Huge variations in the working practices of primary care trust provider arms are masking large potential efficiency savings.

An HSJ snapshot survey based on information supplied by 77 provider arms that responded to a freedom of information request to all primary care trusts revealed stark differences. Spending on community services per head of population varies from under £100 to over £200.

Almost six in 10 provider arms are working without any wireless IT systems, which would help clinical staff use their time more efficiently when visiting patients.

The big productivity gains are around service redesign and workflow redesign. If all we do is keep doing what we currently do but try and make people work harder rather than smarter, we’re missing a massive opportunity

Helen Bevan

And some district nurses are making three times more visits to patients per week than others, for example Leicestershire County and Rutland reports 17 visits per district nurse per week while Richmond reports 54 per week.

PCT provider arms are responsible for a wide range of community based services such as district nursing and health visiting.

The sector accounts for £11bn - more than a tenth of NHS spending - and employs a quarter of its clinical workforce, but is behind the pace in terms of reform.

Although some of the differences may be down to variable data quality and different reporting methods, investigations by strategic health authorities and preparatory work for the NHS Institute for Innovation and Improvement’s Productive Community Services programme (see box) have also found large variations in practices.

Variations in community services

Variations in community services

These have led to warnings that possible funding cuts before services are re-engineered risk blocking significant savings and quality improvements further down the line.

Productivity specialists are urging managers to intensify efforts to transform service delivery.

NHS Institute director of service transformation Helen Bevan told HSJ: “If you rush into short term cost cutting measures in the face of financial pressure, you can miss massively bigger opportunities.

“The big productivity gains are around service redesign and workflow redesign. If all we do is keep doing what we currently do but try and make people work harder rather than smarter, we’re missing a massive opportunity.

“Unless we fundamentally look at the way care is delivered, we could end up doing something really horrible.”

SHAs have reported cost per health visitor contact ranges from as little as £25 to £100 per patient. A number are talking to provider arms to see whether some provider functions could be performed on a regional basis.

An SHA source said: “[Provider arms] don’t want to give up the crown jewels just yet.

“But they want to be competitive. They can’t afford to hold onto too much fat because then they won’t be able to do that.”

The source added there were many opportunities for provider arms to redesign teams with a more efficient mix of skills, but warned: “If you want to invest in getting skill mix right, some of these things take time and the clock’s already ticking.”

NHS East of England’s provider arms have begun their own benchmarking exercise.

Management consultant Paul Whiteside, who is working on the project, said providers are drawing up plans on how to improve productivity and “starting to discuss with commissioners how to release extra value”.

But he warned it would be hard for them to improve efficiency and quality without better information systems.

Community services managers said they were trying to increase the pace of reform, but needed a joined up approach from the centre if efficiencies are to be realised before the public sector spending downturn hits home.

Nottinghamshire Community Health head of service improvement and productivity Pip Dean said: “The biggest challenge is trying to demonstrate that we are striving to get into the 21st century but with comparatively limited support compared with acute trusts and GPs.

“We want to move forward quickly so support to do that would be great. We’re desperate to get mobile working because we can see the benefits for staff as well as patients.”

The provider arm was waiting for new technology, but there was a “big, quite frustrating time lag”, she said, with the provider arm’s IT specialists struggling even to find a suitable laptop for nurses.

NHS Confederation deputy director of policy Jo Webber said variations often resulted from completely different operating practices that had grown up in different areas.

But she added: “Some services are immensely good but that doesn’t mean all services are immensely good – it’s about bringing all services up to that level.”

The Department of Health’s transforming community services programme, launched in January, put provider arms and PCTs in contracting relationships and pushed for speedy reform.

But last week the DH said one of the programme’s main deadlines – to decide on new provider arm organisational structures by October – was being axed, amid fears it was distracting managers from improving service delivery.

Funding for community services is particularly vulnerable in the downturn as there is no national tariff or benchmarking data for the sector.

The Department of Health said it was still planning to pursue a local approach to currency setting for community services, except in the two areas - child health promotion and end of life care – where it is working on a national approach.

A spokeswoman said: “”The transforming community services programme recognises that we must drive up quality, innovation and productivity in community services to meet the challenges of rising consumer expectations, growing demand and a tougher financial climate.  It is important that the quality of community services be improved, because quality is fundamentally linked to efficiency.”

Productive Community Services

The NHS Institute is preparing to launch its Productive Community Services programme in October.

The institute’s early testing with six provider arms has found it is possible to increase productivity by 25 to 30 per cent from a baseline of 30 per cent patient facing time as a result of better working practices.

Other areas under scrutiny are travel time, processes, demand and capacity.

Head of the productive series Lynn Callard predicted the programme could produce bigger productivity gains than the highly successful Productive Ward programme.

But she said provider arms faced challenges around data, technology and staffing levels.

The institute is in the early stages of producing benchmarking data that can be used to improve quality and productivity in the sector.

She said: “We know there’s an issue around technology. Some people are using really good technology and some are using really limited technology – even in terms of mobile phones.

“One of the issues around working out cost is accurate collection of data and community services do struggle.

“It links in with technology because the way they collate how many visits they are doing is so highly variable.

“We’re really anxious commissioners don’t just think [provider services] are an easy target – particularly because these services haven’t been scrutinised in the past in the same way that acute services have.”

Variation shows NHS community services ripe for efficiencies