medical Journal indicated that reducing cost through shedding or not replacing frontline nursing staff impacts on the quality and safety of care that, in turn, have implications not only on patient outcomes but also on the financial costs to the health and social care system.
Putting NHS finances on a sustainable footing requires not only different ways of doing things, but also new skills. While it has been estimated that innovations designed and implemented by clinicians could have a value of £9 billion per year in the UK, to date little has been done to harness this potential. As the largest professional group within the NHS, nurses play a critical role in delivering services and innovations in a way that achieves clinical outcomes and patient satisfaction, and will be vital in helping the NHS meet its quality and efficiency challenge. However, nurses often lack the skills to formulate and put forward arguments about the economic impact of what they do, over and above the clinical outcomes they contribute toward achieving. Nurses and other healthcare professionals often feel like they are reacting to, rather than driving efficiency initiatives.
OPM developed a programme aimed at building the capability of nurses and other members of the public service workforce to be able to generate evidence of the costs and benefits of various services in order to inform ongoing service improvements. Since 2013, OPM has been delivering this programme to cohorts of nurses in partnership with the Royal College of Nursing (RCN), with generous funding from the Burdett Trust for Nursing. Evidence to date shows how trained nurses contribute proactively to the Quality, Innovation, Productivity and Prevention (QIPP) agenda – in many cases helping to generate ‘cashable’ savings.
For example, a nurse in Scotland produced an economic assessment that showed how her heart failure nurse liaison service helped reduce both hospital admission rates and lengths of stay per admission, while also reducing demands on other professionals’ time. She was able to calculate efficiencies of around £454,928 per year, representing a return on investment of £489 per patient. More importantly, based on the evidence, she was able to make recommendations for where there may be further scope for increasing efficiencies. She identified that by improving part of the patient referral pathway, the service is likely to generate additional efficiencies, the potential return on investment rising to between £671 and £779 per patient per year. Based on this evidence, she was able to mobilise other colleagues and senior management to effect service re-design in a way that secures both quality and efficiency. This is testament to how an empowered workforce, with the right skills, can help the NHS meet its financial challenge while maintaining a clear focus on high quality care.
The Public Accounts Committee noted that radical service reconfigurations require “significant upfront investment”, and that this will become increasingly difficult with less money available for such investment as more NHS organisations move into deficit. Equally, a case may be made that securing a sustainable financial future for the NHS requires not only investment in services and service transformations; but also investments in the workforce to be able to drive meaningful change ‘on the ground’. Valuing public services means valuing our public service workforce, and seeing them as part of the solution.
Note: The programme is currently being delivered to cohorts of nurses in England, and there are still a few places available. More information about the programme, and the process for registering an expression of interest to participate, is available from the RCN website. ‘A guide to economic assessment in assessment in nursing’ supports the provision of RCN and OPM training in how to perform economic assessments and use economic evidence to demonstrate the value of nurse-led innovation.