Comment Blog 9 January, 2018

Improving efficiency through better patient flow

The NHS ‘winter crisis’ has reignited the debate on the best way to improve healthcare in England. Some ideas, like a new funding model for the NHS, have their own problems and would take years to implement. Discussions will continue on the best long-term solution for the NHS but, in the meantime, hospitals can act to improve efficiency to manage demand.

The weekly Winter Situation Report revealed great variation in hospitals performance. Comparing two trusts from the same commissioning region showed that 6 per cent of patients arriving by ambulance experienced delays between 30 – 60 minutes in one, whilst 32 per cent experienced the same length of delays at another. Even when faced with unprecedented demand, efficiency and productivity mean some hospitals manage demand better than others.

Patients wait in ambulances when a hospital’s A&E becomes full because beds in wards are not available for ill patients to move into. If, instead, a hospital has good patient flow (the movement of patients through the hospital to discharge), the pressure on A&E is stable as patients move in and out at a steady rate. Whilst demand for hospitals has certainly increased in the last few weeks, a trust that is able to keep patients moving through the system will be able to treat patients more quickly than one that cannot.

Those working in hospitals often attribute difficulties in patient flow to ‘bed blocking’ from patients medically fit for discharge but needing social care. Evidence supports this. Funding to social care has been cut in recent years resulting in delayed transfer of care (as measured by total number of days) increasing from 115,000 per month in 2014 to 200,000 at the end of 2016, and the number of days lost to bed blocking rising by 50 per cent since 2010. However, delayed packages of care are only one factor. Hospital management must look inwardly and identify inefficiencies in their own systems that contribute to mounting delays.

A 2016 NAO report on discharging elderly patients from hospital found that delayed transfers of care data underestimate the variety of delays patients experience whilst treated in hospitals. These range from lack of knowledge and skills of hospital staff on good discharge planning to delays in transfer to receive care from other NHS providers. Furthermore, discharge planning for a patient late into a hospital stay causes delays, as does discharging a patient late in the day. Discharging more patients in the morning significantly reduces A&E crowding.

Hospitals can improve on these inefficiencies. The most efficient hospitals start planning for a patient’s discharge as soon as they enter a ward. This will mean a review for a patient from a senior doctor every day, an expected data of discharge for the multi-disciplinary team to work towards, and input from the patient into the discharge plan. Hospital management must take responsibility for placing patients in wards suitable to their needs (‘outlying’ patients on a ward typically have a significantly longer length of stay) and discharging patients steadily throughout the week. The NHS aims for weekend discharge levels at 80 per cent of the week, though this is actually significantly lower, at 43 per cent for elderly patients. Hospitals can also make structural changes to improve flow. Guy’s and St Thomas’ frailty unithas reduced admissions for people aged 75 and over, receiving positive feedback from patients.

In addition, a more intelligent use of data could play a significant role in reducing delays. International healthcare leaders are showing how live data can be used to track patients stay in a hospital and identify hold-ups. Saratosa Memorial Hospital in the USA is using live data to track patient’s clinical progress and provide a full oversight of bed occupancy. Since introducing these data, 40 per cent of all discharges now occur in the morning (the NHS aims for 33 per cent, though it is normally much lower, at 20 per cent). In addition, tools such as TeleTracking examine to-be-admitted patients data on their electronic health record to match them to most appropriate hospital bed. Using data more effectively offers the NHS real benefits both in terms of better patient care and improved efficiency.

Whilst government should decide on a lasting solution to improve the NHS, more can be done now to better plan for and manage winter pressures. Lessons can be learnt from those trusts with exceptionally busy A&E departments who still continue the flow of patients to discharge. Improving hospitals productivity will give the NHS a real opportunity to avoid a ‘winter crisis’ in the future.