2Pressure & patient flow
Patient flow & performance
16.Good performance within an emergency department is dependent on maintaining the flow of patients through hospital. Professor Keith Willett, National Director of Acute Episodes of Care at NHS England, explained the relationship between patient flow and performance against the four-hour standard:
If you look at the breaches of the four hour standard, where they [patients] have not had their treatment and admission completed, yes, there is an issue there. […]That is due to the flow through the hospital, and that is when they are on what would be called trolley waits, although, clearly, most of these patients are on beds and not on trolleys, but they may not be in the appropriate environment and they may not be in the specialist area they should be. That is about the flow.23
17.The Nuffield Trust’s written evidence said that “improving inpatient flow is likely to be fundamental to fully addressing the problem”24 of pressure in emergency departments. Their evidence outlined in more detail the relationship between performance and flow:
Looking across trusts, forthcoming Nuffield Trust research will show that those achieving the 4 hour target have lower bed occupancy across all acute beds. The mechanism by which this happens is not simply that all beds are occupied, preventing any admissions. Rather, it relates to the reduced capacity for patients to “flow” through the system when space is very tight. A certain proportion of free beds is needed to move patients through quickly, due to the need for cleaning, preparation and proper staffing to be put in place. As fewer and fewer beds are left free there is a slowdown. A “one in, one out” dynamic emerges, with queuing causing a back-up in A&E.
18.Dartford and Gravesham NHS Trust’s written evidence described the practical problems that inefficient patient flow can create within an emergency department:
Exit block prevents A&E trolley and cubicle space being used to see and treat other A&E patients as these areas contain patients awaiting a hospital bed, significantly impeding the flow through A&E.25
We also heard during our visit to Luton and Dunstable hospital that the most complex patients within the emergency department demand a significant amount of staff time.26
19.Professor Willett, however, argued that the “delays and inefficiencies” associated with patient flow described above are tied into the way the entire urgent and emergency care system operates and how beds are utilised as a result:
We measure our urgent call handlers’ performance in seconds, our ambulances in minutes, our emergency departments in hours, our hospitals in days, and we probably measure community and social care in weeks. When you have a surge, the responsiveness you need has to be across the whole pathway and we are not capable of doing that. What happens is that, because we exceed something in a very short space of time, we then make a set of decisions, because we are forced to, which are counterproductive. We start moving patients to the wrong wards; we open escalation beds; we do that sort of thing.27
Early senior review of patients
20.One aspect of care which is regarded as significant in maintaining flow is for each patient to be seen by a senior clinician soon after arriving at the emergency department (commonly referred to as “early senior review”). Our predecessor Health Committee’s 2013 report on urgent and emergency care said this could avoid “laborious triage” by a hierarchy of doctors and concluded:
Accessing early senior review of cases can reduce duplication and accelerate the path of a patient through the system. Senior clinicians are better able to balance risk and make key decisions.28
The Nuffield Trust’s evidence highlighted “a lack of senior decision makers” within some trusts, which could contribute to difficulties in transferring patients to inpatient wards or discharging them.29 They added that “Senior decision makers should be available early, with an emphasis on resolving cases in one assessment”.30 Their findings are backed by those of the Health Foundation in a study published in April 2013.31
21.The Centre for Urgent & Emergency Care Research based at the University of Sheffield, however, observed that the evidence on outcomes for early assessment by senior clinicians is limited:
Early assessment by a senior doctor is intended to accelerate progress through the emergency department. Our systematic review of 25 studies (Abdulwahid 2016) found some evidence that senior doctor triage reduced waiting times and the risk of patients leaving without being seen, but did not find evidence of an effect on adverse events, patient satisfaction or cost-effectiveness.32
Visiting Luton and Dunstable trust we heard that early senior review was most helpful for complex patients who were likely to need admission rather than for patients with minor conditions.33 The Trust continually evaluates the effectiveness of their interventions to improve flow and outcomes for patients and staff in all areas share responsibility for achieving those benefits.
Conclusion
22.Both the Nuffield Trust’s and the Health Foundation’s research support the case for early senior review of complex cases. The systematic review cited by the Centre for Urgent & Emergency Care Research, however, reported limited cost and patient outcome benefits from routine use of early senior review of patients. When redesigning systems and processes with the intention of improving patient flow trusts should assess how they are applied and whether they are effective in their local context.
National policy interventions
23.The Government’s evidence listed five improvements (“interventions”) which trusts were expected to make in 2016–17, if they had not already done so:
The initiatives that relate to streaming, flow and discharge represent actions that have already been shown to have a positive impact in local systems that have implemented them effectively. This is about implementing these actions everywhere and also about a focus on outcomes and processes.34
The five interventions designed to improve flow affect all stages of the patient’s pathway through urgent and emergency care:
(1)Streaming at the front door—to ambulatory and primary care.35
This is designed to reduce waits and improve flow through emergency departments by allowing staff in the main department to focus on patients with more complex conditions.
(2)NHS 111—increase the amount of clinical input into calls to the NHS 111 number in advance of winter.
This is expected to decrease call transfers to ambulance services and reduce A&E attendances.
(3)Ambulances—Dispatch on Disposition and code review pilots; Health Education England increasing workforce.36
The aim is to help the system move towards the best model to enhance patient outcomes by ensuring all those who contact the ambulance service receive an appropriate and timely clinician and transport response. The aim is for a decrease in conveyance and an increase in ‘hear and treat’ and ‘see and treat’ to divert patients away from the ED.
(4)Improved flow—‘must do’s that each Trust should implement to enhance patient flow.
This is designed to reduce inpatient bed occupancy, reduce length of stay, and implementation of the ‘Safer Patient Flow Bundle’ will facilitate clinicians working collaboratively in the best interests of patients.
(5)Discharge–increase proportion of patients receiving RRR (rehabilitation, recovery and reablement), care in home or community settings mandating ‘Discharge to Assess’ and ‘trusted assessor’ type models and oversee these initiatives, linked to Regional Delivery Boards.
The aim of RRR is to improve the quality of patient care and outcomes by delivering a seamless RRR service for acute admitted patients. To ease pressure on capacity in acute hospitals and to improve the experience for patients, it is generally more beneficial if patients received RRR care in home or community settings.37
24.Commenting on these initiatives, Pauline Philip said they were the central element of the national bodies’ efforts to improve performance and instil resilience as winter approaches:
At the heart of the A&E improvement plan are five “mandated” initiatives, basically five things that we want each local delivery board to consider, the local delivery board being where the provider sits surrounded by commissioners, surrounded by other stakeholders.38
25.Ms Philip said that A&E delivery boards should concentrate on applying the interventions related to patient flow that are the direct responsibility of emergency departments and hospitals:
The second piece of work is very practical, around how you cope in an emergency department that is under pressure. Do you have the right streams for the patient who appears at the front door of your department? You saw that in evidence when you came to Luton & Dunstable. The first thing that happens is a patient comes to the desk and sees the senior nurse, and we have the ability to say, “Look, your needs can be best dealt with by general practice today or by ambulatory care today and so on,” but it is working with departments all over the country to see if they are doing that.
The next area is to look at the flow—how you are actually managing within your department. Do you have the right information systems in place? Do you have the right number of trolleys? How are you phasing your staffing? How are you interacting with the rest of the hospital? What is happening the deeper you go into the hospital and you look at the patient pathway? Are diagnostics readily available, right down to the back door of the hospital?
That leads me on to the fourth initiative, which is around discharge, looking at patients who are medically fit, occupying acute beds.39
26.The Minister of State for Health, Philip Dunne MP, giving evidence to us, supported the view that the interventions designed to improve flow can significantly improve emergency department performance.40
Conclusions
27.It is welcome that the interventions designed for use by A&E Delivery Boards and individual trusts focus on the practical aspects of patient flow throughout a patient’s stay in hospital. We support the whole system approach to providing a better experience of care to patients in the right setting at the right time. This includes care that may be more appropriately delivered within the community rather than in acute beds.
28.The Centre for Urgent and Emergency Care Research, however, has expressed concerns about the strength of the evidence base for some of the interventions which are intended to improve emergency department performance. The Centre is concerned that the solutions being implemented are not fully backed by evidence:
NHS England has produced a guide to good practice (NHS England 2015) with evidence-based principles to deliver safer, faster, better urgent and emergency care. However, the cited evidence consists almost entirely of uncontrolled before-after studies, observational studies and expert opinion, all of which are recognised to carry a high risk of bias and confounding.41[…]
The lack of acceptable evidence explains why implementation of the principles has been variable and why implementation has not led to clear improvements.42
29.Ministers and senior officials should acknowledge the reservations expressed by the Centre for Urgent and Emergency Care and re-examine the evidence base for the initiatives being applied within emergency departments.
30.Applying the principles of safer, faster, better emergency care will be central to winter resilience planning for many trusts.43 We recommend that NHS England and NHS Improvement set out how they intend to formally evaluate the effectiveness of the interventions that they have mandated and how they will be encouraging trusts to do likewise. Data collection and evaluation should be built into future programmes from the outset to improve research into the most effective interventions.
Practical improvement
31.Whilst acknowledging the importance of national research and evaluation, we were struck by the practical measures applied at Luton and Dunstable University Hospital NHS Trust which has achieved the best performance of any type 1 emergency department in England. As already noted, we were told that the Trust does evaluate their own interventions to measure their impact on performance. The steps taken by Luton and Dunstable which they told us underpin its exceptional performance included:
- Investing in information technology to provide real time monitoring of bed capacity and demand.
- The use of a two stage triage process at the front desk, first to identify cases requiring an emergency response or to redirect patients to the co-located GP service, and secondly to initiate diagnostic tests.
- Allocating beds prior to final diagnosis for those patients that will require admission. This required early involvement of senior decision maker for patients identified at triage to be at risk of admission.
- The creation of a culture where all medical staff within the Trust as well as the social care team will support the emergency department and are invested in its success. The culture within the Trust and community is that this is because it is in the best interests of patient safety to meet the four-hour standard rather than rather than simply a ‘box-ticking’ exercise to meet a target.
- This culture extends to all sectors within the hospital who have seen that they can reduce their own pressures and problems with patient flow if the emergency department is managed smoothly.
- The development of an integrated NHS / adult social care discharge team which identifies patients likely to need help at an early stage.44
Conclusion
32.In its report examining urgent and emergency services, our predecessor Health Committee identified the importance of a professional culture which regards meeting the four-hour standard as a sign of good and safe care rather than as an objective in itself.45 The ongoing decline in performance of type 1 emergency departments against the four-hour target should be regarded as a matter of patient safety rather than a failure to meet a bureaucratic objective.
33.Through the improvement work they are undertaking with trusts, NHS England and particularly NHS Improvement should facilitate the development of the cultural approach we witnessed in Luton, where waiting times in A&E are seen as everyone’s responsibility.
Flow & delayed transfers of care
34.We recognise that even the best performing trusts cannot continue to manage increasing demand if hospital discharge becomes impossible for those who are medically fit to be discharged. The British Geriatrics Society offered an overview of the effect felt by patients and trusts of delayed transfers of care:
The recently published National Audit Office report on discharging older people from hospital estimates in the past two years 1.15 million bed days were lost due to delayed transfer of care, and that delayed transfers rose by almost a third (31%) between 2013 and 2015. There is inevitably a knock-on effect on A&E departments as patients who are assessed as needing admission are delayed […] if beds are not available. This means they must remain in the emergency department and be cared for there.46
35.The Government’s evidence provided an overview of the existing position in relation to delayed transfers of care from hospital (often referred to as delayed discharges). The Government put this in the context of increased demand and higher rates of bed occupancy and noted that delayed transfers of care have grown at the same time as bed occupancy has risen “resulting in greater stress upon the whole healthcare system”, adding:
The majority of all delays (whilst a small proportion of total beds) are attributable to the NHS, although more recently the proportion of delays attributable to social care has been increasing. In 2015–16, there were a total of 1.1 million delays attributed to the NHS (61.2%), whilst delays attributed to social care were 565,000 (31.2%). This represents an increase of 24,000 delayed days (2.2%) attributed to the NHS compared to 2014–15, whilst the delays attributed to social care increased by 144,000 (34.1%) compared to 2014–15.47
36.The Government’s evidence noted that “historically the number of delayed days due to social care were relatively stable until February 2015 when they began to steadily increase”.48 Data published in September 2016 showed that delayed discharges as a result of shortages of adult social care had risen by 80% in July 2016 compared to the same month in the previous year.49
37.In order to maintain patient flow out of their hospitals some trusts have taken to developing their own domiciliary care services. Oxford University NHS Foundation Trust, for example, has recruited 60 care support workers to provide care in patients’ homes following their discharge from hospital.50 The trust’s Chief Executive told the Health Service Journal in July 2016 that 75 beds within the trust had been freed as a result of the initiative and that 50 full time equivalent staff were now providing 1,600 hours per week of care in people’s homes. In the seminar we held with trust leaders drawn from across England we heard from one Chief Executive who is launching a similar initiative. He observed that it is cheaper for the trust to recruit staff and to provide care at home than it is to accommodate the same cohort of patients in hospital beds.
38.Pauline Philip told us that a number of acute providers have developed similar arrangements and they have been:
extremely beneficial in reducing the length of stay of patients in hospital but also in supporting people who then need to go on to further care elsewhere.51
Ms Philip said that these services had been developed by trusts for clinical reasons relating to length of stay in hospital but, significantly, she acknowledged that:
some of the hospital at home service is compensating for the fact that other forms of care are not available to maintain people in their own residence, whether it is their private home or residential care, and is moving them from the acute bed to allow an assessment to take place elsewhere, and then to have them in the type of supportive environment they need for the future.52
39.We heard from NHS trust leaders that it would still make financial sense for an acute trust to provide a domiciliary care service even if, as in the examples mentioned to us, the local authority may not commission them to do so.53 The National Audit Office’s assessment of the costs relating to the discharge of older patients from hospital said that the daily bed cost to the NHS of delayed transfers of care was £303 per patient. This compared with the daily cost of local authority provided adult home care at just £41 and NHS community services care estimated at £89 per day.54 This analysis, however, did not account for the costs that may be borne within an acute trust of stalled patient flow, the consequential miss-allocation of beds and the inefficient operation of the emergency department. Furthermore, trusts which free up acute beds by limiting delayed transfers of care can undertake more profitable elective activity.55
40.The scale of the problem that trusts face in managing a lack of adult social care was reinforced by the Nuffield Trust’s evidence, which concluded that:
The social care system is currently showing signs of serious strain following years of cuts. This is almost certainly linked to rising delayed transfers of care, and presents a potentially serious obstacle to safely discharging many patients.56
Building on this analysis, the Care Quality Commission’s report on the state of care summarised the extent of the problems facing adult social care and the consequences for NHS providers:
we are concerned about the fragility of adult social care and the sustainability of quality. This is concerning for the continuity and quality of care of people using those services, and for the knock-on effects across the whole health and care system: more emergency admissions in A&E, more delays for people ready to leave hospital, and more pressure on other services.57
Conclusion
41.It is an indictment of the existing state of adult social care provision that some acute trusts are having to establish domiciliary care services in order to improve patient flow through their hospitals and ease pressure in their emergency departments. This only serves to underline the perilous state of adult social care in England and the fundamental inadequacy of provision in some parts of the country. The Government should undertake an urgent review of the state of adult social care and its impact upon the NHS and the most vulnerable individuals who depend upon both.
23 Q5
26 Note of Committee visit to Luton and Bedford
27 Q22 (Professor Willett)
28 Health Committee, Second Report of Session 2013–14, Urgent and emergency Services, HC 171, para 78
31 Health Foundation, Unblocking a hospital in gridlock, April 2013, p 9
33 Note of Committee visit to Luton and Bedford
35 As patients enter the emergency department, a streaming system should be put in place which directs those patients who are not sufficiently sick to require emergency care to a service which is better able to meet their needs.
36 Changing the categorisation of calls to the ambulance service so that the process of dispatching paramedics and vehicles can be guided by clinical need rather than meeting target response times (see chapter 5)
38 Q41
39 Q41
40 Q25
41 “Confounding” is the presence of extraneous variables which are not controlled for in analysis
44 Note of Committee visit to Luton and Bedford
45 Health Committee, Second Report of Session 2013–14, Urgent and emergency Services, HC 171, para 67
49 BBC, ‘Sharp rise in care delays ‘piles pressure on hospitals’ September 2016
50 Health Service Journal, ‘New Oxford Hospitals chief reveals delayed transfers turnaround’, July 2016
51 Q58
52 Q59
53 Note of Committee visit to Luton and Bedford
54 C&AG’s Report, Discharging older patients from hospital, HC 18 Session 2016–17, 26 May 2016 figure 15
31 October 2016