2.12 Since early 2010, the Department has set up a number of workstreams10 to help identify areas where the NHS can improve quality and productivity (Figure 4). Each workstream is led by a senior NHS figure. These workstreams fall into three broad categories:
● commissioning and pathways - these aim to support the commissioning of more efficient and higher quality services through improved clinical pathways and the decommissioning of poor quality services;
● provider efficiency - these aim to support providers to respond to reductions in tariff, for example, by reducing back office costs, improving procurement, improving the efficient use of medicines and improving workforce productivity; and
● system enablers - these aim to support and drive change, for example, through improved primary care commissioning (such as by improving the performance of poorly performing practices), better use of technology, and ensuring that all staff across the health sector are involved in delivering quality and cost improvements.
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Figure 4 Workstreams
| Commissioning and pathways | ||
| Workstream | Aim | |
| Safe care | To develop a safer system in which everyone understands their role in delivering safer care and works towards achieving that goal every day, for example, by reducing pressure ulcers, catheter acquired urinary tract infections, blood clots (pulmonary embolisms), deep vain thrombosis, serious injury and death from falls in care settings. | |
| Right care | To increase value and address unwarranted variations in spend, activity and outcomes through: using programme budgeting and marginal analysis to improve clinical commissioning; better value commissioning with knowledge, information and coaching; reducing the use of lower value interventions; reducing unwarranted variation in referral rates to elective care; and improving patient satisfaction and reducing the costs of treatment, by involving patients in shared decision-making. | |
| Long-term conditions | To improve the quality and productivity of services for the 15 million people who currently have a long-term condition in England so they can access higher quality, local, comprehensive community and primary care services and reduce their need for unscheduled acute care by helping them manage their condition better and slow its progression. | |
| Urgent and emergency care | To ensure that patients requiring urgent and emergency care get the right care by the right person at the right place and right time, through designing a simple system that guides patients to where they should go. It aims to achieve a 10 per cent reduction in the number of patients attending accident and emergency departments with associated reductions in ambulance journeys compared to those expected under a 'business-as-usual' scenario. | |
| End of life care | To reduce the emergency attendances and bed days, the use of inappropriate or unwanted treatment and the number of complaints from people near the end of life. By identifying patients nearing the end of life, and putting in place more systematic use of care plans for patients to support care in the most appropriate setting. | |
| Provider efficiency | ||
| Back office | To present NHS provider organisations with ways to reduce their back office costs. | |
| Procurement | To help NHS provider trusts reduce and optimise non-pay expenditure by 10 per cent to 20 per cent, without compromising quality of patient treatment and care, through guidance and toolkits to spread best practice. | |
| Pathology | To improve the service quality and productivity of pathology services. | |
| Productive care | To improve quality and productivity in provider organisations, and in particular to: reduce length of stay and readmissions; reduce sickness absence and overtime; free up non-productive time for staff; improve staff morale and wellbeing; and improve patient experience. By increasing local capacity and capability to scale up delivery of four initiatives: the Productive Ward; the Productive Mental Health Ward; the Productive Community Service; and the Productive Operating Theatre. | |
| Medicine use and procurement | To improve cost-effective prescribing in primary care, improve medicines management in secondary care, support patients to get maximum benefit from their medicines, and improve patient safety. | |
| System enablers | ||
| Primary care commissioning | To improve the way the NHS commissions and contracts for primary care services to reduce unwarranted variation, deliver more consistently high quality services and contribute to the efficiency needs of the NHS. | |
| Technology | To provide the underpinning technology required for the other national workstreams, support the development of regional and local IT strategies and compatibility and interoperability of IT systems. | |
| Mobilisation | To ensure staff, patients and the voluntary sector are actively engaged and working to deliver quality and cost improvements. | |
| Workforce | To plan for and ensure a flexible, mobile, well supported NHS workforce based on local needs both now and in the future. By delivering a framework to support the NHS to reduce agency staff costs, to reduce sickness absence and increase labour productivity. | |
Source: National Audit Office literature review
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2.13 Workstreams provide support, training and tools to help providers and other bodies realise improvements and efficiency savings. For example:
● The right care workstream produced: the NHS Atlas, a series of 34 maps of variation, which can be used to identify unwarranted variation in quality, outcomes, expenditure and activity within all levels of the NHS; and a Health Investment Pack for each primary care trust that shows what can be done to analyse and prioritise health investment within local populations.
● The workstream covering back office functions published a report, Back Office Efficiency and Management Optimisation, in November 2010, which outlines ways to simplify core functions (for example, by re-engineering processes around best practice), drive out unnecessary work and activities, standardise process and maximise opportunities for sharing services and cost bases.
● Over a nine-month period, the clinical support programme offered participants four, two-day learning modules focusing on different aspects of leadership development, including self-directed problem solving and mentoring sessions.
2.14 The material generated by the national workstreams is shared with the strategic health authorities who are free to choose between the different schemes and adapt them to their local health economies as they see ft. Strategic health authorities can choose to use as many workstreams as they wish. Once a workstream becomes embedded and requires less management and clinical effort, strategic health authorities can pick new workstreams to develop.
2.15 The number of workstreams does not remain static. Originally, the Department established 12 workstreams. A few additional workstreams have been added, and it is likely that several will be removed as their functions get fulfilled. Some workstreams engage with organisations across the health sector including strategic health authorities, primary care trusts and providers, whereas for other workstreams all communication goes through the strategic health authorities.
2.16 Many of the national workstream leads were responsible for monitoring the uptake of their initiatives in strategic health authority plans. As of April 2011, the focus of national workstreams shifted as the NHS moved out of a planning phase into delivery of plans. The NHS Operating Framework for 2011-12 set out the way that the Department will monitor progress in the NHS, including progress on implementation of QIPP. The overall monitoring of delivery in the Department is led by the Department's Performance Delivery Team, who work closely with strategic health authorities and policy teams to understand and performance manage progress. Monitoring performance is challenging for some QIPP workstreams because:
● robust measures to assess progress have yet to be developed;
● tracking and attributing financial benefits can be problematic as some strategic health authorities have individual targets attributed to each workstream but others are focusing on the overall savings; and
● attributing savings to individual workstreams can be problematic, for example, the workforce and primary care workstreams are interrelated with the productive workstream making it difficult to measure and attribute financial savings independently.
2.17 Workstreams collaborate with a number of health organisations to develop ideas, support implementation and promote good practice. For example:
● The NHS Evidence website hosts a collection of practical examples of how health and social care staff are improving quality and productivity across the NHS and social care.11 NHS staff can submit examples which are then evaluated by the National Institute for Health and Clinical Excellence (NICE). This evaluation is based on the degree to which the initiative meets the QIPP criteria for savings, quality, evidence and implementation; each criterion is given a score which are then combined to give an overall score. The overall score is used to identify the best examples, which are then shown on the website as 'recommended' or 'highly recommended'.
● The productive care workstream is overseen by the NHS Institute for Innovation and Improvement. The Institute is also developing a web-based tool which will identify key products and services that the Institute has available to help organisations with the implementation of the QIPP challenge.
2.18 Strategic health authorities told us that they found some of the workstreams very useful, such as the end of life care workstream and the right care workstream (and in particular the Atlas of Variation), but that overall, the majority of them were of limited use. They cited the fact that savings needed to be identified from the bottom up (i.e. what can work locally) and, therefore, national workstreams were of limited use. They also told us that some national workstreams were less proactive in their engagement with the health sector, which limited their usefulness.
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10 http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPPworkstreams/index.htm