Comment / Dig deeper on quality issues

By John Yarnold

There is a real danger following the Francis report of knee-jerk reactions to quality and patient experience issues. Colleagues will look for additional resources to address such problems – the fear of failing to address such shortcomings could grow as stories unfold of substandard care and neglect. 

However, there are no more resources. In fact, in real terms, they are reducing while emergency admissions rise. It is against this backdrop that we face the need to improve safety and quality.

Most people would feel intuitively that spending more will result in higher quality. However, four years ago, my then colleague Dr Steve Allder and I argued this is not always the answer (Healthcare Finance, March 2009). We said higher quality was in many cases achievable at lower cost, rather than by relaxing the purse strings. Our arguments still hold true, and are worth restating. If anything has changed, it is the urgency with which we need to drive change.

Many demands for more resources are not based on an examination of the root cause of a problem. Often the cause is not lack of funds but the way resources are deployed. For example, why, when one has adequate establishment levels, is there often a refrain of insufficient staff on duty. The most common reason is poor rostering – a complex job often given to the lowest grade staff member, resulting in a rota based around staff wishes.

On a typical ward with an establishment of 30 staff, there should be five staff on annual leave at any one time. Any week where you have less than this will mean there are more staff available than you need for the rota and in future weeks there will inevitably be less. How many wards in your organisation have an equal number of staff on annual leave every week? What happens in school holidays? Allowing higher leave levels at these times has an impact on bank and agency staff costs.

Sometimes cases for resources are backed by evidence. But this often needs close examination. For example, a correlation between occupancy levels and serious untoward incidents might be offered as evidence of the need to open additional beds.

But correlation does not equate to cause. To understand why beds are full, organisations need to examine demand and length of stay by cohort (short stay under two days; medium stay two to seven days; long stay more than seven days). The most likely cause is not higher demand but variation in discharge rates and resulting delays in complex discharges.

Even where there is increased demand, it is often in the short-stay cohort. Could these patients be treated in the community? Or could a hospital stay have been avoided with better upfront diagnostic testing?

Addressing variation offers potential for service and cost improvement. There is a direct relationship between the level of variation and the resources needed to deliver. Yet most variation is caused by the way we organise processes. Most referral to treat problems are not due to lack of capacity but to poorly organised processes and variation in capacity.

I am not pretending for a minute that all the quality and safety issues in the NHS can be resolved through innovation and process improvement – there will be occasions when extra resources are the answer.

But in today’s financial climate, senior finance staff have a duty to make sure any funding is reserved for those issues that cannot be resolved by other means. They can do this with rigorous root cause analysis. Failure to ensure this optimum use of resources could see the NHS back in financial crisis again and that will not help patients or our profession.

John Yarnold is a director of Mount Vernon Consulting, currently working at Imperial Healthcare NHS Trust, and a member of the HFMA Governance and Audit Committee