“Efficiency savings” is a frequently used term, which simply means doing more with the same resources or doing the same with fewer resources. On reflection of my experience of supporting efficiency savings within a specialist centre in a tertiary setting, I have some key points that I would like to share.
Generally, efficiency savings can be considered within four specific themes: operational performance, financial performance, evidence base and safety, and regulatory considerations.
Broadly speaking, operational performance is influenced by key factors including staffing, both numbers of staff and skill-mix, capacity and workflow processes. Those key factors are in return affected by:
- Reduced number of trained staff
- Staff retirement
- Lack of funding for posts
- Increased activity in peak times such as the winter period
- Increased survivorship and complexity of care
- The challenge of mapping accurate data with cost and activity due to the complex commissioning picture in tertiary centres.
The above results in an increase of routine activity at specialised centres, consequently increasing waiting times and affecting delivery of care, which ultimately leads to poor patient experience and potentially affecting clinical outcomes.
You may like to consider the following:
- Develop a masterplan of pitfalls within all aspects of the service pathway
- Understand local data and compare with peer groups
- Staff support and development is key: ensure career pathways are defined and that staff are listened to, trained and supported
- Deliver new models of care and take advantage of new opportunities to ensure pharmacy is present during key decision making (e.g. telephone consultations, multi-professional clinics, subcutaneous self-administration at home, couriering services of oral medicines)
- Ensure where possible that services are being delivered closer to home and work closely with all system providers
- Provide training for the routine use of Quality Improvement tools, such as PSDA and IHI improvement principles, for all staff.
Financial considerations are also important in order to ensure that cost savings are delivered, wastage is minimised, and good relationships with the commissioners are maintained, which ultimately limits negative cost implications and maintains the tertiary centre’s reputation (figure 2).
The following suggestions may be helpful:
- Develop credible investment proposals with defined returns on investment in terms of safety, outcomes and monetary domains
- Negotiate with the commissioners on risk sharing models
- Seek funding from charitable organisations for projects, staff training or creating new posts
- Maintain engagement with clinical and non-clinical staff. For example, ask all members of staff to provide at least one idea each year for service improvement.
- Benchmarking could be tackled by using digital platforms such as Define Rx-Info and ensure IT systems can capture data accurately
- Use Quality Dashboard for specialised services and NHS Improvement tools
- Lead and develop the medicines optimisation agenda
- Visit best practice within and outside the Trust, nationally and internationally, to gain inspiration to solve existing problems.
Evidence-base and safety
A tertiary, highly specialised centre is expected to be a role model in delivering and leading the way for Cost Improvement Initiatives (CIPs), Commissioning for Quality and Innovation (CQUINs) and Quality Innovation Productivity and Prevention (QIPPs). This demand increases pressure on the service particularly in light of the paucity of evidence for highly complex and rare treatments which leaves fewer treatment options that tend to be more expensive. The lack of evidence also complicates the horizon scanning process for new drug regimens, which is heavily relied upon for local and national capacity and costing planning. All in all, this results in a reactive approach rather than a proactive one, with several negative implications.
You may like to consider the following:
- Train staff to develop competence in creating evidence as well as interpreting any limited available evidence
- Visit national and international cases of excellence to help expand personal and professional networks with experts around the world. This further supports innovation and ideas for the development of a personalised clinical pharmacy services.
- Establish Research and Audit Forums in order to oversee the research profile and identify priorities within a high-pressure service
- Strengthen and optimise academic links to further develop pharmacy practice and research, overcoming issues related to staff shortages while upskilling the team with a continuous flow of research opportunities.
Regulatory and ethico-legal considerations
Legal and ethical considerations within various working processes at tertiary centres are highly complex. These, amongst other factors, pose a significant impact on the availability of medicine and also affect the timeliness of having this medicine.
The following suggestions may be helpful:
- Update and maintain Standard Operating Procedures and guidelines
- Carry out Medicines Safety Thermometer reports regularly
- Ensure the overall training programme is optimal with on-going competence assessment
- Implement a culture of continuous reflection with audits, service evaluations and effective recorded keeping whereby accurate documentation of both, practices and clinical consultations, is paramount.
Common influencing factors
The above themes are heavily interconnected and discussing them in isolation is not appropriate. In addition to this interconnection whereby they impact each other, they are all further complicated by the following aspects:
- Exceptions offered by commissioners to tertiary centres on a case-by-case basis can mostly lead to erroneous and misleading expectations from patients, clinicians and even organisations. Optimising communication channels, proactively dealing with problems and keeping all key stakeholders aware of updates as they arise can manage expectations.
- Benchmarking at specialist centres, with relevance to drug usage and local practice, is challenging and affects the optimal identification of key performance indicators for efficiency savings. As discussed, digital platforms such as Define Rx-Info comparing practice with other Trusts are useful. This is in addition to the optimal utilisation of NHS Improvement Model Hospital tools as well as Quality Dashboards.
- Hard working staff giving up their time beyond standard working hours in order to meet unmet demands on the service, while commended, potentially leads to inaccurate assessments for accurately identifying pressures on the system. This is a tricky situation which requires a balance between what is important and what is urgent.
In handling these challenges we should keep in mind the importance of defining:
- Clinical profile and strategy
- Key strengths
- Key strategic documents within a local context (such as the NHS Long Term Plan, CQC Medicines in Health and Adult Social Care, as well as other relevant strategy in the specialist area such as oncology, paediatrics, etc)
- Priorities and success measures; identifying key performance indicators for operational performance, financial performance and safety metrics.
Working to a timeline, reviewing and revisiting priorities, and creating contingency plans are all very effective in achieving efficiency savings while providing high quality care.
It is noteworthy that recognition of consequences in failing to consider all aspects is of invaluable significance. Likewise, sharing (and celebrating) success where services are efficient, benchmarked safe, and person-centred is important to provide best care for staff and patients, maintain the organisation’s reputation and enable an environment that supports and drives change and quality improvement.
Positive cultures are powerful and I am a firm believer in the importance of teamwork. We must aim to move towards a service where pooling resources, collective responsibilities and joint working on improvement are at its heart. Every challenge is an opportunity to create a culture of commitment rather than compliance.
Sarah Carter, Jatinder Harchowal, Sarah Pacey, Zahra Laftah, Fleur Harvey, Lucia Van Bruggen, Haytham Shahata
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.