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An insight into frontline clinical care in acute hospitals

Having spent time shadowing frontline physicians in acute hospitals, Chris Ham and Don Berwick set out the challenges they observed and talk about how the Fund is working with others to develop an agenda for improvements.

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.