Interview: Hospitals must 'take fate into their own hands', says Carter

The Labour peer was speaking ahead of publication this morning of his long-awaited review of NHS productivity, which sets out the detailed steps he argues will save £5bn across the acute sector by 2020.

The wide-ranging recommendations touch on almost every aspect of the hospital sector, from clinical workforce management, to procurement, to administration and corporate costs.

HSJ revealed extensive details from the report last month, including recommendations for a “single reporting framework” through which savings opportunities can be identified.

But in an interview with HSJ yesterday, he warned that a “significant proportion” of the estimated £5bn savings in the acute sector “cannot be unlocked” unless delayed transfers are managed more effectively.

He also told HSJ that:

• Most hospitals have acknowledged that significant savings can be realised by improving staff rosters. He recommends that all trusts have electronic roster systems by October 2018.
• “Persuasion and assistance” must be used to ensure trusts deliver their Carter savings, rather than a “national do this, do that” approach.
• His model hospital should give more power to trust non-executives, who in many places have been “powerless” due to a lack of data.

Lord Carter said his work initially focused on ways that hospitals can reduce costs, but he soon realised that delayed transfers were a crucial part of the picture. He found many cases in which trusts were losing revenue due to cancelled elective operations, and salaried clinicians were left “sitting around”.

The blocked beds also resulted in work going out to the independent sector, for which NHS provider expenditure increased by about a third last year, to £482m.

He said hospital trusts should be “taking their own fate into their own hands” by taking responsibility for, or contributing to, the post-acute phase of care. He suggested accountable care organisations, currently being tested in some areas, could ensure the financial incentives are better aligned.

Asked whether hospitals could realistically tackle delayed discharges given the funding cuts to social care services, he said: “A number of hospitals are saying ‘we’re going to contribute to stepdown care and we’re going to contribute to the post-acute phase so we can clear the beds, (because) it’s in our total self-interest’.

“In some areas they’re working well with local government and social services. They’re saying we’ll pay for some of this, and some areas are now moving towards building, with the independent sector, stepdown care facilities and sort of taking their own fate in their own hands.”

His report cited Mid Yorkshire Hospital Trust, which recently opened a 42-bed stepdown facility in Pontefract, as well as the Dudley Group Foundation Trust, which has halved the days spent in hospital by fit to discharge patients by working with care broker CHS Healthcare, as examples of successful schemes.

His report, Operational Productivity and Performance in English NHS Acute Hospitals: unwarranted variations, estimates that about 8,500 acute beds are “blocked” each day in the acute sector, costing NHS providers around £900m per year.

On staff rosters, Lord Carter said he found cases in which trusts were squeezing nurses on to weekday shifts in order to make up their weekly hours, and said improving productivity by five minutes per shift could save as much as £280m.

Responding to the report, NHS Improvement chief executive Jim Mackey said: ”We will do everything to help trusts implement these recommendations, but those that fail to do so will face closer scrutiny from NHS Improvement until they can demonstrate appropriate grip. ”

When asked about the approach regulators should take, Lord Carter said: “What I’ve constantly advocated is [the recommendations are] not used as a stick, they’re used as a tool to hold the debate…

“I hope what’ll happen is it’s taken on a hospital by hospital basis and it’s bottom up, with the NHS Improvement team understanding line by line the hospital’s challenges. No big sort of national ‘do this or do that’, but ‘you’re doing that very well, perhaps you can tell me so I can make sure the others do it’, or ‘looking at this we don’t think you doing that very well, we’ll be back in a couple of months and you can tell us what you’ve done’.

“This isn’t a system you can run by bullying it, you’ve got to lead it. It’s reall,y really important that we stick together.”

Asked how the NHS could expect to find £22bn of efficiency savings by 2020-21, as required under the Five Year Forward View, given that more than half of NHS England’s budget is spent on the acute sector, Lord Carter said: “There’s community and mental health to go. [But] it’s not something I’ve been asked to look at. I’m very confident we can deliver [£5bn]. You have to ask the Olympians for the rest of the view. I’m just one of Santa little helpers.”

Lord Carter is now set to join NHS Improvement as a non-executive director.

He recommends the broad set up metrics outlined in the report should begin being collected by regulators from April, with the first full phase of the “model hospital” tool completed by April 2017.