“This year is the most challenging year we have ever seen………”
You would be forgiven for thinking this quote relates to the Scottish Rugby Team after their disappointing performance at this year’s World Cup (c’mon Wales!!! – only just…..!). However, the rest of the quote helps to put into perspective what we have said in recent years:
“………..across the NHS, in delivering our national performance targets and delivering financial balance”.
You will have heard this before!
This has been our annual mantra for the last 5 years in the finance team – but we always seem to make it at the end of the day.
We also appreciate that this message may be received with a certain level of cynicism when:
- We have always achieved financial balance; and
- Other NHS Boards have had additional funding to write-off historic debt.
But we need to reiterate this message again this year with cost increases to our services outstripping income uplifts resulting in the need to deliver savings yet again.
During the past 5 years, there has been a certain level of non-recurrent flexibility in our funding, be it through slippage on recruitment, or delays in implementing new services. This has meant we have been living beyond our means for 5 years as the new hospital was built and now the recurring gap has caught up with us. We have already released all remaining non-recurring flexibility this year and the scale of the gap remains at £4.8m. This means that we still need to find savings of £4.8m by the end of March 2020 to achieve financial balance this year. In addition, we need to maintain similar levels of savings in future years to continue to balance the books.
Sounds pretty grim doesn’t it??? !……………….
Fixing the Gap
So there’s this financial gap – but we are still working very hard with all services across the organisation, including the Integration Joint Board (IJB) to look at what else we can identify to help close the gap.
Our Sustainability and Modernisation programme (SAM) is now in full swing, gathering over 600 ideas already from front line staff and managers across the region. This has been really positive, with ideas received already either passed to workstreams or teams to consider, or already implemented.
But there is still a gap………………………………
So we thought we would share with you the top ten ideas where we continue to generate further efficiencies and reductions in costs.
- ‘Recruit Recruit Recruit!’ – Investment in our recruitment team to focus on attracting staff to Dumfries and Galloway. In particular, we have significant vacancies across Medical, Nursing and Allied Health Professional services. Last year we spent in excess of £12.6m on medical agency costs, on top of £8.5m on other agency, bank and overtime shifts. There is a real focus on prioritising filling vacant posts and ensuring we have a workforce plan to demonstrate where our future workforce requirements will be over the next 5 years and beyond.
- Squeeze agency costs out of the system – This is related to recruiting staff. Obviously, if we recruit to vacancies then our reliance on agency staff quite appropriately will diminish. However, the way in which we engage current agency staff can be actively managed to ensure we maximise the value for money of all agency staff. In particular, by ensuring we engage medical staff directly, we could reduce agency costs by £1m based upon the current level of expenditure incurred on medical agency.
- Reducing clinical variation – There are two streams to this. The first links with Realistic Medicine, in comparing the clinical variation of our services compared to other NHS Services. For example, comparing the number of patients we treat per 1000 population for a particular procedure compared to other NHS services and understanding the reasons for this level of clinical variation.
The second relates to how clinical variation compares within and between our local services and similar services across other Scottish Boards. This could include; length of stay, theatre efficiency or differences in the clinical practice of using a variety of consumables and suppliers. Information Services Division (ISD) Scotland have published data via a system called ‘Discovery’ which indicates that by matching the Scottish average across a variety of clinical benchmarks we could save over £7m – this increases to £11m if we were to be in the top quartile. So, there is an opportunity to find further efficiencies by reducing clinical variation across all services.
- Managing Demand – This isn’t necessarily about stopping or reducing the number of patients we need to see, but more about reviewing our capacity to see how it meets our service requirements. We currently spend over £3m on running additional capacity to meet our waiting time targets. If we could ensure our capacity is sufficiently robust to service our demand, there are significant savings in this area to deliver.
- Effective Prescribing – We currently spend more than £51m on Medicines, ranging from less than a penny per tablet to over £300,000 per treatment. If we can ensure we have a consistent approach to Primary Care prescribing, adhere to the Board’s formulary guidance and utilise pharmacists to ensure prescribing is as effective as it possibly can be, then we will drive down, not only the overall cost of Medicines, but prevent inappropriate admissions, as well as enabling more patients to be treated in their communities. To date, we have identified over £1.5m of savings across the prescribing areas, however, there are other NHS Boards who have an average medicines’ cost per patient lower than us and practices throughout the region who have higher than expected prescribing costs than elsewhere within their own locality and the Board’s average. There remains current potential savings of in excess of £500k if we minimised prescribing variation across these services.
- ’Love IT’ We are already improving efficiencies by embracing digital solutions and looking at the way in which we interact with patients and services. Where appropriate, patients can now be seen in their home or in a local NHS service rather than having to travel all the way in to the main hospital. This not only prevents unnecessary time wasted for patients and their families, but also frees up valuable space in the hospital.
- Become smaller – Review how we use our estate. Our property strategy, as evidenced by building the new hospital as well as other modern buildings (Dunscore and Dalbeattie GP practices for instance), is all about ensuring appropriate infrastructure is in place to deliver an innovative and modern service. Whilst we have upgraded significantly our Acute estate, our Primary Care and Community buildings require significant backlog maintenance and we have an opportunity to redesign how we provide services to our local communities in a modern 21st Century way.
- Reduce Waste – I recall a blog that Ross McGarva (Finance Manager for Acute and Diagnostics) wrote way back in February 2015, entitled – “CRES and Our Collective Responsibility”. In this, Ross stated, “how the responsibility sits with everyone employed by the Board and how it’s not really a million miles away from what we do every day at home”. This statement still rings true now. We currently spend £250k on disposing of clinical waste, whereby audits carried out in the past have identified that up to 20% of what we dispose of this way can be disposed of in the general waste bags. In addition, we spend a further £300k on general refuse collection and disposal – if we could really ‘tidy-up’ our act, then these are two areas where we could reduce costs significantly.
- SAM Ideas – To date, we have now received over 600 ideas through the ‘small ideas matters’ intranet page. The SAM team continue to work through these ideas, passing them on to the relevant senior manager or onto the appropriate workstream to mandate the change suggested. As can be seen, the response from our frontline staff has been overwhelming. These ideas are now being considered and discussed within the SAM workstreams to agree how best to implement them to maximise not only the potential level of savings suggested, but to ensure our services are as sustainable and as modern as they possibly can be, with the backing of our staff across the entire organisation.
- Building on our success – Given the incredible response to date from our front-line staff, we would urge everyone to keep going and suggest new ways of working. Oh – and don’t be afraid to ‘hold people to account’ or ‘challenge’ behaviours or practice that could be improved. Compassionate Leadership does not preclude the practice of asking people, “why they do things”, or “why they do things differently”. At first, being asked how or why you do something, can feel awkward and frustrating, often leading to defensive positions. We are no different when challenged by colleagues across Scotland. However, understanding why and how we approach things (no matter how slight the differences have been), has made us reflect and challenge how we do things across the wider team back in Dumfries and Galloway. We urge everyone to welcome questions that open a ‘healthy’ debate about how we could do things differently and help us all to improve the quality and delivery of our services across the region.
What Next ?
“It’s not enough to be busy, so are the ants. The question is, what are we busy about?”
Henry David Thoreau
We are indeed all busy all of the time, however, focusing on what is next and preparing for what the key changes we need to make, encapsulate what we need to be able to demonstrate as a successful NHS organisation. We need to continue to evolve and change our practices, shine a beacon on examples of excellent care and services as well as looking to the future to continue to strive towards what the next set of challenges will be. And challenges there will be. In this time of austerity and uncertainty, the NHS needs to continue to be able to demonstrate its immeasurable capacity to accept change and focus on improvement and innovation to ensure the quality of services we will continue to provide are amongst the best in the country.
We see SAM as a resource that can help support this beyond this year and the next, identifying the best way to ensure our services can be sustainable in the modern world of the NHS.
We would love to hear from you on any ideas you may have that you think will help us on this challenging but achievable journey.
Graham Stewart is Deputy Director of Finance and Katy Lewis is Director of Finance at NHS Dumfries and Galloway