GIRFT: right way to go

05 June 2018 Seamus Ward

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With the NHS focused on integration together with the current and future financial position, steps to improve the quality of patient care have arguably taken a back seat. But separating quality and financial sustainability would be foolish – reducing unwarranted variations and sharing best practice can improve care and patient outcomes, reduce the amount of unnecessary procedures and cut costs. Often such improvement programmes have been managerially led, leading to accusations that they are being driven by cost cutting. That’s where Getting it right first time (GIRFT) has an advantage – the programme is clinically led and based on spreading best practice.

GIRFT was piloted in orthopaedic surgery and, though primarily aimed at improving clinical quality, the savings it generated immediately caught the eye. After the pilot, an NHS Improvement survey of more than 70 trusts found they had saved £30m in 2014/15, with a further £20m forecast in 2015/16. Extrapolated across the 140 trusts visited by the orthopaedic pilot, savings would reach almost £100m.Maze

In November 2016, the programme was expanded, with £60m funding from the Department of Health. It now covers 31 medical and surgical specialties, four clinical services (including pathology and imaging) and six cross-cutting workstreams (including coding, litigation and medicines optimisation). Health secretary Jeremy Hunt said at the time GIRFT would help save the NHS £1.5bn a year.

When the expansion was announced, GIRFT chair Tim Briggs – who led the orthopaedic pilot – said: ‘Because GIRFT is led by clinicians, frontline medics in the specialties being reviewed welcome it because they can share both their best practice and their challenges with people that understand clinical service. But importantly, good patient outcomes and safety have remained paramount throughout the programme.’

GIRFT is now part of the Carter efficiency and productivity work, and though run by NHS Improvement and the Royal National Orthopaedic Hospital NHS Trust, is seen as complementary to NHS RightCare.

It is both a national and local programme. Generally, the GIRFT process has a number of stages. Trusts to be reviewed answer an extensive questionnaire prior to a visit from the GIRFT team. The team combines this with relevant existing data to produce an information pack, identifying areas of opportunity that are discussed in detail during a visit to the provider. GIRFT teams also offer support to trusts to help them implement their recommendations. The reviews of individual trusts are merged to produce a national report, which draws out trends and potential savings, together with recommendations for reorganising services.

To date, four reports have been published. As well as the initial report on orthopaedic surgery, there have been reports on general, cardiothoracic and vascular surgery (see boxes for the recent reports).

GIRFT has been praised nationally. In a report last year, the King’s Fund said that, on the limited evidence so far, the programme was achieving real gains in procurement, productivity and quality. However, buy-in varied and it was important that clinicians and managers work together to deliver the programme’s full potential, the thinktank said.

Trusts such as Maidstone and Tunbridge Wells NHS Trust have used GIRFT, patient-level costing and Model Hospital data to improve efficiency, performance and quality (see report on HFMA Healthcare Costing for Value Institute website).

It is also having a significant impact on services. In the south of England, some trusts have reportedly stopped performing procedures after being identified as an outlier by the GIRFT programme.

University Hospitals of Leicester NHS Trust deputy head of operations Judy Gilmore says that GIRFT has provided the trust with information that has helped to support clinical and operational developments. Three of the trust’s departments have been involved in GIRFT reviews – the cardiac and thoracic departments, which are separate in the trust, and vascular surgery.

Tackling inefficiency

Ms Gilmore (pictured), who manages the trust’s renal, respiratory and cardiovascular clinical management group, believes using the review information in conjunction with the Model Hospital data is a useful tool against inefficiency and links well to the trust’s cost improvement programme (CIP). While GIRFT identifies the opportunities, the Model Hospital data is used to pin down the potential financial benefits.Judy_ Gilmore

She says: ‘Opportunities identified tend to be on efficiencies, but also support clinicians. Day of surgery admission is one of the key areas – some wards are doing that really well, others not, because we don’t yet have the buy-in across all clinicians.’

The cardiothoracic review showed good compliance in many areas, together with opportunities for clinical and operational development. As well as the day of surgery admissions, which applied to both cardiac and thoracic departments, these included recommendations to improve processes to have a positive impact on patient care.

In cardiac services, for example, the review recommended weekend consultant-led ward rounds – these are being held on an informal or voluntary basis pending review of job plans and probably further investment.

In thoracic surgery, the review found that the unit performed 41.6% of lung resections for cancer via video-assisted thoracoscopic surgery (VATS) in 2016, which is below the 51.6% national average. However, the thoracic surgery department does not have access to a surgical robot – most of its peers are developing a robotic surgery programme, and access to a robot would facilitate an increase in robotic-assisted resections in line with the GIRFT recommendation.

VATS surgery for empyemas is below the national average, though it is likely to be due to coding discrepancies. Ms Gilmore says the service is likely to achieve the GIRFT-recommended 50% VATS empyema surgery target within six months.

The review also gave recommendations on litigation and bed numbers. In cardiac services, it suggested litigation cases be presented at regular mortality and morbidity meetings, with a biannual report to the clinical management group board. The thoracic group will aim to implement a five-point litigation plan as soon as trust-wide guidance has been produced.

To comply with GIRFT practices, the review said there should be ring-fenced beds for cardiac surgery in intensive care and on wards. Added pressures in winter 2017/18 forced thoracic surgery to accommodate breast care, vascular and cardiac surgery patients. No intensive care beds were ring-fenced for thoracic surgery patients.

The trust is realistic about the GIRFT recommendations – for example, ring-fencing beds to increase activity is an opportunity, but it is difficult, especially during the busy winter period. This year it has prioritised working up a case to support ringfencing beds in the winter to reduce cancellations.

It is also prioritising reducing length of stay by increasing day of surgery admission in both cardiac and thoracic surgery; standardisation of techniques; and supporting development, for example robotic surgery.

‘We have good clinical engagement. The surgeons just want to operate – they don’t want to have to cancel operations because there are no beds – so they are willing to support the management team to become more efficient,’ Ms Gilmore says.

Claire Wilson, chief finance officer at Liverpool Heart and Chest Hospital NHS Foundation Trust, which was also reviewed for the cardiothoracic report, is positive about the trust’s experience with GIRFT. ‘It had real credibility with the clinicians, so they fully engaged with it. It was led by an experienced cardiothoracic surgeon, who our clinicians knew or knew of, so he had a high level of credibility and clinical data was taken from strong data sources.’

This was reinforced by the GIRFT review team knowing the trust’s data pack ‘back to front’ and being able to triangulate the clinical and productivity information, she adds. This gave its clinical and managerial leaders detailed information on where the trust’s cardiothoracic services excelled and where they could potentially be improved.

‘I imagine that to achieve that level of depth and triangulation is very resource intensive, but it was incredibly powerful. They gave us plaudits, but also pointed out where we could potentially improve and the clinicians listened.’

Leicester’s Ms Gilmore, who trained as a radiographer, says the GIRFT reports can increase clinician buy-in as the programme is clinically, rather than managerially, led. It has also helped bring together finance staff and clinicians to engage in reduction of unwarranted variation. ‘We’ve found GIRFT to be a useful programme. Sometimes it just tells you what you already know, but it gives us a focus and impetus to look at length of stay and day of admission. It helped me bring the clinicians on board.’

CIP programme

GIRFT is an integral part of the trust’s CIP programme and is used alongside the Model Hospital data to identify transformation schemes included within the CIP plans. This is particularly true in vascular services, which has six component notifications in the Model Hospital dashboard. A number of actions have been identified to improve efficiencies and outcomes for patients, and these include:

  • Reduction in re-admissions specifically in revascularisation including bypass and angioplasty
  • Reduction in length of stay for abdominal aortic aneurysm procedures through day of surgery admission and prehabilitation
  • Increased frailty/geriatrician support.

‘Judy’s clinical management group is more advanced than most others, and that’s where we want everyone else to be,’ says Ben Shaw, Leicester’s director of efficiency and CIP. He oversees the productivity improvement work at the trust, including GIRFT, Model Hospital and its CIP, and says the GIRFT programme is very useful.

‘We set the CIP targets and then the department should use GIRFT as one of the key tools to help identify and deliver those improvements.  These improvements range from identifying the need to reduce the average length of stay, theatre efficiency or even revise our clinical pathways. All of these can ultimately help us to become more efficient as a trust but most importantly the changes are good for our patients.

‘This year, we’ve used the Model Hospital data to help set CIP targets. It’s helpful in identifying what each department is more or less efficient in. We can then set varying targets based on the data and challenge those departments where there are greater opportunities for efficiencies or service improvements. GIRFT shines a torch on the opportunities.’

Clinician focus

GIRFT has the advantage of being a clinician to clinician programme. ‘If it had a corporate focus it would be difficult to engage clinicians, but the challenge is coming from fellow clinicians,’ continues Mr Shaw.

‘At one review meeting, the lead clinician from the GIRFT review asked our clinicians questions such as whether they knew the cost of an additional night’s stay and if not, why not. He also explained to our clinicians that after two nights, any additional night is going to end up in a loss for the trust. Many didn’t know that.’

Apostolos Nakas, a consultant thoracic surgeon who is the trust’s head of service for thoracic surgery, allergy and immunology, says: ‘Although some data appeared inaccurate, we felt that an external review was helpful in providing benchmarking to peer services.

‘Having said that, the report does not delve into depth in reasons for variance, such as casemix or regional workload, and some of the recommendations have been contested in specialty fora.’

Mr Nakas says the service will aim to comply with the recommendations clinicians find useful and feasible, such as day of surgery admission. He adds: ‘Others, such as proportion of VATS cases or ring-fencing ITU beds, are going to be more difficult to implement and are likely to cause some friction.’

The review information and recommendations are informing the Liverpool trust’s clinical and operational planning, as well as its financial targets. ‘We have a £150,000 CIP this year in one of the areas they picked up – pre-operative bed days – though the greater benefit will be in the improvement in patient experience,’ Mrs Wilson says. ‘While we already had plans to address this, the GIRFT report helped provide evidence for the business case and encouraged us to speed up the implementation – our same-day admission ward is due to be up and running from 1 June.’

Trusts now have a lot of benchmarking information to support their planning and cost reduction processes.

‘At Liverpool Heart and Chest Hospital, we are bringing together all of this information, together with listening to our staff to get their ideas, and this will inform our improvement priorities for the next few years,’ Mrs Wilson says. ‘Some of this benchmarking data is in the Model Hospital – the Model Hospital is a really useful tool, though there are challenges with data in some areas, which we will need to address. Specialist trusts have not yet been brought into the use of resources assessment, but we will be incorporating a shadow use of resources framework into our internal reporting processes to support our productivity work.’

Though some clinicians remain cautious about GIRFT recommendations, it has established a new level of engagement both nationally and locally. Retaining that clinical support will be crucial as the programme clearly has a lot of potential to be a major driver in improving efficiency, productivity and quality.

Cardiorthoracic surgery review

Designated specialist teams and better bed management could lead to better outcomes for patients with debilitating chest, heart, and lung conditions and greater efficiency, according to the GIRFT cardiothoracic review.

The review, published in April, examined all 31 NHS cardiothoracic units in England and made 22 recommendations to improve practice, process and outcomes, including:

  • Making bed management more efficient by ensuring surgery on day of admission is delivered routinely, helping reduce delays and time spent in hospital
  • Ringfencing beds on intensive care units and general wards for the care of cardiothoracic patients
  • Moving to sub-specialisation for certain critical procedures, such as aortovascular surgery for aorta rupture
  • Using less invasive thoracic surgery (VATS) for lung resection surgery – the report says VATS reduces complication rates as well as length of hospital stay.

Cardiothoracic surgery can benefit patients suffering from conditions such as blocked arteries, lung cancer and heart valve disease. According to the report, emergency surgery rotas for major trauma should be covered by both thoracic and cardiac surgeons, ending the practice of using cardiac surgeons to provide cover for emergency thoracic surgery.

It also proposes that all patients should be reviewed by a consultant both pre- and post-operatively, seven days a week, to ensure more timely patient discharge, particularly over weekends.

The efficiency savings could reach £52m overall when other savings such as better procurement and reduction of litigation costs are factored in.


Vascular surgery review

A network model for vascular surgery would save 100 lives a year, improve recoveries and save the NHS up to £25m a year, according to the vascular review.

The national review, published in March, said a vascular surgery network would reduce the likelihood of strokes, TIAs (transient ischaemic attacks), aortic aneurysms and arterial blockages.

Seventy NHS trusts in England perform vascular surgery and though many collaborate in a local network, there is no standard network model across the NHS and there are large variations in size, staffing and throughput.

GIRFT said a nationwide, 7/7 vascular surgery ‘hub and spoke’ network of specialist units treating every vascular surgery case as ‘urgent’ could save 100 more lives, substantially reducing the risks associated with blocked arteries such as sudden death, strokes, restricted movement and amputations. The network would ensure that early diagnostics, decision-making expertise and intervention – which are so often essential to the successful treatment of vascular conditions – are available around the clock.

GIRFT said the report identified a gross notional financial opportunity of between £7.6m and £16m, with a further £6.5m savings opportunity in procurement.

Supporting documents
Right way to go - June 2018