Stratify, specialise, standardise, analyse: maximising quality and efficiency in elective care


Achieving more with the same has become a well-established mantra in the NHS since the financial crisis, usually under the slogan ‘efficiency savings’. It inevitably held an important role in NHS England’s momentous Five Year Forward View. The 5YFV prescribed new models of care and in particular supported the idea that less productive providers should ‘catch up’.

Indeed, productivity can vary substantially between different NHS providers (Castelli et al, 2015). This seems to imply room for improvement. Monitor (England’s health services regulator) recently published a report detailing some possible means of achieving such improvements, focusing on what they describe as ‘resource-hungry’ care pathways.


Can less productive providers ‘catch up’?


The study sought to identify some of the more productive elective care pathways in eight NHS trusts and five international hospitals, using case studies to summarise the findings. The researchers carried out site visits and interviews, as well as analysis of data provided by the sites.

The research looked specifically at ophthalmic and orthopaedic elective care, but the findings have implications for other specialties. Together, ophthalmology and orthopaedics account for about 30% of total expenditure on elective admitted patient care in England. Detailed analysis was carried out for the patient pathways associated with six procedures in four general categories:

  1. Outpatient procedures (ophthalmology)
    • injections for wet age-related macular degeneration (AMD)
  2. Day case procedures (ophthalmology)
    • cataract surgery
  3. Straightforward inpatient procedures (orthopaedics)
    • primary total knee replacements
    • primary total hip replacements
  4. Complex inpatient procedures (orthopaedics)
    • revisions to total knee replacements
    • revisions to total hip replacements

These procedures together account for about 11% of total elective spend on admitted patient care in England.

For each procedure at each hospital, the researchers looked at the number of patient contacts, the staff costs per contact and the overhead costs per contact for each stage of the pathway from first outpatient appointment to discharge.

A variety of research methods were used, and stakeholder workshops were held to review and challenge the findings.

Stakeholder workshops were held to review and challenge the findings.


The study identifies 9 levers to improve productivity, 5 of which can be translated into good practices to achieve the majority of the potential benefit:

  1. stratifying patients by risk and creating low-complexity pathways for lower-risk patients
  2. extending clinical roles to enable lower-grade staff to undertake routine tasks
  3. increasing throughput in theatres by measuring, communicating and managing the number of procedures per session
  4. implementing enhanced recovery practices to reduce length of stay
  5. providing virtual follow-up for uncomplicated patients

Extending nurse roles in surgery, and other forms of task shifting, is a valuable source of efficiency.

A set of 5 conditions are specified to help bring about productivity improvements. These are:

  1. standardised pathways and protocols
  2. effective performance management systems
  3. visible leaders accountable for continuous improvement
  4. adapted staff contracts
  5. efforts to engage patient and families in their own care

The report claims that “if every NHS provider followed the good operational practices adopted by the highest performers… they could save 13% to 20% of today’s spending on planned care in these two specialties”. It is also argued that these savings could be made in other specialties because of the general nature of the improvements prescribed.

Reducing length of stay was found to have the biggest potential for saving.

Reducing length of stay was found to have the biggest potential for savings.


Variation in productivity does imply room for improvement. But the size of variation does not equate to the potential savings from increasing productivity. Different providers serve different patients with different needs.

There is a lot of wishful thinking in this report, which is overly optimistic. Even if we accept the tenuous notion that less productive providers can improve by simply copying the most productive examples, there is also little basis for the belief that the same techniques could be applied in specialties outside ophthalmology and orthopaedics.

Nevertheless, the prescriptions seem sensible and their basis intuitive. I myself have written about the potential cost-saving and outcome-improving benefits of risk stratification, and it is easy to find evidence that specialisation, standardisation and better data collection can improve patient care.

However, I would put little faith in the report’s estimated potential savings, which might be far less or far greater in reality.

There is also an important question to ask here. At what point do these changes cease being about improving the productivity of existing services and become about providing different services? If pathways are stratified this may mean that groups of patients are receiving quite different programmes of care. This might undermine the evidence base supporting the provision of such care and necessitate new evaluative research. Similarly, if different staff are providing care it will be necessary to demonstrate that this care is at least as effective (and cost-effective) as previously.

Even if implemented in the name of productivity improvement, changes in the delivery of elective care need to be based on evidence not intuition. This report presents a number of key targets for future research.


Monitor. Helping NHS providers improve productivity in elective care. Monitor: London; 2015. [PDF]

Castelli A, Street A, Verzulli R, Ward P. Examining variations in hospital productivity in the English NHS. Eur J Health Econ. 2015;16: 243–254. [PubMed] [RePEc]

NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England, Trust Development Authority. NHS five year forward view. London: NHS England; 2014. [PDF]

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