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The National Audit Office's health work is focused where we can add most value. Working in tandem with experts in each field, we tackle some of the most difficult problems confronting health managers today.

A key part of our process is to identify good practice, and practical solutions that can be applied more widely. The purpose of this Briefing is to summarise our key findings in each report and the steps that can be taken - steps that should lead to improved patient outcomes and better value for money. These summaries complement other guidance issued by the NHS Executive and NICE on subjects covered by our Reports.

I hope that you will find this helpful. More details are available from the contacts listed and full copies of each report can be found on our website (www.nao.gov.uk).

Over the coming months we will be issuing studies on charitable funds, the National Blood Service and obesity. We are also very interested in your ideas for future studies that we could carry out.

If you have a suggestion please e-mail Jeremy Colman through our enquiries desk, mark your email for his attention

Martin Pfleger

Elective total hip replacements

The management; of medical equipment

The management and control of hospital acquired infection

Inpatient and bed management

NHS Summarised Accounts

Elective Total Hip Replacements

• report ( 744Kb)
• executive summary ( 70Kb)

The NHS performs over 30,000 total hip replacements each year, and they are generally highly effective, reducing pain and increasing mobility.

Most patients are implanted with one of a small number of established designs and can expect their new hip to work effectively for some ten to fifteen years. However, there are over 60 different hip prostheses available, and evidence of long term effectiveness is not available for all those in current use. NICE has now issued guidance on this.

There are also widespread variations in areas such as the follow-up of patients after their operation, and the supervision of surgery.

NHS trusts spent £53 million in total on the purchase of prostheses in 1998-99. Many have taken initiatives to reduce purchasing costs, but there is scope for some trusts to do more to reduce costs.

We found many consultants believe that length of stay for hip replacement patients could be reduced from the current average of 11 days, though most trusts have no plans to do so.

In the light of these findings, based in part on major surveys of orthopaedic consultants and NHS trusts, we make 20 recommendations for improving the service provided to patients who require total hip replacements.

Those of interest to Chief Executives are, in particular:

• Trusts should consider restricting the prostheses used to those with long term evidence of effectiveness, in line with the recent recommendations by the National Institute for Clinical Excellence. 
• Trusts should review the scope for improving their prosthesis purchasing procedures to save costs, while maintaining quality standards.
• Trusts should ensure that where operations are carried out by non-consultant grades without consultant supervision, there are effective risk management assessments and procedures in place.
• Trusts should take steps to reduce unnecessary length of stay in hospital.

From NHS Trusts; Department of Health; Medical Devices Agency; Audit Commission; Accounts Commission (Scotland); Age Concern; British Orthopaedic Association; Nuffield Orthopaedic Centre; British Orthopaedic Association; Council of International Hospitals; Hospital for Special Surgery and Hospital for Joint Diseases (New York); US Food & Drug Administration; Government Accounting Office; US Agency for Healthcare Research and Quality; University of Gothenborg; hip prosthesis suppliers and manufacturers.

For further information contact Tim Fry on 020 7798 7290 or email him through our enquiries desk, please mark your email for his attention.

Managing medical equipment better

• report ( 879Kb)
• executive summary ( 54Kb)

We defined medical equipment as all medical devices connected to patients as part of their treatment and care in hospital, and medical devices used for diagnostic and laboratory purposes. It represents a £3 billion asset for the NHS that needs to be managed efficiently to provide good quality care of patients at least cost.

We found many examples of good practice in the management of medical equipment, from strategic overview, to day to day activities such as maintenance, and in the field of medical equipment safety.

But more needs to be done by trusts to manage their equipment assets effectively. Important measures include the needs:

• to allocate clear responsibility for medical equipment at board level;
• to ensure that inventory information is comprehensive and used fully in decision-making;
• to better co-ordinate the procurement of medical equipment across trusts, with more involvement of technical personnel who can also usefully contribute to non-clinical aspects of user training; and
• to take action that should help to improve standards of reporting of adverse safety incidents and to reduce their occurrence.

We found scope across the NHS in England for savings of many millions of pounds by following best practice. Benchmarking of costs and management practices may well yield benefits in lower costs, quality improvements and reduced safety risks. For example:

• medical equipment maintenance costs vary widely across similar trusts. There may be scope to keep equipment in good order and achieve savings;
• while clinical requirements dictate that a minimum number of makes and models of the same type of medical equipment is needed in a hospital, where appropriate, standardisation can save on costs, improve flexibility in the use of medical equipment for patient care, and reduce the potential for serious incidents; and
• ensuring that all users of medical equipment are properly trained to best practice standards.

From NHS Trusts, ECRI, Royal College of Surgeons, Association of Anaesthetists, British Society of Gastroenterology, National Performance Advisory Group, University of Strathclyde, key medical equipment suppliers and manufacturers.

For further information contact Tim Fry on 020 7798 7290 or email him through our enquiries desk, please mark your email for his attention.

The management and control of hospital acquired infection

• report (1,016 Kb)
• executive summary (200Kb)

Hospital acquired infections can have serious consequences for patients, and may be costing the NHS in the region of £1,000 million a year. We found that they could be reduced by around 15 per cent across the NHS through better management and control.

We commend the professionalism and dedication of NHS hospital infection control teams and their application of good practice. But there are at least 100,000 hospital acquired infections each year and some groups of patients are particularly vulnerable, see below.

The Department of Health has launched a number initiatives recently to raise the profile of hospital acquired infection and improve its prevention and control. But there is scope to do a lot more, particularly as part of efforts to tackle the growing problem of antibiotic resistance.

In many NHS Trusts there may be a growing mismatch between what is expected of infection control teams in controlling hospital infection and the staffing and other resources allocated to them.

Prioritisation of resources for dealing with hospital acquired infection is not helped by the general lack of basic, comparable information about rates of hospital acquired infection. The Nosocomial (hospital acquired) Infection National Surveillance Scheme and the Department's new Clinical Governance and Controls Assurance initiative, among other things, require a focus on ways of improving the management and control of hospital acquired infection.

The top five ways hospital acquired infections can attack

1. Blood infections
2. After surgery
3. Urinary infections
4. Chest infections
5. Skin infections

Six main things about hospital acquired infection

1. Around one in 11 hospital patients at any one time has an infection caught in hospital
2. There are at least 100,000 hospital infections  a year
3. They cost the NHS hundreds of millions £s a year
4. They can mean several extra days in hospital
5. The old and young are most likely to catch one
6. Hospital acquired infections may kill

Among 29 recommendations for improving the management and control of hospital acquired infection, NHS Trust Chief Executives should:

• along with Trust senior management, accept greater ownership for the control of hospital acquired infection;
• ensure the Hospital Infection Control Committee operates as the Department of Health intended and that they or their nominated deputy attend its meetings;
• ensure the infection control team has an adequate annual programme for infection control that is approved by them, and that the Trust Board receive regular feedback on performance in relation to the programme;
• ensure that the infection control functions are resourced in line with Departmental guidance;
• ensure that there is appropriate feedback of surveillance data to clinicians;
• ensure that infection control considerations are an integral part of bed management policies;
• in developing their IT systems, take account of the requirements of the infection control team.

Hospital acquired infections are a huge problem for the NHS. They prolong patients' stays in hospital and, in the worst cases, cause permanent disability and even death. By implementing our recommendations the NHS could make real improvements in the quality of care for patients and could free up significant resources for additional patient care.

From NHS Trusts & Health Authorities, Department of Health; Public Health Laboratory Service, Regional Epidemiologists; London School of Hygiene and Tropical Medicine, Nosocomial Infection National Surveillance Unit, Joint Royal College Committee on Infection and Tropical Medicine; Royal Colleges of Surgeons, Pathologists, Nursing, Paediatrics and Child Health, Orthopaedics, Anaesthetists, GPs, Obstetrics and Gynaecology; Health & Safety Executive, Infection Control Nurses Association, Hospital Infection Society, UKCCN, BMA, National Association of Theatre Nurses.

For further information contact Karen Taylor on 020 7798 7161 or email her through our enquiries desk, please mark your email for her attention.

Inpatient admissions and Bed Management

• report(1,327Kb)
• executive summary (408Kb)

Many NHS hospitals have made important improvements in the way they admit and discharge patients, and manage their bed stock. But there are significant variations in performance, and some trusts could do more to reduce the number of cancelled operations and delays in discharging people from hospital.

In 1998-99, around six million patients in England stayed at least one night in NHS hospitals, a record level, and two thirds were emergency cases. This record was achieved despite a fall in the number of general and acute hospital beds in recent years, made possible by changes in patient care practices.

But there are signs of significant pressures, with the number of operations cancelled for non-medical reasons on the day of admission reaching record levels, and around 20 per cent of emergency patients waiting longer for admission than the Patient's Charter standard of two hours.

In addition, 35 per cent of hospitals reported facing times when demand for beds exceeds availability at least once a day, and delays in discharge from hospital affect an average of nearly 6,000 people over 75, costing trusts about £1 million a day. Significant numbers of patients were waiting for an outpatient consultation in excess of the Charter standard.

In response to these pressures, many NHS hospitals make considerable efforts to improve the way they admit and discharge patients, and manage their bed stock. In particular:

• almost all hospital Accident and Emergency departments will have an admissions unit or observation ward by July 2000 to reduce patient waiting times, to accommodate patients with medical emergencies more comfortably, and to reduce the overall level of emergency admissions;
• there has been a 20 per cent increase in two years in the number of trusts with bed managers, whose role is to ensure patients are placed promptly in appropriate beds;
• almost all hospitals have strategies to respond to short-term bed shortages; and
• around three quarters of trusts now employ discharge co-ordinators to help overcome obstacles to patients being discharged when ready, compared to around 40 per cent in 1997.

But, very few hospitals have systems providing up to date information to monitor and co-ordinate key resources such as beds and theatre time, and in over 90 per cent of trusts, bed managers obtain information on bed availability only through physical inspection and telephoning wards several times a day.

More than a quarter of trusts do not begin to consider discharge needs of patients as early as they could.

Our report highlights 20 areas where more NHS acute trusts could follow the lead of others. In particular, more trusts could assess patients before they are admitted; admit greater numbers of patients on the same day as their operation; and more could begin liaison earlier with other care agencies to plan patient discharge.

In addition, there are three areas where across-the board improvements are necessary. These are in:

• developing significantly improved information systems to allow hospitals to monitor and plan better the use of key resources such as beds and theatre time;
• enhancing the role of bed managers to move away from crisis management, and make better use of their knowledge to plan admissions and think strategically about the use of beds; and
• improving co-ordination between different professional groups within hospitals, and between hospitals and other external care agencies such as social services, to minimise the risk of delays in discharging those ready to leave hospital.

From NHS Trusts, Health Authorities, Local Authority Social Services Departments, Department of Health, NHS Confederation, Association of Community Health Councils in England and Wales, Audit Commission, Emergency Action Team, Health Services Management Unit, Institute of Health Management, King's Fund, National Patients' Access Team, Royal Colleges of Nursing, Physicians, and Surgeons; University of Manchester Institute of Science and Technology, College of Health.

For further information contact Craig Adams on 020 7798 7317 or email him through our enquiries desk, please mark your email for his attention.

NHS Summarised Accounts

• report (205 Kb)
• executive summary (49Kb)

We are responsible for the audit of the summarised accounts for the NHS, which comprise separate summarised accounts for NHS Trusts, health authorities, Funds held on Trust, each of the special health authorities and the Dental Practice Board. Our audit draws primarily on the work of your own external auditors, appointed by the Audit Commission. However, we also report annually on key issues related to the various accounts. The latest 1998-99 summarised accounts covered the following topics:

the overall financial performance of the NHS, highlighting that:

• 48 of the 100 health authorities reported a deficit for 1998-99, the same number as for 1997-98. Health Authorities in aggregate reported a surplus of £18 million but the forecast is for a £80 million deficit by the second quarter of 1999-2000;
• 98 of the 402 Trusts reported a deficit for 1998-99, compared with 149 of the 425 Trusts in 1997-98. The aggregate 1998-99 net deficit was £36 million, with a forecast deficit of £117 million by the second quarter of 1999-2000; and
• the financial performance reported by both health authorities and NHS Trusts in 1998-99 would have been adversely affected had the Treasury not allowed departure from generally accepted accounting practices;

progress in countering fraud in the NHS:

• work to date of the NHS Directorate of Counter-Fraud Services aims to introduce trained anti-fraud specialists in each NHS organisation, and regional & national teams;
• targets are in place for the Directorate, culminating in reporting on the level of fraud in the NHS early in 2001;

liabilities of the NHS for clinical negligence:

• the potential liability for clinical negligence was reported at £2.4 billion by the end of March 1999, an increase of £0.6 billion from the previous year. However, the value of incidents incurred but not reported, which are excluded from this £2.4 billion, may now be below the previous estimate of £1 billion; and

developments in accounting and internal control. The main issues raised were that:

• there were a number of important areas in which, with Treasury approval, accounting practice in the NHS diverged from UK generally accepted practice. We were therefore pleased to note that, subject to operational assurances, future NHS accounting will be overseen by the Financial Reporting Advisory Board; and
• more NHS Trusts and health authorities met all of the minimum internal financial control standards in 1998-99 than in 1997-98, and we welcomed the further developments to provide wider assurance on risk management and organisational controls in 1999-2000.

For further information contact Sid Sidhu on 020 7798 7489 or email him through our enquiries desk, please mark your email for his attention.

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