Good care costs less
This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Jeremy Hunt, Secretary of State for Health, talks about how improving the safety and quality of care will reduce avoidable costs for the NHS.
Let me start by saying what an enormous pleasure it is to be here today at Birmingham Children’s Hospital. This hospital is rightly proud of its record on quality and safety and has led the way in bringing the safety agenda to paediatric care, not least with its work on improving patient handover and on developing a safety thermometer for children and young people.
Indeed this hospital is powerful proof of the case I want to make today: that world class care is not just better for patients, it reduces costs for the NHS as well. And in doing so creates a virtuous circle where ever more resources can be invested in improving patient care rather than wasted on picking up the pieces when things go wrong.
A turning point
With huge financial constraints and the pressures of an ageing population, we are at a critical moment in the history of the NHS. So today I want to challenge head on those who say that the future will be about cost and not quality; who suggest that it is time to ‘move on’ from Francis and the lessons of Mid Staffs and want to focus on the ‘next thing’ - which they usually say is about money and nothing else.
“The path to safer care is the same one as the path to lower cost”. Those words were spoken to me earlier this year by Dr Gary Kaplan of Virginia Mason Hospital in Seattle, recognised as one of the safest hospitals in the world.
As a result of his hospital’s journey to safer care, which started with the tragic death of a patient in 2004, his costs for acute diagnoses are between 20 and 60% lower than his major competitors. Shorter hospital stays, more motivated and productive staff and lower litigation claims have led him to believe that hospitals could double their output on the same resources simply by eliminating the waste of resources associated with harming patients.
Not just in the US, but here in the UK too where Salford Royal is recognised as a leader in patient safety and quality improvement. Chief Executive Sir David Dalton says the focus they have had on quality improvements has yielded productivity improvements of around £5m each year, which they continue to reinvest in frontline care.
Across the hospital sector, the enormous progress made in recent years to prevent hospital acquired infections is showing how quality improvements save money. We have reduced C. diff infections by 45% and MRSA infections by 56% in the last four years, saving patients untold trauma but also an estimated £22.5 million in costs for the NHS.
The extraordinary ‘Sign up to Safety’ campaign that David Dalton leads has so far signed up over 100 trusts, including this one, to help spread good practice - making it one of the biggest hospital safety initiatives in the world. Indeed the enthusiasm for ‘Sign up to Safety’ is a remarkable testament to the commitment of the NHS to learn the lessons of Mid Staffs.
But my message today is that learning those lessons is not a one-off: it’s a permanent process of constant questioning and continual improvement in which the elimination of waste and the elimination of harm walk side by side as part of the same process.
Variation and lost value
Today the CQC are publishing their annual ‘State of Care’ report. Inevitably there will be media focus on examples where care is sub-standard. Indeed, shining a light on poor care is essential if we are to have the highest standards.
But the biggest lesson from today’s report is not actually the existence of poor care - it is the unacceptable variation in care outcomes across the system. And it is my job as Health Secretary to ask why it is that similar levels of resourcing, similar values and similar numbers of committed staff can produce such differences in quality.
My conclusion is that too many people still think that providing the best care is something you do only when you can afford it - and fail to appreciate that improving care is one of the best ways to control costs in financially challenged circumstances.
Which is why the report published today by Frontier Economics is so revealing in its analysis of the cost of poor care.
They estimate that it could be costing the NHS up to £2.5 billion every year.
And they highlight some of the shocking costs of poor care – from the £1.3 billion spent every year on litigation costs, to the cost of not ‘getting it right first time’ in orthopaedic care - which Professor Tim Briggs’s excellent work shows could save between £200-300 million every year.
These are large sums of money which the NHS is potentially wasting. But we should be careful not to anonymise their impact by sticking to large numbers. So today we publish further work to look at the cost of individual episodes of avoidable harm.
A single fall in a hospital is a tragedy - potentially life threatening - for the patient affected. It also costs the NHS on average £1,200 because of the extra care needed and longer hospital stay.
Likewise a hospital-acquired bedsore is very dangerous for a patient. But it is also dangerous for the NHS, costing on average £2,500. And we had 19,000 of them across the NHS in 2013 to 2014.
Catheter-acquired urinary infections are unbelievably painful. They also cost the NHS £67 million in 2013 to 2014 - which could pay the salaries of 1,300 nurses.
So I want every director of every hospital trust to understand the impact this harm is having not just on their patients, but also on their finances.
And I want every nurse in the country to understand that if we work together to make the NHS the safest healthcare organisation in the world, we could potentially release resources for additional nurses, additional training, and additional time to care.
So today a poster and leaflet will go out to all NHS hospitals to display this vital message to their staff.
If you’re short of money, poor care is about the most wasteful and expensive thing you can do.
Good care costs less.
The right model of change
But it is one thing to identify lost value, quite another to develop practical strategies to release it. So how do we reduce variation and improve safety?
In the best of NHS traditions it would be very tempting to set up a new target. Or issue a new ministerial decree.
But that would be a mistake.
Because the culture change we need to achieve has to come from inside, not because hospitals are being forced from the outside. What Gary Kaplan called ‘institutional culture change’ is based on listening to and valuing doctors and nurses on the frontline - the people who know more than anyone else what is needed to improve care.
So let’s take a moment to look at some of the traits shared by organisations that have excelled in improving patient care and eliminating waste.
The aggregation of marginal gains
The first trait is attention to detail.
When I was Secretary of State responsible for the Olympics I had the privilege of meeting Sir Dave Brailsford when he was training the Team GB cyclists. One of those cyclists was actually called Jeremy Hunt so I was just a tiny bit disappointed that despite their extraordinary medal haul - the best in British cycling history - Jeremy Hunt didn’t pick up a gold.
Sir Dave famously argues that the success he brought to Team GB cyclists was not about a new big bang approach, but what he called the ‘aggregation of marginal gains’. Paying close attention to the detail, to things which, on their own, seemed insignificant - but when added up mean the difference between winning and losing. At the Manchester Velodrome Chris Hoy told me about his first ever gold medal at the Copenhagen World Championships. He won by 0.001 of a second. His aggregated marginal gain set him on the path to being our greatest ever Olympian.
This is really important because we should not think we can unlock £2.5 billion in one go with a new policy. But we will unlock it in hospitals with a new culture. And it’s a culture that really cares about the details, the little things, all of which add up to better care and less waste.
Some of these gains will be in the form of money – in management jargon, ‘cash releasing’. But some will be in the form of increased value for patients and staff - freeing up resources in ways that lead to better patient care, greater staff motivation and long-term productivity gains. In high-performing organisations, these two things will go hand-in-hand.
The right relationships
Another trait in hospitals with world-class safety standards is proper collaboration between management and frontline staff. We have recently seen powerful evidence to support this from the joint work by the Academy of Medical Royal Colleges and the NHS Confederation. They explore what they call ‘Decisions of Value’ and conclude that good relationships between clinicians and managers is critical in securing value for patients.
Their report shows that over half of clinicians do not believe they are involved in the financial decisions that affect their service or team. But how can you break the dangerous nexus between poor care and higher cost if the clinicians responsible for patient care have no input into the financial decisions that affect their work?
Likewise we need to build better partnerships between commissioners and providers, not least in developing integrated care pathways that we know both improve care and eliminate waste.
Openness and transparency
What else characterises leading organisations? Along with a focus on detail and relationships, they have an obsession with openness and transparency based on high-quality data.
Not far from here, patients at Queen Elizabeth Hospital can log onto ‘My Stay@QEHB’ which allows them to see how their specialty performs compared to hospital expectations.
Transparency can also be about reaching out to patients and the public: it is fantastic that one of the first things you see on the Birmingham Children’s Hospital website is a section called ‘What’s it like here?’ that makes the strange world of hospital care more familiar for children.
The best organisations crave data as a vital tool to drive improvement. We are blazing a trail with the new MyNHS website, which makes the NHS by far the most open and transparent healthcare system in the world. Now with detailed and easily accessible information on hospital, local authority and mental health performance, I am confident that this project will demonstrate that in the modern NHS the best way to improve performance is transparency not targets.
The best example of the power of transparency has been the way the NHS has responded to the tragedy at Mid Staffs. I could have said as part of the government response that I intended to hire another 10,000 nurses - and it would have been a disaster. Not only would we have ended up with the wrong nurses in the wrong places, but the measure of success would have been meeting an input target, not improving care for patients.
Instead we did something far more powerful.
Firstly we asked every hospital in the country to collect and publish information from their patients on whether they would recommend the care they received to a friend or member of their family. Based on the net promoter principle, this was the first time anywhere in the world patient views had been sought comprehensively across an entire health economy.
Then working with Chief Nursing Officer Jane Cummings we asked every hospital to publish the number of planned and actual nursing staff for every single ward. Finally, we made patient experience a central part of the new independent CQC inspection regime.
And the result? Yes the NHS did hire 5,000 more hospital nurses to fill in critical gaps after Mid Staffs, often in elderly care wards. But more importantly a change in attitudes to the importance of quality of care - as opposed to simply quality of treatment - saw an 8% jump in just one year of the people who believed they were treated with compassionate care by the NHS. No target, no extra money, just transparency about performance.
And in some cases improving on this has not required more staff at all. For example, there are some Trusts – including Portsmouth, Coventry and Royal Surrey – that are using an electronic physiological surveillance system to improve the monitoring of vital signs, with impressive early impact on patient mortality that has not required large increases in staffing.
And consider the example of Guys and St Thomas’s where they have been looking at how redesigning basic processes and using technology can give nurses more time with their patients. With only a small increase in staffing of one extra nurse working on discharge and another at night, they were able to increase contact time with patients from 48% to 75% while also reducing length of stay. Hugely beneficial to patients, and better for staff too.
Cost and quality: challenging assumptions
These therefore are some of the traits of high-performing organisations.
And underlying all of them is the shared assumption that cost and quality are not alternatives to be traded off, but different aspects of the same ambition to provide safe, effective care on a sustainable basis. This directly challenges the conventional wisdom that ‘you get what you pay for’ - as does the CQC’s ‘State of Care’ report which shows massive variation despite similar input costs.
It also challenges the received wisdom that there is little value left to get out of the system now that the so-called ‘low hanging fruit’ has been plucked.
And it challenges the other commonly held view that only large-scale change will release significant value. Of course we will need to continue to make important changes to care pathways - but as we do that we need to support trusts in making the small improvements that, when aggregated, will make a big difference.
I hope therefore that from today in hospital board meetings up and down the country one simple change happens: patient experience and patient safety are not discussed separately to finances - but as two sides of the same coin. Wouldn’t it be fantastic if a hospital board was as focused on its ‘safety improvement plan’ as its ‘cost improvement plan’, and saw them both as part of the same objective of doing a better job for patients.
I am proud of the additional investment this government has provided and will continue to provide to the NHS. Nobody would pretend that the financial sustainability of the NHS will be ensured by improving safety alone. But it has a critical contribution to make.
The path to lower cost is the same as the path to safer care.
Hospitals that embrace one embrace the other too.
Hospital safety and hospital finances both improving and patients as the winner.