Striking the balance between efficiency and quality of care

The overall priority at Mid Staffordshire Foundation Trust, and previously at Liverpool Heart and Chest Foundation Trust where I was the director of finance for four years, is to make sure financial imperatives do not have a negative impact on patient care.

In the past three to four years at Liverpool Heart and Chest Foundation Trust, our efficiency target went up from 3 to 4 per cent − from £3m to £4m annually − which required us to save an additional £1m. We managed to make these savings to the overall budget without having an adverse effect on patients.

In fact, things got better for patients during that time, which was clearly demonstrated by improving mortality rates, a decline in infection rates and an increase in reported patient satisfaction.

If you improve the quality of your services and patient outcomes, it can result in a reduction in costs

Mid Staffordshire, where I am director of finance and performance, is now looking at a requirement to save 5-6 per cent year on year over the next five years. And these savings have to be made against a background of increasing demand for healthcare and growing expectations of a high-quality service from clinicians and patients.

Happily, evidence shows that if you improve the quality of your services and patient outcomes, it can result in a reduction in costs.

In Liverpool, a clinically led review looked at why the resternotomy rates − where patients were reopened for control of bleeding following heart surgery − were higher than expected.

The impetus for the review was to improve the outcomes for patients, not to produce cost savings.

Having complications following cardiac surgery meant patients had to go back into theatre to be reopened and operated on again, which was not only bad for the patient but was more expensive for the trust.

Better for patients

The review improved outcomes for patients by reducing resternotomy rates. And because the trust was getting patients home quicker, using less theatre time and fewer blood products, it was making savings of £200,000 a year.  

Another example was the introduction of one-stop clinics in Liverpool, where a patient was able to come into the trust for their outpatient appointment and have all their diagnostic tests completed before they went home. When they left, they already had a diagnosis and management plan.

This is much better for patients on every level. A quicker diagnosis means a likely better outcome. Passing through the system quicker is likely to reduce costs and length of stay for the trust.

Areas for improvement

The challenge for the finance director is to work with the clinicians to provide the information that directly demonstrates the relationship between efficiency and quality.

By introducing a patient-level information costings system and a service line management system at Liverpool to identify the cost of poor quality or inefficient care at patient or consultant level, the trust was able to make substantial savings.

PLICS is a computerised information system set up to track and enable analysis of the costs of care incurred by individual patients. Service line reporting gives the aggregate level of costings making it easy to see why some doctors cost more to carry out the same treatment. Although we might have been having conversations regarding standardisation and quality previously, we did not have the data to inform that debate properly.

These systems gave us an evidence base to challenge clinicians and we were able to capture the information and make it more transparent and easier for consultants to review their practice.

Liverpool Heart and Chest FT won awards six years in a row for its patient care and improved its financial outcomes

We had a thoracic surgeon who had good with good patient outcomes but who was consistently £300-£400 more expensive than his colleagues for one treatment. Using the data captured in this system, he discovered he was consistently using more staples to close a lung section in a particular procedure. Where his colleagues used two packs of staples, he used three. He had been taught to put one staple either side of the section and one for good luck in the middle.

Once it was apparent he did not need a third he stopped doing it and saved about £400 per procedure. Without the information system, he would never have been presented with the evidence to challenge his thinking.

Implementing new systems

However, this did not happen without pain and difficulty. Our initial approach to implementing the information gathering systems was very top-down and very finance-driven. We struggled to get people to accept the data and to adopt the new systems.

After about eight months we established a different structure with clinical leads and structured our reports differently to bring together quality and finance. It took about 18 months to refine and develop an off-the-shelf product to make it the right fit for Liverpool Heart and Chest FT.

We will be looking to develop the same kind of solution in Mid Staffordshire but the situation is different here because the focus over the past four years has been almost exclusively on patient quality and getting that right at any cost, which is why we are in a difficult financial position.

The excitement for me about Mid Staffordshire is that now the quality measures are much improved we can concentrate on getting the finances right. And because the trust does not already have the data systems in place that worked so well in Liverpool, it means there is significant scope for financial improvement here.

Significant change required

Liverpool Heart and Chest FT won awards six years in a row for its patient care and improved its financial outcomes. The challenge for me is to see if I can adapt the systems, which worked very well at Liverpool, to the very different situation at Mid Staffordshire.

The board and Monitor have recognised that it will not be possible to recover the £15m deficit in the immediate future without significant service change. This means looking at how health services will be delivered across Staffordshire.

We are looking forward to contributing to the outcome of the Monitor-led review in October, which will identify how the local population will be ensured access to safe and sustainable health services in the future. At the heart of the review will be the consistent focus on ensuring improvements in quality and patient safety are delivered during any period of change.

Aaron Cummins is chair of the Foundation Trust Network’s financial network and director of finance and performance at Mid Staffordshire Foundation Trust