The NHS faces a big challenge in delivering healthcare to patients in the face of budget pressure and continuous growth in demand for services. This has led several trusts to scope out efficiency cost savings in greater detail and depth. Managers are becoming more willing to explore ways in which they can create large-scale savings.

People are often reluctant to change longestablished practice, and the energy and complexity of changing a structure can appear daunting to managers. As a healthcare delivery improvement specialist, we have supported trusts on improvement projects to drive savings within months.

The key areas of opportunity have proved to be in operating theatres and outpatient clinics and in reducing length of stay.

We recently delivered a project on behalf of the Royal Wolverhampton Hospitals NHS Trust (RWHT), which, due to lack of capacity in-house, was outsourcing six orthopaedic elective theatre sessions to another acute provider each week. These sessions, which were not as well used as sessions carried out in-house, represented a significant loss of income for the trust.

In-house push

Newton worked with the team to create capacity to bring in all the outsourced sessions. This involved optimising existing theatre facility usage, increasing the use of day case theatre sessions and reducing the number of cancelled sessions.

The project began with a detailed assessment of the performance of theatres at RWHT. Historical data, live studies and discussions with clinicians, nursing staff and management enabled all losses to be identified, quantified and prioritised. Three areas of opportunity were identified:

• Unallocated sessions being inaccessible due to a multitude of complex and interdependent timetabling constraints
• Reduced day case theatre use due to late starts and early finishes
• Lost sessions due to cancellations.

A detailed project plan was agreed with all stakeholders. Analysis identified permutations of theatre timetables that would free up six sessions a week, working within constraints such as theatre clinical suitability and physical configuration, staff external commitments, and surgeon and anaesthetist partnerships.

The problems solved included theatre preparation, communication and rota planning. Early finishes were avoided by decreasing inpatient cancellation rates and improving theatre list booking efficiencies.

Working across a number of specialties, with managers, clinicians, nurses and clerical staff, Newton quantified true capacity and demand in all types of theatres, taking in all constraints associated with possible moves and validating all possibilities to increase orthopaedic elective capacity.

Forty-six session moves were agreed, making use of sessions previously inaccessible and cascading case mix down from main theatre to day cases, and from day case to treatment rooms. Within weeks, all stakeholders were so confident the capacity was available in-house that they terminated the contract for the outsourced theatres.

Greater uptake of sessions was achieved by simplifying the process of cancelling and reallocating theatre sessions. This process, created after input from all levels of the administration and management team, improved the visibility of cancelled theatre sessions and simplified the process of cross-speciality list reallocation.

All six outsourced sessions are now being carried out in-house, resulting in a 14% increase in the number of orthopaedic theatre sessions being run in-house – a saving of £744,000 a year.

This comes with the additional benefits to RWHT of reduced infection risk, streamlined patient pathways, greater patient choice, reduced waiting times and reduced cost. In addition, improvements in day-case theatres led to a 15% increase in use over all specialties, recovering £303,000 a year.

Enhancements to the visibility of cancelled sessions and the process by which they were booked, cancelled and reused has also created 2.4 extra sessions every week – worth £197,000 a year.

In total, RWHT has made £1.25m in recurrent annualised savings by optimising and improving orthopaedic theatre sessions in six months. We have also helped create a further annual 3,400 appointments across RWHT's rheumatology, dermatology and diabetes outpatient clinics.

The efficiency measures increased clinical activity per clinical nurse specialist to national benchmark level and ensured demand and labour availability were correctly matched, saving the trust about £685,000 a year.

Culture shift

Realising and implementing these efficiency improvements across a trust calls for work at a detailed level with dozens of clinicians, managers and staff who already have an established effective way of working.

Booking theatres and clinics accurately is also difficult because you need the right information systems in place to optimise lists and to provide future visibility.

What is essential with all changes is having full clinical and management buy-in to updating areas such as clinic templates, session times and patient pathways.

The efficiency challenge remains critical for the future of the NHS – but this means looking closely at the areas where there's still opportunity to squeeze out cost.

With pressure growing for trusts to realise dramatic cost and service improvements, there is more need than ever for clinicians and managers to deliver complex, hard to reach opportunities such as these.