Sustainable financial improvement at Liverpool University Hospitals NHS Foundation Trust
The Challenge
The NHS nationally is facing a period of unprecedented pressure with waiting lists, industrial action, the legacy of Covid-19 and financial constraints creating a perfect storm for many hospital providers.
In addition to the outlook nationally, LUHFT was facing local challenges arising from the impact of a recent (2019) merger and the complex provider landscape in Liverpool, with a high number of acute and specialist trusts needing to collaborate to deliver services. The Trust was rated ‘Requires Improvement’ by the CQC and had a growing financial deficit.
Instilling a culture of improvement is as important as embedding the governance to support it
In this context, LUHFT was placed under greater regulatory scrutiny at National Oversight Framework Level 4 (NOF4) by NHS England. As well as addressing quality improvement actions, the Trust needed to achieve a Financial Recovery Plan by developing an £83m Cost Improvement Programme (CIP) and implementing run rate controls to exit NOF4. Doing so would need to include realising opportunities to improve workforce productivity, optimise core operational efficiency and implementing a range of controls and data driven insights to contain unwarranted expenditure.
Deloitte’s Support
Over nine months in 2023, an embedded Deloitte team supported the Trust in a range of critical workstreams in areas with the greatest scope to address budgetary pressures and reduce the deficit. The success of our approach illustrated the importance of several principles at the core of how we work in partnership with NHS organisations:
More efficient and better quality care is more cost-effective.
We guided the Trust through implementation of a rostering improvement programme to increase fill rates – improving the stability of the nursing workforce and delivering associated benefits for patients and staff – while reducing spend by decreasing high-cost agency shifts.
In theatres, an operational improvement drive on productivity in six specialities, enabled by optimising the theatre timetable and right-sizing the trauma capacity to reduce the impact on the running of elective lists, resulted in a c. 30% increase in sessions undertaken between April and October 2023, meaning more patients were treated by the Trust.
Transferring knowledge to the Trust’s Transformation teams to sustain long-term change.
We worked alongside the Trust to set up the Programme Management Office (PMO) and reporting processes. Specifically, a rostering Improvement team was created and trained to deliver a programme that supported ward managers and compliance with revised nursing controls.
Senior leadership at the Trust lent their support to the programme, establishing financial governance at the Trust, Site, and Divisional levels. As well as designing the financial improvement governance and reporting, we ensured the Trust was able to “stay the course” and embed a culture of scrutiny, accountability and support in these forums that would outlast our involvement.
“Working with Deloitte has been an example of true partnership working between the NHS and the private sector. As well as delivering a return on our investment, it has equipped us with the tools, skills and plans to succeed in this journey into the future as we continue to make LUHFT financially sustainable."
James Sumner, Chief Executive, LUHFT
Data and insights are vital in supporting improvement.
Operational leads didn’t have the data they needed to make the right decisions. Together, we gathered data through a workforce insights dashboard at the Trust to provide ongoing overview of cost control and monitoring compliance. We used this data to identify and plan targeted recruitment initiatives focused on addressing areas of excessive temporary staff spending – including temporary staff pay and vacancy approvals – and redesigning senior management structures to streamline operations and reduce costs. Navigating and consolidating disparate Trust data and insights helped us plan medium-term interventions to deliver a financially sustainable junior doctor staffing model.
When applying any of these principles working in partnership with Trust teams was at the heart of the project’s success. We developed close working relationships with individuals at all levels across the Trust, demonstrating a willingness to get to the heart of the issue and enabling Trust teams to feel comfortable, supported, and able to be candid about the challenges they were facing. Our interactions with the Trust Executive and senior teams focused on delivering a Return on Investment (ROI). To do so, a flexible approach and willingness to pivot our energy and resource was required as we developed our collective understanding of where the greatest opportunities lay. We demonstrated our commitment to this approach by contracting on a contingent basis.
- A financial improvement programme worth c.£100m full year effect was developed, with in-year delivery on track.
- Enhanced oversight of temporary staffing drivers from “ward to Board” with revised workforce controls governance and a bespoke data dashboard implemented.
- For nursing, from July to October 2023, 95% of rosters for supported wards complied with approvals more than 42 days in advance, compared to c. 30% between January and June, helping to avoid expensive agency usage. For rostering intervention wards, there was a c. 25% reduction in agency spend and reduced bank usage for the majority.
- Intensive work with Nursing leadership resulted in a > 20% reduction in filled additional (unbudgeted) shifts across the Trust, with greater fill rates supporting better outcomes for staff and patients.
- With our support, the Trust teams went on to develop a recruitment plan that when implemented will reduce temporary staffing spend by a further £8m per year.
Creating a legacy that lasts
Instilling a culture of improvement is as important as embedding the governance to support it. Together, we fostered open and honest communication channels, celebrated our successes, worked collaboratively, and transferred knowledge to the Trust’s staff before supporting a sustainable handover to them. Since Deloitte’s exit, Trust teams have continued to use the tools and skills provided to plan and deliver further changes that will set the Trust on the path to financial sustainability.
LUHFT’s “impressive progress” has been recognised by NHS England, enabling the Trust to be lifted from NHS England’s Oversight Framework segmentation 4 and exit the national Recovery Support Programme.
"By putting patients at the heart of everything we do and by placing those who are closest to the issues in control of the solutions, our staff have been empowered to deliver these improvements. This is a huge step on our journey to make LUHFT a place where every patient has the trust and confidence to be treated and where every colleague is proud to work."
James Sumner, Chief Executive, LUHFT
