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Urgent action is needed to save the NHS’s efficiency drive

Alastair McLellan
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The Carter efficiency drive has been going nowhere fast, but needs to be a mainstream priority - here’s how to make it so.



The £22bn target may have brought the NHS’s efficiency drive into disrepute, but few of the service’s leaders would dispute there are significant savings to be made.

Lord Carter’s review into “unwarranted variation” in NHS acute sector productivity and performance remains the most useful piece of work done to date on this challenge.

Yes, some of the data it uses is pretty “dirty” and most think it overstates potential savings by a couple of billion. But the report does not pretend to be the final answer – and its comprehensiveness and focus provide a good start.

Most importantly, it alone gives some hope the NHS can find some breathing space during the unprecedented cash squeeze of coming years.

Contradictory aims

Which is why it is particularly worrying the initiative is going nowhere fast. The deadline for trusts to agree savings targets has come and gone, but more concerning is the lack of progress to begin delivering efficiencies in a systematic way beyond some useful data sharing on procurement costs.

This is not the fault of newly birthed NHS Improvement. Never can an arms-length body have been given a more terrifying to-do list: “Return the NHS provider sector from a £2.8bn plus deficit to the black; do so in the first year of your existence; while also reversing the collapse in waiting time performance; oh, and try make it seem part of a carefully planned reform programme designed to enhance care quality.”

Jim Mackey is a wise, pragmatic and self-confident leader who can deal with the contradictions inherent in this mission, and he is building a strong team, but it would be a wonder if some important issues did not fall by the wayside.

The implementation of the Carter recommendations is one of them – and by far the most significant.

Work is going on, but we have yet to see a comprehensive implementation plan for the various workstreams, including adequate resourcing and realistic, but ambitious, milestones. Momentum has to be established before the summer break or the programme will risk losing any credibility with NHS leaders.

Jeremy Hunt suggested to HSJ in March that the Carter review constituted that “plan”. No, health secretary, it does not, and its author never intended it should.

The Carter review is, like the Five Year Forward View, a vision of what can be achieved – with some guidance as where to start. It now needs the equivalent of December’s “Delivering the Forward View” to make that vision a reality.

It is very easy to be cynical about NHS efficiency programmes and at present there is very little incentive for trusts to engage with Carter given their competing priorities

The delivery plan should:

  • stipulate the appointment of a number of full time Carter champions for each workstream. These should be public sector directors senior enough to command the attention of trust boards and make sure they engage with areas of variation indicated by the data. Yes, they will not come cheap – but it is worth remembering many management consultants are already opening meetings with trusts’ CEOs by sliding a copy of the Carter review on to the desk and saying: “How are you going to do this, then?”
  • acknowledge that, while NHSI is the right home for initiative, it should be owned and funded additionally by NHS England and the Department of Health – and possibly also the Treasury. These organisations have plenty of skin in this game and must recognise NHSI needs their direct support during 2016-17, particularly in the development of better data, which will avoid the process becoming a tick box exercise.
  • make sure trusts are not left in a situation where making progress on Carter threatens their ability to deliver any of the system’s other “must-dos”. For example, where future Carter savings depend on up-front investment (of money or time) that would threaten a trust’s ability to deliver its 2016-17 financial or performance targets, national bodies must acknowledge something will have to give. If they do not want it to be Carter, they need to help provide that investment, or to consider relaxing the arbitrary target of break even in 2016-17 handed down to the provider sector.
  • make it clear that a condition of NHSI sanctioned financial support will be a trust adopting the best practice set out in Carter (which is often long established and well supported by royal colleges etc).
  • set out how trusts will be given the air time to get their Carter work going. Information demands from commissioners and the centre need to be eased unless specifically relevant to this work; contributions to new care models, sustainability and transformation plans etc should be kept to a minimum over the summer months while the work is bedded down.
  • give more time to NHSI to merge, sorry integrate, its Monitor and NHS Trust Development Authority arms so it can increase its focus on delivering Carter.

It is very easy to be cynical about NHS efficiency programmes and at present there is very little incentive for trusts to engage with Carter given their competing priorities.

But cynicism serves little use other than giving those who would prefer not to take difficult decisions an excuse for inaction.

Take most of the steps set out above and the NHS has chance of mainstreaming its Carter work, and expanding it into other areas.

Failure to do this will not represent just another failed efficiency drive, but a fatal misstep. The consequences will be felt by all, patients included, as the money runs out.

Making sure the NHS is in a position to “deliver” Carter should be the number one priority of the services’ national leadership over the coming weeks and months.

Their appetite to take urgent action is the acid test of how seriously they are committed to creating an efficient NHS.

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