Working together to improve patient flow

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This event provided delegates with practical whole-system approaches to improving patient flow. We also explored the new opportunities arising from place-based systems of care and how key organisations plan to make delayed transfers of care a problem of the past.


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Siva Anandaciva - Patient flow: a systemic problem for all agents to solve


  • SA: Siva Anandaciva

My name is Siva Anandaciva.  I'm the Chief Analyst here at the King's Fund and it's my pleasure to welcome you to today's conference, our event on working together to improve patient flow. But why are we here? What are we doing here? You may have already forgotten in this atmospherically lit room that the sun is shining outside, we're forecast to hit 22 degrees and yet we're talking about patient flow, a subject that particularly in the NHS we talk about from about November to February and then move on to other things. Whereas you are all, I'm sure aware, we don't have winter pressures anymore in health and care we just have pressures. These pressures on services last year round and so part of this day is understanding those pressures but a  large part of the day is, how do we find a way through them? So hearing best practice as we already did this morning from Luton and Dunstable in our breakfast session and throughout the day and I think a common theme of both this opening plenary session and the whole conference will be that the way through these pressures, the way through these challenges is by working more collaboratively, by working in partnerships, by working as systems of care and thinking more widely.  

I'll do a scene setting piece which is to open the conference, patient flow, a systemic problem for all agents to solve. And I've got to admit when this topic, when this title was given to me by our events team, I thought in football parlance surely this is an open goal because honestly, what is the alternative? Are we to look at patient flow and say it's not a systemic problem, that it's a localised problem, an organisational problem and that it's not a problem that all the agents in the system in the health and care economy have to come together to solve?  

Well after ten to twelve years of working in emergency care I tell you, doesn't the reality feel like we spend most of our time treating patient flow as a problem for individual clinical teams, for individual organisations and we talk about the whole systems focus but we behave still very much in a sovereign organisational mind-set though there's some hope that's changing?

So I want to do two things over the next ten minutes or so, the first is very quickly canter through the national data to give us an idea of where we might be with regards to patient flow coming out of winter and the second thing is just to leave you with two or three reflections to carry through the rest of the day.  

So as is traditional when you're talking about patient flow, I'll start with A&E, partly because it's a totemic indicator, partly because it sucks up all the oxygen in the room because that's where the data is richest. Now what this animated table is showing you: each of these squares is a hospital trust providing major A&E services type one consultant led A&E services.  As you can imagine, the square is green if you hit the standard for 95% of patients to be seen in four hours and you can see over time how that has shrunk and shrunk and shrunk in terms of the number of trusts meeting the standard. When I was working at the Department of Health ten years ago you could count on two hands the number of trusts not meeting the standard, now you can count on two hands the number of trusts that are meeting it. 

That has led to quite a few challenges as you can imagine, but the key challenge I would say is first of all are we getting our expectations right?  You read the national planning guidance last year and the expectation was we will once again meet the four-hour standard in A&E in 2018. The latest national guidance is we'll met the four-hour standard in 2019.  It does seem that we are setting ourselves up to fail if we're planning based on hope and aspiration rather than reality, and the second thing that really worries me is the number of chief operating officers, number of clinical directors, the number of medics and nurses who say in one way or the other, "I'm starting to lose my calibration of what good looks like. When all my peers are struggling, when we haven’t met the target nationally since July 2015 in any month I'm starting lose my sense of what good looks like in patient flow and what I will accept in terms of the care I deliver."

So this is still A&E data presented slightly differently, so here poorer performance is shown by a higher line because this is the percentage of patients who are waiting over four hours and you can see that yes we do have a challenging period in winter, more patients waiting over four hours in the months of December, but we seem stuck this year. For the first time in a long time if this is 2017/18 performance we haven't seen the return back to greater performance that we normally see at this time in March or April. This is when the weather gets better and hospital trusts will start thinking I'll start to book planned operations again. Instead we've had the worst February, the worst March and the worst April for A&E performance on record - at least since we started collecting it.  

I will absolutely recognise there are demand-side pressures, norovirus and things like illness, of course there are, but when you see the sustained level of challenge the hypothesis switches to, have we got a supply side problem? A fundamental under resourcing of beds, staff, both in and out of hospital that is the rate limiting factor for improving patient flow?
The net result of this is that patients are stranded both in and out of hospital. So for the first time this winter NHS Improvements and NHS England collected data on what was termed stranded patients, patients who remain in hospital over seven days, the thousands of patients who remain in hospital over 21 days. First of all obviously a major data caveat that you can stay in hospital for a long period of time and still be receiving ongoing medical care, you're not necessarily fit for discharge. Secondly anecdotally, quite a large proportion of patients in some trusts were former … they'd gone through norovirus and obviously you don't want to discharge back to a residential nursing home or a care home too soon.
Having said that, you look at the number of patients waiting over 21 days in hospital before returning to their normal place of residence, you think about the patients who are stranded on waiting lists for planned care, the number of patients who are visiting GPs saying, "I'm now in extreme pain waiting for my hip and knee operation, this is not a lifestyle operation this is me with chronic pain," and the word stranded becomes really important. You can debate the definition but stranded captures this sense of not just clinical decompensation but the emotional cost of poor patient flow that we need to reduce if we're not as tight as we can be on operations and resources, but this is not meant to be unrelenting negative because there are some positives that we've seen over winter.

So this chart is a chart I think you'll see probably at least three or four times today of delayed transfers of care whether they're due to … whether they're attributed to NHS delays, social care delays or both and you can see that, yes, it was a rising tide for a long time but round 2017/18 we start to see a kink in the curve. We start to see a reduction in the average number of delays, whether due to the NHS or social care.  Partly this shows that the system can deliver, it can deliver a return on investment, it can deliver more patches of care, it can deliver quicker assessments, it can deliver more placements to reduce delays, to improve patient flow when the system is given the resources it needs. So it's not all necessarily doom and gloom.

So if that's where we are on the data I just want to very quickly leave you with a few general reflections. The first is, if you look through conversations about health and social care integration or the interface between health and social care, it feels like 90% of our dialogue is about delayed transfers of care. You could be confused for thinking that the sole purpose of health and social care integration is to reduce delayed transfers and obviously it's not and there is an opportunity cost in focusing on it. I don't want to dispute that delayed transfers of care have that punishing social cost, emotional cost, clinical cost that we talked about earlier, but at the same time as the CQC noted in its thematic review, which again I recommend you read if you haven't done so already, of health and care systems, an excessive focus on delayed transfers of care misses the opportunity for the wider contribution that an interaction between health and social care can have in prevention, in health and wellbeing, in health promotion, in more holistic services. So I … one thing is, are we talking about the right things? 
The second point I'd made, again a slightly obvious one, is each part of the system has to do its bit and that goes beyond health and social care. If this is what we want, if we want people to age well and stay well, if we want people … if we want more support for complex, comorbid, frailty, if we want basically holistic person-centred care, then obviously that involves wider systems of care, everything from the voluntary service to your specialist acute trust. But the point I want to make is a slightly different one and slightly countercultural which is, we've almost started to fetishize systems of care as if all we have to do is wrap a system of care around an existing set of organisations and that will magically solve all our problems. Now the one note of caution or one thought I'd like to leave in your head is, how do we balance the need for every individual module within this network of care, every individual organisation, to still do its role efficiently and effectively whilst still working as part of an effective system of care?  

The analogy someone gave me was, we keep talking about a baton pass, yes, you're doing a relay race in patient flow and you do a baton pass, don't focus all your time and thought on getting the baton pass right because most of the work is done in the actual running when you're holding the baton. And the final point I'd make is as we talk through these examples of best practice and as we start thinking, could I take that back to my own system and apply it? And then you run into this hurdle of but, but I will run into a barrier, I will run into a hurdle that I have to surpass, try and diagnose what really is that barrier.  Is it money? Is it staff or is it trust?  

This is an email I received in … sorry if you'll indulge me I'll very quickly read it out.  We've run a successful pilot on placing housing officers in acute hospital integrated discharge teams. It places a specialist housing resource close to people at the most vulnerable time when they're in a hospital inpatient and could offer the usual lifestyle and housing services. This team helps people move on and return to the best possible home situation once their health problems have stabilised. It has taken a lot of goodwill from the local district councils and the hospital. We have unfortunately had to suspend the service because there is no long-term funding. Funding it by joint contribution seems hard to achieve.  

Now the meat of that is the middle, the fact that if you've seen hospital discharge teams they're fantastic, but any time things get complex, any time housing is brought in, the pace slows down. So solve that problem, put in the housing specialist expertise, but the paragraph starts we've run a successful pilot and it ends, we've had to suspend it because funding is hard to achieve. So if you've look at where power, where funding sits in the local system, is the rate limiting fact that we don't have enough funding for health and social care? Is it that we don’t have enough staff? Or in some cases is it that we don't have enough trust, enough of a sense of risk for one party with more resources to underwrite another party with less resources? That sounds … it's been a little bit more negative I start to think than I hoped, but hopefully the inspiration will come later. 

So in summary, you look at the national data and I've got to be honest, we're in the deepest hole I've seen in my career particularly in the NHS, but there are green shoots of good practice that we're going to hear about throughout today and the green shoots of national performance for delayed transfers of care. But, to be honest, I don’t care.  I don't care if in your local system it's the sustainability and transformation partnership or the integrated care system or the accountable care partnership or the accountable care system, whatever the three letter acronym is, for me the most important three letter acronym is NMP. As someone who came up at a time when foundation trusts were king, when the hospital was by far the king in a local system, I remember speaking to a chief operating office and he said, "Look, my job is to get patients from the front door to the back door and after that NMP, not my problem what happens to them next." Speaking to that same chief operating officer now, and he's a different person, and he says, "It's our problem," and it may sound Polly Anna'ish but that's given me more hope than anything in these national data.