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Productivity in acute hospitals – are the recommendations of the Carter Review realistic?


The final report of the Carter Review on operational productivity in acute hospitals is the culmination of an impressive work programme. Since its inception in June 2014, the review team has engaged with 136 acute hospitals in England, 40 per cent of which Lord Carter personally visited. In terms of engagement with local leaders in the acute sector, this must surely set the standard.

The report gives a detailed account of the extent of variation across acute hospitals. Though it is often difficult to prove that this variation is unwarranted, it is hard not to be persuaded that there is the potential for significant savings. While identifying exactly where the variation lies is a necessary first step in reducing it, it will not be sufficient on its own given the long history of efficiency reviews in the NHS, going back to the Rayner reviews of the early 1980s and beyond. Is the report as convincing in its approach to implementation?

The report provides recommendations as to where action needs to be taken. Many of these recommendations are very detailed and imply a lot of further work. For example, trusts will need to develop separate operational plans for pharmacy, procurement, estates and facilities, data-reporting burdens, and corporate and administration costs (if these were above 7 per cent of their income in 2015/16). These plans are designed to raise efficiency and to save money and will be signed off by NHS Improvement and subject to ongoing central monitoring. The extra demands on NHS Improvement when it is already in the middle of its own change programme are hard to underestimate.

If the recommendations are carried through, they will reinforce the trend towards central control, as seen in other recent developments summarised in our briefing paper, What the planning guidance means for the NHS. However, just writing plans and agreeing targets does not enable organisations to undertake change. So it is encouraging to see the report is also clear about the need for greater leadership capacity and capability within the NHS and the need to engage better with staff. We at the Fund agree; our 2015 report Better Value in the NHS emphasised the need for improved clinical engagement and leadership.

But at best these other actions will be taken alongside (rather than before) the operational actions the Carter report recommends. This means there is a risk that implementation relies too heavily on the ‘what’ and its associated process, and too little on the broader enablers. Of course this report is not – and nor was it meant to be – a quality improvement strategy for the NHS, but it underlines its absence. We will be publishing a report about the need for such a strategy later this month.

The Carter report has implications for the wider sustainability of the NHS. In total it has identified around £5 billion of savings that could be made by 2020. However, given that the overall efficiency target for the NHS is more than £20 billion, it raises the question of where the rest of the savings will come from. It took almost 20 months to produce this final report, so there will need to be a much more rapid assessment of opportunities in other sectors if this approach is to help the NHS manage its finances in the years up to 2020 – and none of this is likely to help with the more urgent financial challenge in 2016.

Finally, it is perhaps worth noting that the report also refers to the need for the successful implementation of new care models, vanguard and success regime programmes, underlining the wider delivery challenge facing the NHS. The review also calls on NHS Improvement and other organisations to define the best practice staffing requirements for different types of hospital ward. It hardly needs to be said that this has proved notoriously difficult to do ever since the publication of the Francis Inquiry report. Guidance that was once in demand due to a desire for clarity over safe staffing levels is now in demand due to a desire to save money. The change in emphasis will not make it any easier to achieve.