We must nurture all the apples on the NHS tree

Of course the health service would be nothing without its clinicians. Yet they, and we, know that the whole picture involves the whole team delivering healthcare. As the NHS faces rising demand and years of funding growth well below the long-term average, the hard choices ahead need to involve planning with an eye on the whole picture.

Non-clinical staff make up a substantial proportion of the staffing headcount and pay costs in an NHS provider trust (be they acute, community, ambulance and/or mental health provider organisations). The range of such NHS professions is wide: patient administration, IT, estates, HR, catering, cleaning, procurement, parking, security…

While doctors and nurses rightly get the lion’s share of attention, they could not do what they do so well without the committed and professional support of non-clinical colleagues

All the staff in these occupations provide a wide range of services that have an impact on the patient experience. Their vital work includes:

• Cleaning premises, including the special requirements of all clinical areas, so that the environment is clean, looks clean and, so far as possible, eliminates healthcare-associated infections;
• Providing a service which ensures each patient has meals that meet their preferences and support their recovery;
• Moving patients, linens and clinical supplies to ensure that patients are in the right place at the right time and the hospital functions smoothly;
• Procuring equipment, supplies and services to support good clinical care while securing best value for the trust;
• Looking after the whole physical estate, ensuring that buildings are maintained and all facilities are fit for purpose;
• Providing all forms of patient administration to ensure that appointments are made to support good clinical care; are convenient for patients; meet access targets; minimise the number of appointments missed or cancelled.

Lion’s share of attention

As well as directly patient-facing roles, non-clinical staff ensure running of the corporate functions which underpin all successful organisations, including:

• All aspects of employee lifecycle, from workforce planning, recruitment, accreditation and performance management;
• Deployment of technologies, including IT, to ensure hospital functions (and those in community settings) are well supported – efficient and effective;
• Financial, planning, legal and compliance functions.

While doctors and nurses rightly get the lion’s share of attention, they could not do what they do so well without the committed and professional support of non-clinical colleagues. In the best-run NHS organisations, non-clinical functions are expected to have an impact on the patient experience, clinical outcomes, the productivity of frontline clinicians and the utilisation of expensive clinical assets.

Some examples of good practice we have seen include:

• Patient catering provided to the highest standards of nutrition and hydration, with special care given to patients with (for example) dementia or diabetes, so that their care and recovery is as good as it can be.
• Patient moves to and from radiology planned to optimise the utilisation of equipment, as well as to support individual care.
• Information to support patient booking helping patients arrive in the right place at the right time. Likewise, booking processes that help to ensure pre-clinical activity and diagnostic tests are undertaken in good time, to make the outpatient clinic appointment productive.
• Estates maintenance activity will be programmed to ensure best value is achieved over the lifetime of expensive physical assets.
• Tracking technologies will ensure that mobile clinical equipment is not lost or hoarded, is properly maintained and clinically clean, and is replaced when no longer safe or properly functional.

Unfortunately, some parts of the non-clinical workforce do not enjoy the support they need to allow them to provide high-quality services. In our experience, non-clinical services – especially patient administration – can be poorly served by operational processes, which rely heavily on personal knowledge and sometimes heroic efforts to achieve acceptable outcomes. Equally, investment in technologies is often poor, leading to inefficiencies, poor productivity and inconsistent services.

Carter observed that there is huge variation in costs between trusts, and huge, seemingly unwarranted, differences in cost per meal and cleaning cost per square metre

Comparatively low paid non-clinical staff are often not highly motivated: this is not just about money but can be linked to poor working conditions, lack of proper tools to do the job and lack of understanding about what goes on in other parts of the organisation.

The recent Carter report into NHS procurement highlights many potential efficiencies and improvements. In estates and facilities management, it set out a target to make savings of £1bn per annum out of current total spend of around £8bn – one fifth of the total Carter savings target of £5bn.

Carter observed that there is huge variation in costs between trusts, and huge, seemingly unwarranted, differences in cost per meal and cleaning cost per square metre of occupied space.

Naive observer

In administration and corporate costs, the staffing totals 137,500 full-time equivalent roles; total costs are £4.3bn across all non-specialist acute trusts. Median costs in acute trusts are 8 per cent of revenue, within a range of 6 per cent to 11 per cent. Carter sets out the aim to save £300m by initially driving down costs to 7 per cent of revenues, or below. It also outlines a requirement on trusts to commit to a nationally orchestrated Procurement Transformation Programme, expected to deliver £700m savings in spending on goods and services.

Part of these variation may be attributable to data inconsistencies, but only the most naïve observer would think there are not huge opportunities to improve cost-effectiveness in many organisations.

It seems to us that in making these savings, care needs to be taken not to damage the support that these important non-clinical services make to the care of patients and the productivity of frontline clinical staff.

All of these are a missed opportunity to make care better, safer and perhaps cheaper. For these reasons, we wanted to work with HSJ on this inquiry to understand the current and potential value of the NHS’s non-clinical staff.

Unless we adequately value the contribution of this vital part of the workforce, the risk is that the current ambitious quest for efficiency gains will perceive this as an easy target, worsening the situation. Instead, we need to value all parts of the system, and learn from other parts of the public sector which have had to share or remodel non-frontline functions.

Best in class

We go into this inquiry with open minds, but we should also beware of the “easy cuts” that damage the financial viability of the wider system and potentially impact adversely on good quality care for patients.  

Better, surely, to look for collaborative partnerships that allow investment to take out unnecessary cost: scale of operation may allow adoption of superior technologies and innovations that boost productivity and improve staff engagement, which reduces sickness/absence.  

Getting to “best in class” will support efforts to reduce length of stay, raise quality, reduce delays and poor handovers: all of which is a much more effective route to sustainably reduce costs.

Douglas Ritchie is business development director, Serco Health; Andrew Prince is development director, Serco Global Healthcare Centre of Excellence; Simon Bailey is sales director, Serco Health.