Discussions on eliminating variation in elective care practices and enhancing productivity is likely to intensify in the near future. By Claire Read

When Monitor published advice on improving productivity in elective care, it was both something of an experiment and a likely sign of the future.

The October report centred on ophthalmology and orthopaedics – which together account for about 30 per cent of elective care in England – and explored best practice. Its conclusion? That there is a high degree of variation which, if eliminated, could lead to 13 to 20 per cent productivity gains from today’s spending on elective care in these specialties.

The fact that the work represents something of a departure from that traditionally undertaken by Monitor is acknowledged by policy director Nick Ville. Speaking during HSJ’s War on Variation summit, held late last year in association with McKinsey Hospital Institute, he emphasised that, in light of the immediate problem with NHS finances, “we saw it as our job to do what we could to try and help people address that”.

The estimated productivity gains from eliminating elective care variation in ophthalmology and orthopaedics is 13-20 per cent

The approach embodied by the work “may well” start to set the tone for how NHS Improvement operates, he added.

Collaborative approach

During research for the report, which took close to a year to complete, the aim was very clear: to find ways to improve productivity and to do so in collaboration with clinicians.

The way we designed this, quite deliberately, was very strongly to take a co-production approach

“Probably, like me, you’ve been informed by a lot of the work that is going on around new care models – rightly so, because we need to make a transformation – but this speaks very much to business as usual,” Mr Ville told the invited audience of senior healthcare leaders. “The way we designed this, quite deliberately, was very strongly to take a co-production approach. We wanted to work very closely with NHS hospitals to see what they were currently doing and so that we could learn as a group. But also, probably even more importantly, to work very closely with the Royal College of Ophthalmology and the British Orthopaedic Association, and hear their views, the clinicians’ point of view, about what would help in terms of making their day more productive.

“I’ve been greatly encouraged by the level of support that we had from clinicians.”

Revamping goals

While it may be a new kind of endeavour for Monitor, the idea of identifying variation in elective care practices – and eliminating them – is not new. The Productive Operating Theatre programme, for instance, was launched by the NHS Institute for Innovation and Improvement in 2009 and drew on international best practice. Mr Ville suggested the difference with the Monitor work was the extent of its detail.

“I think what we wanted to do was get to a level of granularity that people could really engage with, so a very clear statement of what optimal practice might look like, and one that wasn’t theoretical – stuff that’s happening here and now, that we can see inside hospitals across the NHS.

“We wanted to provide some measures, some quantification. And I’m not talking about reference costs here, it’s about getting below that level into specific practices and activity so you can see day to day what that might mean to operational staff or nursing staff.”

He added: “There is benchmarking data around, specialty level benchmarking data, but it’s always slightly difficult to interpret because the mix of procedures make it a bit difficult to understand what’s really going on. So we really started to go right down to the level of procedures to find out what was happening at procedure level.”

Speaking statistics

It was an examination that revealed a high degree of variation. Take average length of stay following primary hip or knee replacement: the NHS had a rate 36 per cent longer than the international examples the research looked at (drawn from other parts of Europe, as well as Australia and the United States).

Within cataract surgery, it was not necessary to look abroad to find striking variation. Theatre throughput, for instance, ranged from 4.5 procedures to eight procedures per four hour session at the English hospitals the researchers reviewed. Practices on anaesthesia similarly varied: some hospitals use consultant anaesthetists to administer an injection, which at other units is given by nurses with advanced training – at significantly lower cost.

It was an examination that revealed a high degree of variation

“So there are some very basic facts here about how cataracts should be managed in a hospital that any trust in this country could benchmark themselves against,” suggested Mr Ville.

Disparities within the UK

Recommendations very deliberately encompass the whole care pathway, split as they are into pre-admission, admission, surgery, post-operative care and follow up. During workshops with clinicians, held to discuss the findings, Mr Ville said “we tended to find a curate’s egg”.

He continued: “People would tend to say we’ve got theatres cracked, or we’ve got outpatients cracked, but they were very focused on one part of the care pathway rather than the whole thing.”

The report may well help those keen to make improvements across the whole pathway rather than in isolated areas. Available on the Monitor website, it is accompanied by a range of supporting material.

“We also published case studies of every single trust that we worked with, some of the good things they were doing and international case studies, as well as our model and a set of operational improvements,” he said. “So everything is out there in terms of the work we’ve done – it’s fully available in the public domain.”

People would say we’ve got theatres cracked but they were very focused on one part of the care pathway’ rather than the whole thing

Peer support

Mr Ville admitted the big question for Monitor now – and indeed for the new body, for which it is becoming a constituent part – is how and to what extent it should support organisations in making the changes it recommends.

The interesting question for us is about whether we should provide some practical support, possibly through enabling peer networks

“Having done this research, published it and made it available to the sector, I suppose the question for us – particularly as we move towards NHS Improvement – is how can we help the sector? It’s one thing to say these things are out there; it’s another to see what we can do to help.

“We think probably the simplest way to start is to invite people to participate in benchmarking work at a procedural level – on a voluntary basis because we appreciate this may not be at the top of everyone’s priority list at a local level. And in response to that, provide some feedback to people and analysis about where they compare to other trusts.

“The interesting question for us is about whether we should provide some practical support, possibly through enabling peer networks.

“Some of the clinicians [we worked with] were quite interested in engaging with a number of trusts and providing peer support, so that’s a possible model. And another possible model is some sort of coaching for people on these issues.”

At the time of the HSJ summit, those discussions were continuing. As NHS Improvement forms and beds in, it seems likely these debates will widen and intensify.