At the start of 2019, A&E waiting times in England hit their worst level for 15 years. Meanwhile, NHS figures show non-elective hospital admissions grew by 7.1 per cent between January 2018 and January 2019 – that’s an extra 1,216 admissions per day. And this growing pressure comes at a time when NHS Trusts are facing financial challenges (in September 2018, they reported a defecit of £1.23b)
To balance the demands of improving performance while reducing costs, Trusts should look to patient flow (it has been highlighted that long NHS waiting times are killing UK productivity). By focusing on this crucial area, leadership can align to patient benefits, operational performance and financial improvements.
Based on our work with Trusts across the UK, we’ve identified nine dimensions critical to improving patient flow. When we used this approach with an acute and community trust, we improved A&E performance, keeping a spot in the top 10 performers nationally, while closing 87 acute beds across two hospitals.
A clear vision
Trusts need a clear statement of intent about what they want to achieve for patients. It must consider the benefits to patients and the impact on bed base, quality and staff. A clear vision can shape conversations, create the case for change and ensure alignment across the senior leadership team.
A defined set of targets
A top-down view of delivery targets could include length of stay, admission rates, stranded patients, or ambulatory care capacity. The setting of these targets should be evidence-based, benchmarked against peers and, most importantly, owned at division or service level.
A leadership team aligned to the targets
Establish an accountability framework for Trust leadership that’s aligned to the defined targets. The Chief Operating Officer, Medical Director and Director of Nursing need to agree targets and the impact of achieving them. This then supports alignment of clinical and operational leadership teams to champion and own change across the divisions.
Continuous engagement across the Trust
It’s critical that staff across the organisation understand the vision and case for change and can challenge and buy into the plan to improve patient flow. Internally, the communication strategy should articulate changes to ward configuration so all impacted staff have a chance to feed into the process. Changes to an acute hospital also need clear external communication to commissioners, key stakeholders and the local people so they understand the benefits.
Modelling and action planning at specialty level
Trust-wide reviews of length of stay and associated metrics make it possible to quantify the opportunity for improvement. Often, the areas with the greatest opportunities need the input of the multidisciplinary team. Establishing effective, agile working groups, designed to meet regularly to deliver specific activities, rapidly identify challenges and design and iterate solutions, will deliver results at pace.
The interventions that will impact admissions and length of stay most are specific to each Trust. For example, we’ve been able to reduce the number of follow-ups at an acute Trust by 60 per cent through improved ambulatory care pathways. Elsewhere, we cut trauma and orthopaedics stays by an average of 2.1 days by transforming specialty pathways through system-wide multi-disciplinary team meetings. In another Trust, we reduced the time it takes to place people in self-funded nursing homes from 33 days to 4.4 days by strengthening the management of stranded and super-stranded patients through revised discharge models.
The key is to model the impact on annual bed days of each intervention to appropriately configure the bed base.
When interventions start releasing bed capacity, the Trust can focus on reconfiguring the bed base. To achieve the sustainable closure of capacity, there must be a robust operational plan. It should group patients to initially release capacity but then involve a review of site management processes, including local surge and escalation processes. These are vital to the delivery of a credible programme that will minimise outliers within the newly formed bed base.
Dashboards and reporting
A simple dashboard that tracks top-level metrics, such as bed days, occupancy and length of stay, at a specialty level and the impact of key interventions will create transparency around delivery. Mature Trusts should aim to get this information in real time, use predictive data to drive operational decision-making and create an operational control centre to support patient flow.
Bed efficiencies will be needed every year to support growth, management of surge capacity and changes to clinical practice. It’s essential that regular monitoring of the requirement-to-open capacity in winter happens in a controlled way and condenses through the rest of the year. This will support safer staffing and continual focus on maximising flow while improving cost control.
Trusts need a different approach
The challenges seen by acute trusts this winter will continue. Trusts need a different approach to managing costs and performance. Based on our experience of improving patient flows using holistic interventions, we know flexibility is the key. By assessing a Trust against each of our nine dimensions, it becomes clear how they can lead the way in challenging times.