Analysis

Lord Carter’s model hospitals aim to save the NHS £5 billion a year

A lack of standardised procedures in the use of resources across acute hospitals is costing the NHS billions, according to Labour peer Lord Carter of Coles.

The report on his 18-month investigation into the efficiency of NHS providers says that if acute trusts reduced ‘unwarranted variation’ and standardised their procedures in six core areas including procurement, staffing and hospital pharmacy, they could save £5 billion of the £55.6 billion they spend annually.

This would add up to a cumulative saving of £20 billion by 2020.

Picture credit: Pete Ellis

He cited huge variations in trusts’ performance in areas such as discharge processes, sickness absence and staffing levels.

The review found that the average sickness absence rate calculated over 365 days was 4% but there was a variation of 2.7% to 5.8% at different trusts. The report states that a 1% improvement in sickness absence would equate to £280 million in staff costs and suggests that an improvement in staff motivation and wellbeing would be required to achieve this.

The report makes a total of 15 recommendations, including that NHS trusts adopt a new metric to measure how much time nurses spend caring for patients.

Lord Carter called on NHS Improvement, which comes into being in April, to develop a ‘model hospital’ which will illustrate best practice that can be adopted by all hospitals.

NHS Improvement will also develop a metric to eliminate variation in how staff are deployed.

Lord Carter highlights the absence of a common means of recording and reporting workforce deployment and says that conventional measures – such as using whole-time equivalents, skill mix or patient-to-staff ratios – may not reflect varying staff allocation across the day.

Data from more than 1,000 wards in October showed that in some 6.3 hours were spent on caring for patients by nurses and healthcare support workers (HCSWs) per 24 hours of inpatient admissions compared with 15.48 hours on other wards.

Lord Carter recommends a system to work out the number of hours nurses and HCSWs spend caring for patients.

His care hours per patient day metric involves adding the hours worked by nurses to the hours worked by HCSWs and dividing the total by daily inpatient admissions.

He wants the metric to come into force in April and be the main method of deciding how many care workers are needed. He believes the metric is more comprehensive as it can be broken down to staff bands.

Safe Staffing Alliance chair Susan Osborne welcomes the metric, saying it could help get more nurses on wards and push towards mandated staffing levels. She explains that if such a metric showed positive effects on clinical outcomes, it could make a case for introducing mandated staffing levels.

‘This would mean the health service can inform universities how many nurse training places are required to provide the level of service the hospitals want to achieve,’ she adds.

RCN head of policy Howard Catton has expressed disappointment that the metric is based on care hours using both nurses and HCSWs rather than specifically looking at nursing hours.

‘There is a danger that any member of the healthcare profession having an interaction with a patient could be deemed as contributing to care hours,’ he says. ‘We should call it what it is. It’s about nursing care hours.’

Nursing directors echo his concerns, questioning whether patient acuity, which focuses on patients’ care needs, would be factored in.

Colchester Hospital University NHS Foundation Trust nursing director Barbara Stuttle is cautious about the metric because she fears it may dilute nurse-to-patient ratios because of the focus on HCSW hours.

‘We need to look at how we can maximise the care given to patients and reduce the administrative burden on nurses,’ she says.

Lord Carter has worked with senior professionals, including nursing directors, from 32 non-specialist acute hospitals in England, as well as regulatory bodies and the RCN, to collaborate on nursing workforce efficiency improvement.

1,000 wards were examined over a course of 18-months by Lord Carter to look at variation in performance

225 working days are lost at each acute trust every year due to nurse sickness absence

29% of the wage bill in 136 non-specialist acute trusts is spent on nurses

£5 billion could be saved by acute trusts every year until 2020 through better use of staff, medicines and procurement

£2 billion could be saved on improving workflow, better management of rostering and appropriate staffing levels

Nursing directors identified a range of challenges they face at work and developed good practice for tackling them, including managing the need for bank and agency staffing. These ideas will be factored into the model hospital initiative with a focus on:

e-recording and reporting of nursing and care staff deployment.

e-rostering systems.

Specialling (enhanced or one-to-one care for patients who need more intense levels of care).

Lord Carter reports that while most hospitals use e-rostering: ‘A firmer grip on e-rostering will reduce dependency on bank and agency staff and improve consistency in staff deployment.’

He says all trusts should use an e-rostering system and publish rosters six weeks in advance, reviewing them against key performance indicators, such as proportion of staff on leave and appropriate use of contracted hours.

Portsmouth Hospitals NHS Trust looked at how information was recorded in nurse rosters across the trust.

‘We looked at what a good e-roster would look like and what was needed to make wards safe,’ director of nursing Cathy Stone told Nursing Standard.

She says the rosters factor in what staffing should be per shift, how many staff are on leave, what whole-time equivalent vacancies are filled with agency staff and whether staff worked over or under their contracted hours.

The trust has introduced roster masterclasses for ward managers, matrons and heads of nursing, and monthly clinics where ward managers discuss the coming month’s rotas.

Ms Stone explains that this not only gives greater clarity in how nurses are deployed, but helps staff plan their time off.

Nottingham University Hospitals NHS Trust wanted to reduce agency staffing expenditure on four stroke wards with high vacancy rates. A team of band 6 nurses led a programme of work to use specialling and cohorting more efficiently.

Cohorting involved grouping patients with similar needs in bays in the hope that this would reduce the numbers of staff needed for monitoring.

The group also identified that specialling was often used when it was not required.

‘Staff were not assessing patient needs accurately,’ deputy chief nurse Ann-Marie Riley explained. ‘We want staff to use their judgement more around the need for specialling.’

RCN general secretary Janet Davies has warned Lord Carter that his recommendations must not be implemented to the detriment of safe care. ‘In the past, efficiency drives have eclipsed the focus on safe staffing levels and patient care. In the future the two must go hand in hand.’

But Lord Carter says speed is of the essence: ‘The biggest challenge for the NHS in 2016 is to deliver the changes needed to achieve the efficiency and productivity improvements required by 2020. Rapid, effective adoption and implementation of the recommendations is imperative if we are to achieve this aim’.

Read Lord Carter’s report Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations at tinyurl.com/h24qpet

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