Cambridgeshire and Peterborough Foundation Trust forecast a saving of £16 million and a 100 per cent increase in clinical time spent with patients.
This has been achieved on the back of improved efficiency and elevated staff morale. On an income of £100million this is a 16 per cent saving for the foundation trust.
Uniquely this was not achieved through ‘slash and burn’ techniques but through redesigning internal processes by applying authentic lean thinking, facilitated by Alturos.
The process of achieving these results has been a long and steady one, with the trust now leading the field as one of the most progressive and adaptable NHS organisations in the country. Instigated and championed by Keith Spencer, the director of business development at the trust, this continuous improvement journey started in 2007.
“The work we started three years ago continues to evolve and bear fruit with the trust reaping the rewards of lean improvement and innovation,” commented Mr Spencer.
The largest proportion of overall savings was reported in adult mental care. This is largely because it has the highest volume and also because it has multiple access points and multiple teams. The breakthrough thinking here was:
Active case load management – the number of active cases and the number of cases that could be discharged temporarily were determined. This helped reduce the work load on clinicians and increase their capacity for clinical time spent supporting service-users.
However there remained a concern, among both clinicians and service users, that discharging service-users, even temporarily, might cause further issues, such as services-users finding it difficult to get referred back into the system because of existing waiting times or that their condition could worsen if discharged early.
This concern was alleviated by providing service-users with a fast track re-access number. Additionally, actual waiting time was dramatically reduced as a result of reducing the active case load, thereby allowing the trust to deal with even more cases
Getting service-users to move (flow) through pathways – through a deeper understanding of each step taken by service-users and measuring the time lapse between each, a system was designed to allow service-users to be assessed and treated at the optimum pace. This allowed all service users to move more quickly through the process (where appropriate for their particular mental health circumstances). This in turn made it a more efficient process for both service users and carers and also creating additional capacity to deal with more service users.
The trust also created and published a manual for referrers to the service. This illustrated the key steps of service-users and clinicians and enabled referrers to explain to service-users the journey ahead and ensure referrals were directed appropriately and at the right time
Create a ‘role and purpose’ for teams and for case load – Over time the system had developed complexity causing teams to overlap in their activity. This duplication was taking capacity out of system. The redesigned process re-configured and distributed the service teams along a new high value-adding pathway to optimise service delivery and minimise duplication of effort and resource
Establish resources required – Once the teams understood the steps in the process from a Lean perspective they were in a position to allocate the appropriate resource to each part of the service-user journey. This is known as balancing the system, to achieve even flow. This not only benefits existing service-users but also frees up capacity to benefit additional service-users that need to access the service.
Established demand rates and increase clinical time (obtained by working with PCTs) –assumptions were made about inappropriate referrals and this figure was subtracted from the total to arrive at realistic demand rates that would need to flow through the pathway. The service teams categorised their service-user group to understand how various conditions were represented in the overall service. This enabled them to construct a system to meet current demand and also build-in a measure to allow flexibility to meet future demand increases.
Alturos helped the trust quantify the actual time clinical staff spent with service users. This revealed that in a typical week, clinicians spent only 28 per cent of their working time in direct contact with service-users.
Under further investigation it was revealed that valuable clinical time was been consumed by paperwork, administration, trying to make appointments and duplication of tasks undertaken elsewhere within the service-user journey. Therefore it was obvious that that clinicians need to be released from what could be considered undue bureaucracy and left to do what they do best - adding value.
The trust has now almost doubled the actual clinical time, often referred to as ‘touch time’, with service users from 28 per cent to 55 per cent.
The teams at the trust identified an opportunity to streamline the referral process. Initially they re-designed administration processes enabling a reduction in waiting times from 14 weeks down to four weeks. With service-user’s input and more creative activity facilitated by Alturos, the teams reduced referral time down to one day.
Mental health trusts, by their nature, present a number of differences to the acute setting. These are so often not accounted for by organisations supplying and commissioning lean support. These include:
- The service-user’s journey is quite different from an acute setting. The service user may have a complex array of needs that require being seen by different teams, in different locations and at different times. Care is not delivered at uniformed pace in the same way as the relatively linear, sequential pathway of the acute environment.
- The ‘value’ the service-user places on different elements of pathway can, and will, change over time and this can be more complex to manage than in an acute setting.
- The time that a service user is in the system is highly variable. Support for mental health episodes can range from a few weeks to a lifetime.
- Managing the multiple agencies and stakeholders that feed into the mental health setting can be a challenge.
- Mental health support, by necessity, is often community based. This means that implementing changes can present a series of further challenges for the teams. With locality teams this adds further challenges in terms of standardising services so that all service-users receive the same standard and consistency of service levels.
Yet despite these anomalies, lean can be successfully applied to mental health settings.