Running the NHS: if you get the small things right, will the big things follow?

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Last year we interviewed staff at seven NHS trusts in England to find out how they were implementing service-line reporting and service-line management. Our subsequent report, Service-line management: can it improve quality and efficiency?, published today, explores some of the benefits and challenges of using this approach to support clinical and operational decision-making.

Two examples stand out in my mind from the interviews we conducted with staff at different levels – from chief executives and medical directors to consultants, operational managers and finance support staff. In two trusts, SLR data suggested that clinicians were ordering unnecessary or expensive tests for their patients.

In the first case, the team then used patient-level data to explore further and found that some patients were undergoing duplicate tests. One unfortunate patient had had one test more than 40 times, during a hospital stay in which the result could not possibly have changed from the first occasion.

The trust realised that this issue was linked to the arrival of newly qualified doctors. These inexperienced doctors, who appear on the wards every six months, were more prone to ordering duplicate tests. In response, their induction training programme was changed to highlight this issue.

In the second case, staff found an anomaly when they compared the quantity of tests ordered by clinicians within a department. One clinician appeared to be ordering a £50 test far more frequently than the rest of the team, with no clinical justification. Was this due to differing clinical opinions between colleagues?

No. In fact the real reason turned out to be far more mundane: the doctor in question mistakenly believed that the test cost £0.50 rather than £50. The trust used this information – in an anonymised form – as the basis for a seminar for the rest of the team, who were shocked to realise how much tests cost. This information proved to be a useful benchmarking tool and in subsequent months prompted a decline in the quantity of £50 tests ordered.

As these examples demonstrate, financial data can be used to improve the quality and efficiency of patient care rather than wielded as a blunt cost cutting tool. Maintaining clinical freedom and autonomy is essential but doctors also have a professional responsibility to avoid wasting resources. Peer review between professionals, and ensuring that clinical leaders are genuinely involved in managing services, will help to ensure that patient interests are put first.

Unfortunately, reducing departmental spend on unnecessary tests will not be enough to achieve the cost improvement targets faced by trusts across the country, and at a system-level, making small changes to improve efficiency cannot close the £15-20 billion funding gap. Nevertheless, these examples show how clinicians are using data to improve clinical practice and drive efficiency, and perhaps a little change might go a long way?


Mike Stone

Comment date
07 June 2012
The 'I thought the test cost 50p' one is very interesting !

Ans so is Melanie's point.

Quynh Nguyen

Community Management,
De Gaspé Beaubien Foundation
Comment date
01 March 2012
We find your initiative in finding solutions to healthcare systems quite interesting. We have a similar approach where we developed a co-management model for medical centers which addresses human resources organizational issues. We encourage the medical and management staff to better communicate in order for them to provide better healthcare service to their patients. This model has been applied in one of our local medical centers called CSSS, in the outer Montreal region in Quebec, and we are seeing very good progress Would you see such a program work to help optimize healthcare systems?
Great post.
The De Gaspé Beaubien Foundation, Montreal, Quebec.


Comment date
26 January 2012
I do hope that the clinician who ordered the unnecessary tests was also was helped to understand why putting patients through unnecessary procedeures might not be appropriate irrespective of cost?

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