Neal Hattersley explains how efficiency can be improved at the service provision level by recognising the need for training

Efficiency is a constantly moving target. It is achieved when a targeted output results from the best technical mix of inputs at the lowest cost.

Clinicians and managers frequently disagree over what the targeted output should be. In these circumstances, the default position is often to meet what politicians or other external sources say it should be.

In general, clinicians are concerned with achieving the maximum benefit for individual patients. Managers and commissioners are more frequently interested in outputs such as waiting times and the number of patients seen rather than pure clinical outcome.

For example, a clinician may achieve a 40 per cent reduction in target symptoms after an average 20 weeks of intensive inpatient therapy with the most severely handicapped individuals. The clinician will view this as cost-efficient when compared with the cost to the country of the untreated patient in terms of loss of working time and cost of chronic healthcare provision.

A manager, however, may well propose that rather than treating the most severely ill patients for 20 weeks, the clinician could treat twice as many patients, albeit with less severe problems, for 10 weeks and achieve a better overall result.

Performance is likely to be better when there is consensus as to what cocktail of targets is needed. Only with consensus can you organise for efficiency. This should come from internally directed business planning.

Efficiency requires attention to three measures:

  • structure (inputs including buildings, staff, materials and staff morale);

  • process (the way the service is delivered using procedures and culture);

  • outcomes.

To attain efficiency, outputs from both medical and service audits must be integrated. A service needs to have defined objectives that can be obtained by operating to set standards. Once standards are set, observing actual practice and measuring performance against agreed criteria can create a continuous improvement loop.

Some standards will refer to customer care and others may include treatment protocols and definitions of the pathways whereby a patient receives differing levels of care.

The regular evaluation of performance may lead to a re-focus on weaker areas or potentially a reassessment of standards in the light of environmental changes. However, standards relating to business efficiency in operations and processes are just as important. The efficiency objective is set by achieving consensus on the optimum mix of standards. Improvement in efficiency leads to improved productivity and will constantly decrease costs. Of course, the development of more effective therapies is an integrated part of this process.

Changing behaviours

The attainment of efficiency requires all involved to have a shared view of quality and standards. In many health environments, this will need training for behavioural change among managerial, clinical and support staff.

This is not about a bland mission statement produced at trust board level while the workers have no knowledge and no interest in its implications. If quality and efficiency are to be delivered, it is essential that all stafffully accept and understand the standards of quality and efficiency and their role in achieving them.

A service may offer superb surgical procedures but if switchboard staff are surly, wards dirty and administrative staff inefficient, the service will be offering a poor quality and thus sub-optimal efficiency. Training for behavioural change stretches beyond adoption of lean thinking to a reassessment that could create a step-change in service efficiency. It is vital that staff at all levels contribute to and understand what the service is trying to achieve.

Some measures of quality are experiential, that is they are in the mind of the patient and not easily measurable as clinical outcomes. This, in particular, may need customer services training for patient-facing staff. Measures of patient satisfaction are almost universally applied in the NHS today. The number of formal complaints is also recorded centrally by the chief executives.

But these are crude measures. Patient user groups can be useful but tend to attract the chronic patient who has a vested interest in long-term treatment rather than using a service and moving on. The growth of foundation trusts with users and carers on the trust board will undoubtedly change the emphasis of services but still run the risk of promoting the interests of certain sectors of society, such as those with chronic involvement in services. Foundation trusts may also gravitate towards more middle class individuals from limited ethnic and cultural backgrounds, rather than representing the whole catchment served by the trust.

Assessing needs

A formal process of needs assessment at strategic health authority or primary care trust level might be to the advantage of service providers. Those with ambitions and plans to be service providers need to have a case that will convince purchasers of their particular merit. Specialist service providers will likely have access to research on local and national needs, while PCTs can draw on GPs and consumer groups to further define the scale of service provision required.

The definition of quality levels and standards should lead to the opportunity to reassess how efficiency can be achieved. It is this step that seems to be missing in many service organisations at present. Most managers live by the 'achievement' of annual cost reduction targets set elsewhere. A step change in service provision will require planning of production processes to be right first time. This will require implementation of information and management systems to assist in process measurement during service delivery.

It is not uncommon for these changes to lead to changes in manning levels. If a service provision regime can be created where dedicated multi-skilled teams can meet most needs on the spot they are also likely to be able to plan, implement and audit activities on a team basis. This is more than likely going to deliver raised staff morale and cost savings of 10 per cent upwards. Training in behavioural change can lead to a new benchmark in efficiency at a particular service level. Collectively, cost savings of 20 per cent plus can be achieved by a comprehensive reorientation towards efficiency.