CAPÍTULO III. MARCO TEORICO Y CONCEPTUAL
3.3 Marco referencial
The period of gains in the efficiency of the NHS in the 1990s was associated with bed reductions (Department of Health, 2000). To the extent that the current NHS operating framework (Department of Health, 2009a) will put downward pressure on both the volume of growth and the price of hospital services over the next three to four years, eventually reductions in capacity will be necessary if trusts are to remain efficient. However, it will be difficult to reduce capital inputs such as buildings and land over such a period, especially if only parts of a site become surplus to requirements. Wards and other facilities can be closed or mothballed, but capital charges can remain. In other words, at times of contraction, building and land costs can impose diseconomies if services are not concentrated on fewer sites, for example. The NHS Confederation has pointed out that it will assist in making savings if whole sites can be closed, and The King’s Fund has concluded that reconfiguration across hospital sites is the only way that some trusts can achieve financial balance while avoiding unacceptable deterioration in quality of care over the next five years (Palmer, 2011).
If downsizing is expected to be permanent or there are already plans in the pipeline for rationalising facilities which can be modified, it may be possible to concentrate services on fewer sites, at least in large urban areas, in the required timescale, thereby releasing buildings and land and restoring the remaining hospitals to something like their former average size before the contraction. However, from a whole-system viewpoint, such concentration is likely to have adverse effects for patient access. In addition, it may have adverse effects for competition, which could impact negatively on efficiency, judging by some of the studies cited elsewhere in this report.
Box 6.4: Increasing day surgery and reducing length of stay
• The Royal Wolverhampton Hospitals NHS Trust went from being in the bottom 25 per cent of the country for day cases in 2005/06 to having all but one procedure meet targets for day cases, and six procedures performing among the top 5 per cent in the country the following year. It also reduced preoperative length of stay and cancelled operations by half during 2006/07.
• Sandwell and West Birmingham Hospitals NHS Trust saw its average length of stay fall from 6.4 days in 2005/06 to five days by 2007/08, and an increase in the proportion of planned work undertaken as a day case or short stay from 88 per cent in 2006/07 to 92 per cent in January 2008. • Barnet and Chase Farm Hospitals NHS Trust considers ‘Discharge Jonah’, a decision-making
tool that identifies blocks in the patient pathway, to be its most successful initiative in terms of improving efficiency. “It helped to explode some of the myths about where the problems were,” says Chief Executive Averil Dongworth. Within the first year it was credited with reducing the number of days of delayed discharge by half (Barnet and Chase Farm Hospitals NHS Trust, 2007).
Private Finance Initiative (PFI) schemes, which provide, typically, private premises, equipment and cleaning and catering services to the NHS on long-term contracts, represent a new and growing challenge in the search for savings. There are
approximately 100 PFI schemes in the NHS at the time of writing, and there are more in the pipeline. PFI schemes can commit trusts to substantial annual payments for up to 30 years. They usually cost more than the equivalent public provision – perhaps because they provide a higher standard of service – and they frequently represent between 5 per cent and 15 per cent of a PFI trust’s income. The Audit Commission (2006) has identified an association between large new building projects (mostly PFI schemes) and financial deficits in the NHS. There is relatively little flexibility in PFI contracts, and because of this it has been suggested that there will be pressure to concentrate hospital activity on PFI sites at the expense of non-PFI sites if there is contraction (Hellowell and Pollock, 2007).
In addition, there is the question of reducing waste in the NHS estate. In a novel and preliminary analysis, May and Price (2009) used frontier analysis to compare total income and patient-occupied area per unit site-area across 115 acute trusts, among others.
Of the trusts, 92 appeared to be more than 10 per cent inefficient, and 63 were more than 20 per cent inefficient. May and Price estimate that wasted space across the whole NHS estate might be costing £500 million a year.
Box 6.5: Reducing bed numbers
At the six trusts there were bed reductions made in the interests of saving money. These are likely to have been associated with gains in efficiency, given the reductions in length of stay mentioned previously. However, the capacity that was taken out was often less than it might have been, due to increases in activity made in the interests of raising income.
• Sandwell and West Birmingham Hospitals NHS Trust treated more patients despite having 150 fewer beds, and saw its income soar.
• Barnet and Chase Farm Hospitals NHS Trust took out 100 beds in its first year of turnaround and then pushed bed occupancy higher.
• The Royal Wolverhampton Hospitals NHS Trust closed 200 beds and four theatres. The increase in activity for this Trust (in all areas except A&E), combined with the dramatic rise in income, suggests efficiency improvements and a smaller acute footprint despite the increase in activity.
• St Helens & Knowsley Teaching Hospitals NHS Trust closed 150 beds while increasing its income from activity.