Focus on the whole care pathway, not just delayed discharges

In February, trusts showing a high number of medically fit patients delayed for discharge - “green to go” patients - were told to cut these numbers in half within a month, as outlined in a recent HSJ article.

Coinciding with this, accident and emergency departments have experienced the most challenging winter in recent years, to the point where the NHS has missed its A&E four hour targets country wide.

Delayed discharges are frustrating for patients, and a large, unhelpful expense for the NHS - one that is usually underestimated in reports.

Studies carried out by Newton indicate most acute trusts have between 20 and 30 per cent of their total bed capacity occupied by medically fit patients - a factor of four greater than reported figures suggest.

‘It’s not as simple as telling trusts to focus on these patients’

To demand trusts improve delayed discharge numbers by 50 per cent in just a month, without putting a plan in place to tackle the systemic cause of the issue, however, is setting health economies up for failure.

It’s not as simple as telling trusts to focus on these patients; they already expend a huge amount of time and energy doing this. For the trusts themselves, these patients may not even be the ones they can have the greatest positive effect on.

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Different priorities

The delayed discharge bottleneck is the result of a variety of factors spanning the whole patient pathway. These include onward care delays and assessments, poor communication across departments and a failure to accurately record up to date patient information while the patient remains medically unfit.

It’s critical that accurate data is captured effectively, so that as soon as a patient enters the system, the next steps in their pathway are not only correct, but delivered quickly.

Joining up systems and internal processes is key to solving delayed discharges. Health and social care is the obvious example.

‘Demanding trusts improve delayed discharges faster sets them up for failure’

Currently, both systems have significantly different outlooks on the same situation: the healthcare side is keen to see patients move on from acute beds to free them up for the next patient, while the priority for social care teams is to ensure the patient goes into the correct long term setting. This means both groups are working to very different timescales and targets.

The same can be said for internal processes within hospitals.

Too often different departments work in isolation towards individual goals, when they really need to be looking at the broader picture - one that’s best for the patient from beginning to end.

This means developing a rigorous focus on each patient’s next step; making sure diagnostics, assessments and system resources are used to their full advantage; and building communication with onward care providers.

By working with trusts to challenge the full pathway in this way, rather than just targeting delayed discharges, we’ve seen the length of time patients spend in acute care reduce by up to 10 per cent in just six months.

Close collaboration

One recent length of stay programme Newton worked on with a trust led to a 62 bed saving across its wards, which translated into an annualised financial benefit of several million pounds.

Most fundamental to achieving these results was improving the flow and visibility of patient information. We created a comprehensive information management system that could track length of stay activity and clearly highlight data trends and possible issues.

This provided one central visible area for departments to access current information on patient status and next steps - information that was drawn from new, easier to update, electronic nurse handover sheets.

‘Improving the flow and visibility of patient information is fundamental to achieving results’

Staff communication was strengthened by implementing specific guidelines to improve the standard of ward and board rounds, and the integrated discharge bureau function was developed to improve communication with community partners.

The complex discharge database linked to the internal IT system and nurse handovers allows all parties involved in patient care to operate with a joined up understanding of each patient’s needs.

Communication and close collaboration with trust stakeholders and staff were key to ensuring all these changes became business as usual and remained sustainable. Running workshops and offering training also ensured the changes were effectively developed, trialled and implemented.

A lot more work is needed on integration before trusts can be expected to meet the challenging “green to go” targets. It’s important to focus on the entire system, not just acute care, and for discharge teams and external care organisations to adopt a joined up approach supported by practical guidance to engage staff at all levels.

Having full visibility of a patient’s pathway between acute, community and social care can ensure the best care is given, in the best setting, which is better for patients and much more cost effective for health economies. It’s better than just focusing on delayed discharges, over which acute teams have less power.

Ric Whalley is business manager for healthcare at Newton Europe