What the Carter Report means for clinical departments

The final version of the Carter report was published in February 2016 and is entitled, 'Operational productivity and performance in English NHS acute hospitals: Unwarranted variations.' In the report Lord Carter sets out 15 recommendations for NHS trusts to reduce their expenditure by £5bn. The central recommendations are that the NHS must reduce variations where they have no good reasons to exist and improve the use of its resources, the primary resource being its staff. The report focuses on the ways in which variation can be reduced and the means by which comparable measurements should be defined.

Carter's concern is that variance across a range of measures he has investigated is too high and that little has been done to examine the causes of variability and look into ways in which it could be reduced. Typically attention is given over to investigating special causes of variation rather than tackling the variation that stems from common causes. As high levels of variation mean a lack of predictability, reducing the common causes can provide a valuable change by improving the predictability of events and making it easier for managers to bring about change and usefully measure it.

Early in the report Carter touches on a desire to create an improved approach to people management across the NHS and classes the NHS as a poor employer which experiences high levels of absenteeism, bullying, harassment and staff turnover. The report sets out the need for good leadership development and regular staff performance reviews, and recommends that clearer policies and swifter decisions are made when dealing with such problems. Staff costs in all acute and non-acute NHS providers total £45.3bn and thus represent the single biggest opportunity for productivity and efficiency savings. The high levels of variability between trusts on staffing costs reveal a lack of common understanding in the co- ordination of staff whilst the continued discussion surrounding the proposed new Junior Doctor contract highlights an organisation whose staff are under severe strain to continue to deliver the service.

Establishing a reporting framework

A major theme threaded through the report is the desire to establish a common reporting framework to be adopted across all trusts. This would bring together clinical quality and resource performance data and compare it to 'best in class', exemplified by a 'model hospital', to allow performance to be examined and areas of variation to be identified, and consequently executive teams could be held to account. The 'model hospital' benchmark is intended to establish a series of metrics and Key Performance Indicators (KPIs) to which trusts can compare their own activity.

Implicit in the definition of a 'model hospital' is the need to improve data collection. In order for data to be accurately collected Carter recommends that trusts begin using tools such as rostering services but also improve the utilisation of the data derived from such systems, to turn data-driven insights into action and then report on the result of changes in process. The case for good data dates back to long before the Carter report: in 2010 in response to a major exercise looking into vascular surgery Professor Sir Bruce Keogh, Medical Director of the NHS, highlighted the value of using good data in improving the service and the importance individuals must place on interpreting that data. He stated, 'Surgeons have a moral and professional duty to know what they are doing, how well they are doing it and to use that information to help them improve – otherwise they have no right to be doing it at all.' Initiatives like the National Peer Review Programme, which dates back to 2001, were established to review clinical teams and services and determine their compliance against national measures and placed value on the need for comparison. However, Carter highlights that at the moment the data being collected still often misses information that is key to improving performance. For the NHS to make the vital efficiency gains needed it is paramount that improved data collection is taken more seriously

Carter's proposed 'single reporting framework' is aimed at delivering comprehensive board-level dashboards that focus on the CQC's five key question regulatory framework of whether providers are safe, effective, caring, responsive and well-led. However, the idea of the department as an organisational entity and reporting unit seems largely absent from the narrative. Very few departments currently understand the full gamut of services they provide, and in many cases departments have expanded to meet demand without the full budgetary implications being considered. Trusts should strongly consider first engaging with their own departments to better understand the service they deliver, equipping them with techniques for improved collaboration. Where departments can be used as the instruments of change, reporting and improvement moved closer to the work being done, then individuals can see the benefits of the gains first hand which enhances morale. Individuals can then begin to manage themselves and help to deliver changes whilst feeling connected to the organisation. In a time of greater austerity and increased scrutiny there is substantial pressure on the NHS and this should be translated into a need for departments to fully understand their own balance sheet and become responsible for it. If this is done well departments can become motivated, data-driven and responsible parts of a wider whole.

Example benchmark of extra paid activity as a percentage of total department activty from our Autumn 2016 benchmarks.

Cross-departmental benchmarks allow departments to compare themselves with those at other trusts helping them gain strategic insight into the service they're delivering and how this compares with other trusts around the country. Rotamap's benchmarks, first published in 2012, compare a variety of department measures, such as use of trainee-led sessions and the amount of additional paid activity. This comparison helped a large University trust realise it was using a significantly higher proportion of trainee led lists than comparable departments. After making changes in their behaviour they continued to monitor use of trainee led activity to bring it down closer to the nation-wide average. Our benchmarking data reveals, as highlighted by Carter, a significant amount of variation between trusts on all measures. For example, our benchmark on usage of additional paid activity shows some trusts where work done at an additional payment represents over 20% of a department's weekly activity and other trusts where none of their activity is done at an additional payment rate. Such substantial variance suggests that departments are not equipped with guidelines or frameworks in which to operate.

The role of electronic rostering

Using benchmarking and performance data to analyse performance and address areas where there is significant variation is clearly useful but data-driven analysis is best used to help solve the operational issues that lie at the heart of any department's ability to efficiently and effectively cover its service. If departments are able to improve their level of reporting and become responsible for reducing undue variations and consequently improve their service then this can help deliver improvement across trusts from the bottom up. Carter sees electronic rostering as an important way that trusts can improve the use of their staff, although the operational aspects of his recommendation are not touched on. Carter asserts that trusts should have a fully integrated and utilised e-rostering system in place by October 2018 and encourages trusts to adopt the following practices:

  • An effective approval process by publishing rosters six weeks in advance and reviewing them against trust key performance indicators such as proportion of staff on leave, training and appropriate use of contracted hours;
  • A formal process to tackle areas that require improvement, with escalation paths, action plans and improvement tracking; and
  • Cultural change and communication plans to resolve any underlying policy or process issues.

While organisation-wide policies are important, helping devolve responsibility to individual departments who have local knowledge of the specific shape and demands of their service and the composition of the staffing teams has clear operational value. Collaboration must exist between different departments but if individual teams can be brought together as jigsaw pieces that connect together to reveal a bigger picture, then departments can still be empowered to meet their own unique needs while still providing the trust with oversight of the whole. At Rotamap our aim is to help departments better understand their service and how they can resource it. Our CLWRota and Medirota services are used at over 95 trusts to roster over 11,000 clinicians and can help make a dramatic difference to the organisation of a department by providing a clear and accurate model of the department's service, helping to highlight areas where improvements can be made. Each department using the service can plan, manage and report on all their activity; reducing errors on the rota and evaluating its use of staff resources. Anne Morris, a Service Manager at Colchester Hospital, commented on the value Medirota had brought to one of the areas she manages: 'Since we put Medirota in General Surgery, we've achieved 18 weeks, which we weren't achieving. We were at the level of half a million pounds of fines a month; we've stopped the fines. This month was the first month we've delivered a positive position in General Surgery; we actually saw a positive return on our income.'

Anne Morris speaks about the value of actionable data at our March 2016 event at the RSA in central London. Click the image above to watch a highlights video of her talk.

In addition to the operational value of the CLWRota and Medirota the service reports we provide to departments at six monthly intervals give individual department the ability to check their current health and spot any issues with department performance. The Service Reports provide a clear focus on a range of important department measures including: the time ahead the department is creating and publishing rotas; where leave has the most effect on the departments service; and, its use of junior doctors and paid additional activities. By evaluating the data available departments can begin to predict their service better and eliminate the variation where it has no good reason to exist and this will provide a strong footing for productivity and efficiency improvements.

Beyond improving individual rotas department data can be shared between rotas and also used to feed information into other systems or applications to increase communication, collaboration and reporting. The online nature of our services lifts the visibility of the rota across the trust, allowing departments to share information in a clear and transparent way. Our mapping tool allows rotas from different departments to map their rotas together so they can see where staff from individual departments are working together, maintaining local control but recognising the imperative for collaboration. On turning on mapping for the first time at East Sussex Healthcare Trust, Louise Simpson, the administrator in a surgical department, stated: 'Mapping is a really useful tool. We reinstated some theatre activity recently and noticed there was no anaesthetist, which enabled me to highlight this to Cathryn [the anaesthetics rota writer] whom [sic] then sourced an anaesthetist to cover. Great work.'


Carter is right to identify use of resources as being the NHS's single greatest challenge to improving efficiency and a greater awareness of data can certainly help identify the areas that require improvement. Rota management systems can help departments collect such data and look for the 'unwarranted variation' and tackle it through operational change. If departments can be the driver of such change and individuals engaged in the process of improvement then this will also provide the crucial boost to morale. Carter's highlighting of the need for tools allowing greater comparison is also important. Benchmarking gives the ability to see how performance measures up against the wider environment. To achieve radical steps forward trusts must build up a culture where improvements are self driven and intelligent use of data helps departments identify where operational improvements can be made. Trusts must also establish an overall framework where departments can link together, facilitating the need for collaboration.

Contact us

If you have any questions about the above ideas or would like to know more about mapping or our benchmarks please contact the Rotamap support team at support@rotamap.net or 020 7631 1555.

Please note that, as with all information on this site, all images and information on this site are copyright © Rotamap Ltd.