Cuts in services for patients are difficult to justify when there are many ways in which hospitals could be improving their efficiency, a major new review has concluded.

While inefficiencies in areas such as rates of day case surgery, length of stay and the purchasing of hospital supplies still remain untackled, it is hard to justify such cuts, says the study, which was commissioned from independent researchers by health care policy think tank the Nuffield Trust. 

"The main questions raised by this study are why, when so much is known about what drives and can improve hospital efficiency, has hospital productivity deteriorated across the board in recent years and so much variation persists across - and sometimes within - hospitals," says the Trust's head of policy, Dr Judith Smith.

The reasons are probably multiple, she suggests. For example, in some areas they will include: - the previous emphasis on growing capacity during a period of plenty; - a lack of data and the capacity to analyse this at a very detailed operational level; - conflicting incentives faced by the organisation; - a lack of involvement of doctors and other clinical staff in determining and implanting programmes to improve efficiency; and - insufficient priority given by managers to the tough business of changing long-standing working practices in hospital.

Based on the findings of the report, and an accompanying policy analysis by  the Nuffield Trust, it recommends that:

- clinical commissioning groups (CCGs) should establish, with local providers, clear goals in respect of day surgery rates and length of stay. At a national level, the NHS Commissioning Board should investigate whether the next Outcomes Framework could be used to encourage commissioners to make a priority of this, building on the avoidable hospitalisation indicators for patients with long-term conditions;

- the NHS Commissioning Board should strongly encourage CCGs to make the most of new technologies and guidelines from the National Institute for Health and Clinical Excellence (NICE), particularly those around optimal practice, "do not do" recommendations and cost-savings technologies. This should be followed up with a national system of publicly monitoring clinical and administrative practice variation, by CCG area, says the Trust;

 - when savings have to be made in staff costs, senior managers and clinicians should -  rather than opting for vacancy freezes - test the benefits of a higher ratio of qualified and senior staff, albeit with smaller numbers overall. This could be a powerful way of mitigating overall reductions in staff numbers, while increasing productivity and improving patient care, it suggests;

- hospital boards should proceed cautiously when exploring organisational mergers, as these do not automatically lead to efficiency savings unless beds and services are closed, and diseconomies of scale can also emerge in organisations above 600 beds; and

- ways must be found to go beyond the crude measures of NHS productivity, with more effort made to develop objective measures of quality and to identify where efforts have successfully reduced avoidable hospital admissions for patients, rather than just increased activity in hospitals.

The researchers' findings suggest the need for a concerted programme of efficiency initiatives across NHS hospitals as a whole, says the Trust, which emphasises that, while the financial challenge facing the NHS will concentrate minds, "much more needs to be done."