An insight into frontline clinical care in acute hospitals

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Part of Frontline clinical care in acute hospitals

During the past year we have become increasingly aware of the pressures facing frontline clinicians working in acute hospitals. Each of us spent time in 2016 shadowing a general physician on his ward round to gain an understanding of work at the sharp end of acute medicine in an NHS trust rated as ‘outstanding’ by the Care Quality Commission.

The challenges we observed included:

  • staff working under constant pressure (notwithstanding substantial increases in the number of clinical staff in recent years) in the face of growing demand from an ageing population with complex needs
  • difficulties for hospital staff in communicating with GPs about patients who are admitted to hospital, including knowing who patients’ GPs are
  • problems in communication within the hospital between acute medical staff and A&E staff, as well as between different specialist teams
  • difficulties in communicating with staff in other hospitals when patients are transferred
  • delays in ordering and receiving the results of diagnostic tests, which in turn lead to delays in treatment and increase in the time patients spend in hospital
  • challenges in teamworking, for example on ward rounds when consultants are sometimes not accompanied by trainees and nurses
  • information systems that do not link data about patients held in primary and secondary care, and that are often slow in use
  • patients having to repeat their histories (where they are able to) at different stages in their treatment
  • care being delivered inefficiently and often ineffectively because of the amount of re-work required by the above
  • old buildings and cramped layouts that do not allow privacy and sometimes dignity for patients, or space for staff to work without interruption
  • poorly organised paperwork and documents
  • inefficient organisation of supplies and workflows on hospital wards.

The experience prompted us to feel both concern and curiosity. Concern focused on the impact on patients, and on staff, of having to provide care faced with these and other difficulties. This concern was more than hypothetical as we heard examples of patients whose care had been compromised by the constraints under which the physician and the team we shadowed were working, despite the best efforts of all involved. How could it be that care of this kind was being delivered in a hospital that was part of an NHS trust rated by the CQC as outstanding?

Curiosity centred on understanding whether this hospital was an outlier compared with acute hospitals elsewhere in the NHS. Our discussions with medical and managerial colleagues from different parts of England confirmed quite quickly that what we had seen was not unusual. Of course, every hospital is different, and some trusts have made more progress than others in mitigating the difficulties we observed. Even so, the pressures of delivering high-quality care to acutely ill medical patients are real and growing, and worthy of investigation.

With this in mind, The King’s Fund has embarked on a project looking into frontline clinical care in acute hospitals. The aim of our enquiry in the first instance is to draw attention to what we saw. We are doing this by engaging in discussion and deliberation with clinicians and others with expertise and experience to offer. We have also commissioned a series of essays to offer different perspectives – including from patients – on how clinical care is provided on general medical wards in NHS hospitals, and we will be publishing these essays later in the year.

In undertaking this project, we want to offer both a diagnosis of why clinicians in acute hospitals experience difficulties and frustrations in their daily work, and an agenda for bringing about improvements. Our hunch is that the well-known funding and staffing constraints facing the NHS and social care are among the causes. Quite simply, demand for care is rising more rapidly than funding, and shortages of clinical staff have increased the workloads of staff providing acute medical care. Similar pressures have been reported in other areas of care, including general practice, as the effects of several years of austerity begin to bite.

We know that resource constraints are not the only causes. Many acute care processes, facilities, habits, and procedures may not be fit for use in the current context. We are interested in discovering and documenting shortcomings in how care is delivered and helping to identify more suitable alternatives. We want to learn more about how hospital leaders and clinicians are improving care delivery and share the lessons with others. Our aim is to build on lessons from previous NHS programmes, such as the so-called ‘productive ward’ series, the use of ‘red and green days’ in hospitals, and work to improve the flow of patients through hospitals.

At the heart of our work are questions about how hospital leaders and clinicians are responding to current pressures. Are they addressing the underlying causes or engaging in firefighting? Are they freeing up time for clinical teams to make improvements in care and do these teams have the skills and resources to do so? Are they focusing on the cultural impediments to the provision of high-quality care as well as the technical obstacles? Are they looking beyond the hospital to strengthen links with primary care, community services and social care in order to meet some of the demands they are faced with in more appropriate settings?

We have been hugely encouraged by the responses we’ve received since we started this work, from clinicians, managers, regulators, junior doctors, nurses, medical students and professional societies. It really does appear that now is the time to shine a brighter light on frontline clinical care in acute hospitals in order to make the day-to-day pressures more visible and to identify how they can be addressed. It’s clear to us that the desire to improve care delivery is strongly ingrained in the NHS.

We shall be working with others during this project to offer practical suggestions on what needs to be done. All ideas on how we can make a useful contribution are welcome.

Comments

Dr Gordon Caldwell

Position
Consultant Physician,
Organisation
Worthing Hospital, Western Sussex Hospitals NHS Trust
Comment date
01 February 2017
Dear Chris and Don

thank you for taking these issues so seriously.

The Clinical Consultation between patient and clinician(s) is vital to the formulation of the most appropriate clinical management plan for each unique patient in his or her unique clinical, functional and social context. The supply of information to the clinician(s) prior to and during the Consultation must free the Clinician to give Undivided Attention to the Patient and allow the Clinician to Hear Him/Herself Thinking. In this way patient and clinician can proceed with best care using neither too little nor too much investigation and neither too little nor too much treatment, and have time and mental space to actively protect the patient from harm during care. We must find ways to optimise the micro-environment for Clinical Consultations. If we can achieve this, patients will experience better, more compassionate and person centred care. Clinicians will not be exhausted by Hunter Gatherer data hunting and will be more fulfilled as they deliver better care in closer professional relationships with the patients. Come to the Gemba and support us clinicians in the work we want to do for our patients!

Heather Hughes

Comment date
01 February 2017
Dear Chris and Don

Totally agree with all of the above, but we ( people working in the Health and Social Care system) have known all of this for decades. The issue underlying all of them except for the first is that
1.People are tribal, and believe that their bit of the system is most important/ fine, the problem is elsewhere
2. No-one will give up any of their budget or status in order to get a better outcome for individual patients
3. The funding is based on history plus a bit for every separate part of the system
4. Ageism. Pure and simple. Due to the sheer numbers of older people. Their care is not funded in the same way as younger adults
5. Egos/ we do it cos we can. So listening to a relative working on a surgical ward, people who should have palliative care are being operated on and surviving another handful of days. All the staff except the surgeon disagree with this approach but ...
6. Lack of flexibility. So all elective surgery cancelled because of emergency demand, but surgical ward wasn't used for acute admissions cos the consultant ( from overseas) hadn't had general medical training rather straight into surgery on qualifying.

The resources and reputation of the Kings Fund need to be used to be a bit blunter about the cultural barriers to better outcomes for more patients. Good luck with it

James Shipman

Position
Executive Medical Director,
Organisation
Staffordshire and Stoke on Trent Partnership Trust
Comment date
03 February 2017
Thanks Chris and Don for this careful and accurate observation. We need a fix for today but with an eye on what is sustainable for the future demand we will have with increasing longevity and population growth. There are lots that can be done in systems to improve efficiencies as you have both identified. The red-green, SAFER care bundle and home first work is spreading and making a real difference to the hear and now.

Some suggestions and observations:

1. We really need a public conversation about what is really covered by the NHS and how best to use it..
2. The reality is we have an NHS constitution but a Health and Social Care act - either we need to bring social care and its funding into the NHS and alter the constitution or be honest and accept the H&SC act needs a radical re-think
3. NHS monies are ring fenced, uplifted annually and providers are able to overspend
4. Local authorities control public health and social care spend and have seen budgets slashed and are not permitted to overspend

The problems the NHS faces are available workforce (and the paucity of clinicians in a number of critical areas) to cope with increasing demand, associated often extortionate agency costs which are effectively met by the public purse when some of it could go into NHS care if we had the appropriate national systems.

We now have a local public health service, a significant lack of domicillary care providers which impacts on the flow out of hospitals and councils without the money to stimulate the markets. Should we have a ring fenced health, social care and public health budget?

We have to work on this urgently and nationally as we are dealing with the tip of the iceberg which is the cohort of people born in the 1930s which had the lowest birth rate in the 20th century. Wait till we 2032 when we get the over 85s born around 1947, highest birth rate, grew up in the 60s and will have different expectations.

In summary we need some system altruism but this will require help from regulators to accept blurring of rules and boundaries so we can try out innovations and work together to develop safer more efficient cultures in order to realize the benefits in a similar manner to the aviation industry.

Good luck!

Philip Darbyshire

Position
Nursing and Healthcare Consultant,
Organisation
Philip Darbyshire Consulting
Comment date
05 February 2017
Incisive and accurate blog. What is staggering are the key challenges indicated. After 40 years in Nursing and healthcare I cannot believe that we are still flagging up the same issues. I attended an 'Innovation in Healthcare' summit last year where a Keynote Speaker suggested that we need an 'integrated health system'. I could not believe my ears. What on earth have we been running and presiding over for the last 40 years? Oh, wait a minute......

Rahul Mukherjee

Position
Consultant Physician and Clinical Director - Medicine,
Organisation
Birmingham Heartlands Hospital (erstwhile HEFT awaiting 'amalgamation')
Comment date
07 February 2017
You make very important points, as usual, but if you want to see a bit of the future you envisage, please come and visit us at Heartlands. We have improved our SHMI and rota gaps in Medicine since 2014 through innovative workforce planning/ Medical Cover Redesign and delivered stable performance despite steady increase in A&E attendance (approximately by 70 patients per day increase going up from 320/day to 390/day). This has largely been under-recognised due to a variety of reasons but it is true that the 'future is already here, it is just unevenly distributed'. Our ideas are outlined in www.rationalmedicine.net and we also have a facebook page (Rational Medicine) for sharing ideas. We use the positive learning from the NHS to help foster universal health care ideas in India. Will be happy to be of help.

Jean Symons

Position
Architect,
Organisation
local community conservation committee etc
Comment date
08 February 2017
Dear Chris

I think we met many years ago when I was working at a unit based at the King's fund on providing all sorts of accommodation for those who were elderly, physically disabled, mentally ill and 'mentally handicapped', with the aim of closing many old hospitals.
I am an architect and in 1985 contributed articles to the Architects Journal, explaining the design requirements of those who were housed in long-stay hospitals because there was little or no alternative accommodation.

Recently, when listening to the Prime Minister talking at length about the NHS and mental illness, I waited for her to mention Social Services and Local Authority provision but by the end she had only spoken of the need for more NHS provision.Fortunately, community care was raised in Parliament a couple of days later.

I hope your campaign succeeds where so little has been achieved in the last 40 years

Karen Barnett

Position
Director of Operations (community),
Organisation
Calderdale & Huddersfield NHSFT
Comment date
11 February 2017
I do agree with your observations and will be interested to see the outcome of this work. I would however note that the focussing the intervention on the tiny part of the system that is the acute in patient stay is narrowing the opportunity for learning. The reasons that a number of people end up, and stay too many days, in an acute in patient bed are undoubtedly similar issues at the front line mainly due to system design issues, poor IT infrastructure and the different funding mechanisms that have created tariff based income for in hospital activity and block based community activity. This fundamentally limits the opportunity to create enough high quality out of hospital capacity that would enable integrated health and social care to reduce the demands on our acute hospitals in turn providing the 'space' required to enable clinicians and managers to recreate a different reality within the walls of the hospital.

Hugo Farne

Position
Respiratory Registrar,
Organisation
North West Thames
Comment date
03 May 2017
Thanks for bringing attention to this - although many of the issues raised are all too familiar to those of us on the front line. I have a couple of others to add, drawing on my background (I was a management consultant for 6 years prior to entering medicine, and am now a junior doctor):

1) Improving the personal development of trainees.
The Shape of Training review provides an opportunity, although I fear it will be missed, to overhaul the training and assessment of junior doctors. The current system is not fit for purpose: we all know that the recruitment and appraisal system does not recognise doctors who excel clinically, whilst simultaneously failing to identify those whose clinical care falls short of the standard expected. The reasons for this include:
a) The time required by the existing assessment system. For example, there are >100 items on the general internal medicine curriculum for registrars, each of which must be evidenced by at least two workplace-based assessments (WPBAs). There are additional requirements in terms of the number of WPBAs of each type that need to be completed each year (e.g. audit, quality improvement, teaching assessments). Neither the trainee nor the assessor has dedicated time for this (the educational and clinical supervisor does, although it may not be sufficient). As a result the forms are filled in hurriedly with emphasis on getting the necessary volume of forms, at the expense of the quality of feedback.
b) A bias against constructive feedback. A score of 3 or less out of 6 on any item on a WPBA raises an alert. This then becomes a problem for the trainee and their supervisor, flagged at their annual appraisal and often requiring additional feedback. There is thus a powerful disincentive to soliciting useful constructive criticism.
c) There is a huge selection bias in feedback, as the trainee solicits feedback and thus will only do so from those positively predisposed towards them. This makes a mockery of the allegedly 360 "Multi-Source Feedback" form and the "Multiple Consultant Report".

In my previous life as a management consultant, there was a genuine culture of feedback - so much so that employees craved constructive feedback, as they knew that this was the only way they would improve. This is wholly lacking in the NHS, despite doctors being amongst the brightest and most driven individuals I have come across. The system is at fault.

2) Best practice sharing.
Given part of the purpose of letting trusts become more independent and do their own thing is surely to see which good ideas emerge, who is then identifying these good ideas and spreading that best practice? You are right to identify the junior doctor workforce, who rotate yearly and thus are exposed to best (and worst) practice at different trusts, as a potential source. But surely this should be centrally coordinated by a dedicated resource, with the skillset and authority to drive change through NHS trusts? Junior doctors by and large do not have this, and as NHS trusts are not set up to listen to them (let alone solicit their ideas), they tend to give up in the face of various bureacratic and organisational barriers.

Again in my previous life, every office had a degree of autonomy and any member of the organisation could come up with a suggestion, see it trialed at a project level, then office-wide and, if successful, rolled out globally. The mind boggles at the potential if this could somehow be applied to the NHS.

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