Assessing the value of practitioner-led innovations
The key argument of the Royal College of Nursing’s (RCN) Frontline First Campaign is that innovative ideas developed by frontline nurses should be prioritised over cutting jobs as a way of reducing waste and improving effectiveness. To this end, the RCN is looking to build the innovation capacity of the nursing profession, and demonstrate the valuable impact of these frontline innovations.
The RCN worked in partnership with OPM to understand and demonstrate the economic case underpinning a number of nurse-led innovations using OPM’s Economic Assessment Tool (EAT). The EAT provides a pragmatic methodology that builds on the discipline of improvement using many of its tools and techniques to map and cost healthcare innovations to help increase the quality, efficiency and effectiveness of care in a given setting. It is also compliant with HM Treasury guidance.
What we did
The EAT comprises 4 key stages: planning and mapping; costing and valuing, calculating; and validating:
1. Planning and mapping
At the outset there are a number of decisions that need to be made (e.g. what is being assessed, over what time period and from whose perspective). This is supported by an embedded ‘Pathways to Outcomes’ mapping tool that help replicate, in diagrammatic form, a whole systems and outcomes-focussed approach to understanding a service.
A ‘Pathways to Outcomes’ model gives an indication of the types of data that are available or need to be collected in order to determine the impact and value of the service, and the type of economic analysis that can be supported by available data.
2. Costing and valuing
In the costing stage, monetary values are assigned to inputs and outcomes (where possible and relevant) associated with a service. The EAT follows HM Treasury guidance and audits the ‘Pathways to Outcomes’ model for all direct and indirect costs, and all direct and indirect benefits.
We also distinguish between costs for setting up the service from costs involved in the steady operation of the service.
The monetary values assigned to outcomes depend on the way in which an outcome is defined and operationalised in terms of measurement, whether market prices are available, whether monetary proxies may be identified in the wider evidence base, and whether it may be amenable to valuation through primary data collection. Monetary values are only applied to outcomes achieved over and above what would have happened without the service.
The EAT sets out different procedures for calculating and presenting ‘costs’ and ‘benefits’, requiring the user to have a clear rationale to justify decisions, and to state assumptions. In some cases, for example, a user may wish to calculate a return on investment dividend in the form of ‘for every £1 invested, £X of benefits are generated’. In other instances, the calculation of a single dividend may not be desirable.
The EAT uses a reporting template that captures the economic/financial results alongside other quality and effectiveness indicators that may not be assigned monetary values. These latter indicators are still important and should be reported. This template has been co-designed with a range of professionals, and with commissioners of services. Every completed output is validated with service personnel and relevant stakeholders.
Using the EAT, we generated return on investment calculations for two nurse-led innovations: a community-based oxygen assessment service in Central and Eastern Cheshire PCT, and an intervention to support Health Care Assistants to manage pressure sores in Bradford and Airedale Community Health Services. In relation to the former, we found that for every £1 spent, the service is generating between £20.22 and £23.51 of benefits. In relation to the latter, the service is generating approximately £11.10 of benefits for every £1 spent. The full case studies can be accessed here and here.
Reflecting on the evidence, the RCN’s Chief Executive Dr Peter Carter noted: “These services provide high-quality care and many of them could easily be rolled out across the health service, saving millions of pounds. In many instances, care can be best managed by community-based services, with as little hospital involvement as possible.”
While recognising that the NHS is under pressure to cut costs, experts feel strongly that NHS managers need to make good, evidence-informed, choices about how they can respond best to this. Reflecting on the economic and quality evidence generated for these two case studies, experts caution that ill-considered cuts can lead to unnecessary hospitalisation or inappropriate use of statutory services (which impose additional costs to the healthcare system) and/or compound the emotional and physical distress for patients. Poorly thought-out cuts may therefore be false economy.