Research and analysis

Improving patient flow: evidence to help local decision-makers

Published 3 September 2015

Applies to England

1. Introduction

Challenges facing local health systems continue to accumulate. In this very difficult context, leaders of NHS organisations across England must find the balance between short-term actions and longer term decisions that will do most to improve and sustain both care quality and their finances. 3 publications from Monitor this Autumn offer related evidence to support their strategic decision-making.

2. Understanding urgent and emergency care performance

Among the quality issues on the agenda for many hospital boards will be this coming winter’s urgent and emergency care performance: between October and December 2014, 91% of all trusts failed on the 4-hour emergency care standard compared to 62% in the same period in 2013.

Monitor’s new analysis of what lay behind this increase in delays last winter confirms that the main reason, common across acute hospitals, was a reduction in the capacity of inpatient wards to receive admissions from emergency departments. More inpatient wards were running at very high occupancy rates of 90% or above. Emergency departments themselves coped well with the 6% average rise in A&E attendances last winter. But the capacity bottleneck in inpatient wards restricted the exit flow from emergency departments, which in turn had an adverse impact on the ability of staff in A&E to care for their patients.

The resulting impact on performance against the four-hour standard shows how this standard is actually a quite sophisticated measure of the performance of the whole urgent and emergency health and care system. The report’s findings suggest that among the best ways to make sure patients receive emergency treatment in a timely fashion this coming winter is to concentrate on smoothing the flow of patients through inpatient wards, to the point of discharge and beyond. That makes capacity in social and community care important, as the report highlights, and this is beyond the control of hospital trusts. But there are many ways to free acute capacity that hospitals can consider.

In this regard, 2 further publications from Monitor will be of interest to NHS leaders.

3. Schemes to deliver care closer to home

The first is a set of materials we have developed to help local health system leaders decide whether to invest in schemes that deliver care closer to patients’ homes, as well as what types of schemes to invest in and how to best implement them. Providers and commissioners across England are developing such schemes to avoid admissions and enable faster discharge from acute hospitals. The schemes aim to deliver better care closer to the patients’ homes at lower than the cost of treating those patients in an acute hospital.

Some of these schemes could divert considerable numbers of patients away from acute hospitals. Evidence indicates they can improve both outcomes and experiences for patients but their impact on local health system costs has not always been clear. Monitor’s materials include calculations of the potential effects of the 4 most established types of community-based scheme on cost expenditure in a typical local health economy over 5 years.

This work shows that such schemes, when well-designed and implemented, could best be used to create capacity for managing expected increases in demand for acute care over the longer term. They could also potentially do this at lower cost than creating new acute hospital facilities. While these schemes may not achieve cost savings from today’s spend in a local health economy, they can reduce the rate of expenditure growth by substituting for – or at least delaying – the need for investment in new acute hospital capacity.

To help NHS leaders develop well-designed and well-implemented schemes, the project sets out further information on the structures of four types of scheme and the data required to evaluate their impact. The information includes a report identifying the main challenges to designing and running effective schemes and some solutions. This information is complemented by a set of case studies and an online platform to help providers deliver change and to share insights drawn from their experiences.

4. Improving productivity in elective care

4.1 (To be published shortly)

The second forthcoming study from Monitor linked to capacity management in acute hospitals reports on productivity improvement in elective are. Evidence from the highest-performing NHS and international elective care units indicates that trusts in the NHS could save 13-20% of what they spend on elective care by introducing tried and tested techniques for managing the flow of patients along elective care pathways.

These techniques, including stratifying patients’ by risk and standardising post-operative ward care, can deliver higher quality care and better patient experiences as well as reducing lengths of stay and overall cost per patient. Most of the techniques are familiar in the NHS are not universally applied.

Interdependencies between elective and emergency care are notoriously difficult to manage. But where both types of care are delivered in a local health system, shorter stays for elective care will automatically release capacity for other inpatients – including those admitted from A&E.

5. Other options for improving patient flow

Any increases in acute capacity gained from schemes to deliver care closer to home or more productive elective care are unlikely to be immediate: experience indicates investment in either type of initiative is more likely to increase capacity after the first few years of operation. That means hospitals need to look at other options for improving patient flow in the short term.

The Nuffield Trust has been conducting research on techniques and opportunities for flow improvements through acute hospital inpatient wards. A short report summarising the research is available, supplemented by case studies of approaches which can be implemented quickly. This work supplements existing studies on NHS operations management, including Lord Carter’s June 2015 Review of Operational Productivity in NHS providers. Monitor has also published a series of next steps which look at ways to improve patient flow, taking into account both hospital and community-based care.