Everything must flow: how emergency care can meet demand

A common assumption in the NHS has been that the more money and people you put into a system, the better the outcome will be. However, increases in resources have not always resulted in proportionate improvements in access to, or quality of, care. With an ageing population and constrained funding the current model of healthcare delivery is rapidly becoming unsustainable, and something needs to change.

‘Most delays and inefficiencies arise from a mismatch between capacity and demand’

The Health Foundation created an improvement programme that explores the relationship between patient flow, cost and outcomes by examining flow through the emergency care pathway and developing ways in which capacity could be better matched to demand.

Flow Cost Quality supported two NHS hospital trusts, South Warwickshire Foundation Trust and Sheffield Teaching Hospitals Foundation Trust, to test this relationship over two years.

The case for improving flow

Both trusts knew their systems were overly complex, costly and patient experience could be poor at times. They needed to provide care in a different way − right first time and on time, every time.

Most delays and inefficiencies arise from a mismatch between capacity and demand. Patients generally arrive for assessment or treatment between 9am and 8pm seven days a week.

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However, the number and skill level of staff needed to meet this demand is usually only available within “normal working hours”, with reduced capacity at night, weekends and on public holidays. When demand is not matched it creates delays and queues and these get amplified as the patient travels down a multistage pathway. Staff working amid a constant backlog of patients, who have not been seen or treated in a timely way, can feel overwhelmed by this demand, especially if the patient’s health has worsened. 

Valuable time can be wasted prioritising, transferring and managing patients rather than adding value by diagnosing and treating them. For example, in the case of one patient in Warwick, during an eight day stay in hospital only 18 per cent of their time in hospital added any value to their treatment − the rest of their time in hospital was regarded as wasted. Flow can be improved by reducing the variation in capacity and ensuring that the capacity meets the variations in demand.

Tools used

Underpinned by the quality improvement principles of “lean”, the “theory of constraints” and “clinical systems improvement”, the Flow Cost Quality programme has three key phases:

• understanding the system;
• testing different solutions and implementing new processes; and
• measuring the impact.

Both trusts focused on hard evidence as a way to engage stakeholders. Sheffield spent a year mapping and translating its complex systems in order to create a complete picture.

Solutions cannot always be bought off the peg, however, and given that South Warwickshire and Sheffield are very different organisations, they approached problem solving differently; though the principles and motivation behind the need to improve were similar.

South Warwickshire is a smaller trust and looked more widely at all adults entering A&E. It used the lean A3 problem solving process, a visual tool used to aid discussion and collaboration among a group of stakeholders, encouraging them to work together to see and understand a problem and track changes made to solve it.

Sheffield, a much larger trust, decided to focus in on frail older patients using the obeya, or “big room”, approach. Developed by Toyota and widely used in the manufacturing industry, the big room approach is a regular, non-hierarchical, standardised and non-seated meeting of the project team within a dedicated room. The thinking behind it is that you can update wall charts by discussing and capturing ideas and testing the process over time. 

Key changes by the trusts

• Both trusts kept the focus clearly on the patients and their outcomes, communicating this to all using slogans such as “one patient one day”, “today’s work today” and “right patient, right ward, first time”.
• Both trusts changed consultant working patterns to bring capacity more in line with when specialist input was needed.
• South Warwickshire implemented a system in which specialist consultants “pull” their patients from A&E, reducing delays and ensuring patients were on the right pathway as soon as possible.
• South Warwickshire reduced turnaround times for blood tests by finding the blockages in the process and fixing them. They also introduced an electronic work management system and improved the take home medicine process.
• Sheffield set up a dedicated frailty unit and also accelerated diagnostic testing by relocating equipment and services within the unit. The key benefit was the collocation of all specialist, medical, nursing and therapist staff whcared for frail older people.
• Sheffield introduced a model of “discharge to assess” whereby patients who needed post-discharge care were discharged as soon as they were medically fit, with assessment and care packages put in place with the patient at home. This was supported by the community Right First Time programme underakent in conjunction with Sheffield City Council and other relevant stakeholders.
• Sheffield merged elderly outpatient and emergency patients into a single system of care.

Outcomes

South Warwickshire realised a range of benefits including more rapid senior assessment of patients, quicker access to specialist input or admission, lower bed occupancy in the assessment unit and a higher percentage of patients on the right ward.

“The surprising thing was that although the symptoms were in A&E, we didn’t have to do anything in A&E at all,” says Jyothi Nippani, a consultant obstetrician and associate medical director for emergency care. These changes were made at no additional cost.

‘Although the symptoms were in A&E, we didn’t have to do anything in A&E at all’

“It’s a really powerful scheme and it didn’t cost us a penny. We just re-engineered it and everyone is really proud of what they’re achieved,” said Glen Burley, chief executive. Another impressive outcome was the change in culture in the organisation, recognised by a National Patient Safety Award.

The biggest impact at Sheffield has been on the improved timeliness of assessment and treatment, at the same time as seeing a reduction in mortality. Sheffield achieved a cut in in-hospital mortality for geriatric medicine by about 15 per cent. While demand stayed the same, there was a 37 per cent increase in patients who could be discharged on their day of admission or the following day.

The programme reduced bed occupancy with the trust being able to close two wards, totalling 68 beds, saving an estimated £3.2m a year. “It is quite possible for every emergency patient to be assessed, diagnosed and a plan for care established by a consultant within four hours of arrival at hospital,” says Dr Kate Silvester, clinical systems improvement expert at the Health Foundation. 

Conclusion

What remains an issue for leaders is how to marry the need for complex, large scale change with the pressure to deliver rapid results.

However, it is a financial and moral imperative that flow is improved across the health and social care spectrum. To do this, organisations need to look at more than just individual “problem” departments (such as A&E) that are, in fact, experiencing the symptoms of poor flow within the wider system.

Giving people the time and space to stand back and assess their own processes must be part of the solution to address this national issue. Sheffield and South Warwickshire are a testament to what can be achieved when an organisation improves flow by giving it the time, attention and support it needs. 

Dr Jane Jones is assistant director at the Health Foundation