Context

In 2017/18 Plymouth Hospitals had a planned CIP delivery programme of £40M as part of their requirement to return to financial sustainability. This requirement was set within the wider context of the Devon Success Regime and a county-wide challenging financial position.

Whilst the Trust was on track with many elements of its CIP programme, it identified challenges in two major areas, namely medical workforce productivity and provision of sub-scale services. The Trust commissioned CF to provide external capacity and capability to gain greater traction on analysing and understanding the issues and blockers to realising savings in these two key areas. 

In relation to subscale services, the concern was to better understand the clinical and financial implications of providing specialist services for Devon and Cornwall, which outside of the peak holiday season, provides a low population base to support some of the more complex and specialised service provision. Plymouth appointed CF because of our deep understanding of the clinical and financial issues within Devon and nationally.


 

Methodology and approach

Medical productivity

The Model Hospital highlighted low medical staffing productivity and so CF identified a representative sample of specialities where a deep dive would provide a detailed understanding of the systems, processes and cultural aspects that were driving current performance. Across the sample specialties:

  • Consultant job plans were reconciled with actual delivery, and conclusions drawn over the effectiveness of session allocation
  • Theatre productivity was determined by considering cancelled sessions, actual start/finish times against planned start/finish times and reasons for significant variances (>30 mins), throughput cases per session, percentage ‘hands on’ time, and individual consultant data activity ratios to show variation across individuals
  • Out patient productivity was determined using actual versus planned clinic data including those scheduled, cancelled and held as well as data including number of slots available, and slots unbooked, unattended and attended for each clinic
  • For ward based activities, interviews explored the efficacy and effectiveness of such activities and sought evidence to support such statements
  • Engagement with clinical and managerial leaders helped test the outcomes and shape the overall findings and provide much needed contextual and soft data to support our findings
  • What-if modelling was applied to lift parameters to good practice statistical goals (e.g. theatre utilisation at 90% capacity)
  • What-if modelling drove the identification of the financial opportunity based on agreed currencies

Sub-scale services

  • CF created and agreed a methodology with Trust leaders to define sub-scale services using activity and workforce indicators
  • A CF facilitated workshop with Trust executives identified further services for investigation based on segmentation as some service rotas ran at sub speciality levels
  • In agreement with the client, CF identified six services for deep dive:
  • CF conducted quantitative analysis based on a defined cohort of HRGs, developed with Trust clinical input. This facilitated benchmarking based on activity and overall cost coverage
  • Interviews and qualitative research and data gathering, conducted alongside quantitative analysis enabled CF to develop multidimensional pictures of each service
  • CF ensured transparency and Trust input throughout the project through close engagement and continuous reality checking of findings and outcomes with clinicians, service line leads and Trust executives
  • What-if modelling highlighted opportunities across the deep dive services, including the reduction of regional variance and break-even of certain procedures within the specialty alongside providing the Trust with a greater understanding of the regional delivery of such services which will support wider cross provider STP level discussions

 

Key outputs

The CF medical workforce productivity work facilitated:

  • Identification of a £12m+ opportunity across job planning, theatre utilisation, and outpatient utilisation, with an additional potential opportunity identified in the improvement of ward-based activity
  • Clear insights for the client on the drivers of low productivity
  • A methodology and toolkit for the client to further investigate low medical workforce productivity
  • High level communications and engagement plan and actions to address current performance
  • Provided the Trust with the required platform to instigate and deliver multiple change programmes focussed on those enablers identified as impeding productivity
  • Clinical buy-in to the key themes and actions required to address poor productivity

The CF sub-scale services work facilitated:

  • Identified £8m opportunity to improve productivity in sub-scale services
  • A clear understanding for the Trust that the sub-scale challenges faced are not exclusively related to the onsite presence of the Major Trauma Centre
  • Further reinforcement of the need to collaborate on a regional level
  • A methodology and toolkit for the client to further investigate all subscale services and challenge the status quo
  • Clear ways forward to address many elements of the drivers for poor financially performing subscale services
  • Clinical buy-in to the key themes and actions required to improve sub-scale financial performance

The success of this project was much more than the identification of c£20m improved productivity – it was the fact that this was successfully positioned as a Trust-owned solution upon which to gain traction with senior clinical leaders within the Trust and galvanise support to deliver the required changes. 

Moving forward, Trust executives are leading the various workstreams of the improvement plan we created. These workstreams included operational items such as Theatres, Outpatients, Job Planning and also enabling tasks to embed and sustain the changes, a refreshed accountability framework and a review of the clinical management structure. Given the challenging nature of the task and the difficult messages that we delivered, we are proud of the fact that we successfully engaged with the clinical and managerial leaders of the Trust, and obtained their buy-in to the delivery phase which the Trust is now taking forward.

Ann James CEO: “Through a highly skilled process of review and reflection, working with the Trust’s teams, CF quantified the potential within two long-standing hypotheses and have helped turn these into tangible programmes of work for both the Trust and the wider STP”

Project SRO and Finance Director Neil Kemsley: “The output of the CF work has provided the key building blocks for the Trust’s Financial Improvement Plan for 2018/19, giving a clear focus within the organisation and a basis for articulating our response to some key Model Hospital metrics”