Patient flow is about ensuring people receive high quality care at the right time and in the right place. With services overstretched and under resourced, this can be challenging and requires collaborative working between trusts and across the whole health and care system.
Improving patient flow is also central to recovering NHS performance standards. We know long waits for ambulances are linked to emergency department handover delays, which are caused by high demand at A&E, compounded by workforce shortages, and then exacerbated by high bed occupancy rates, also linked to a lack of community and social care capacity.
In short, delays do not happen in isolation. As such, improving patient flow is not just about resourcing and expanding urgent and emergency care capacity to keep pace with rising demand – it is also about delivering transformation in how services are delivered, expanding out-of-hospital capacity, embedding preventative approaches and realising the benefits of emerging technologies.
In our new Providers Deliver report we examine practical examples of where trusts, across the acute, mental health, community and ambulance sectors, have all used innovative and collaborative approaches to improve patient flow.
Reflecting back on the conversations we've had with trusts, some notable key themes emerged.
Leadership matters
A leadership approach that focuses on autonomy and empowering staff to make decisions was a key feature in several trusts.
For example, the Mid-Yorkshire Hospitals NHS Trust explained how planning their same day emergency care service in a 'bottom-up' way, co-producing operating models with clinical staff and putting trust in clinical leadership to deliver care effectively, created a more patient centred environment where quality is central, and staff are motivated.
It also means clinical staff are not overly focused on national targets – rather they are concentrating on delivering high-quality ambulatory emergency care – a by-product of which is improved waiting times and progress toward achieving national performance targets.
Sharing risk = sharing reward
Collaboration was another recurring theme. A central feature of collaboration is that risk has to be shared to realise rewards. This is seen in Leicestershire Partnership NHS Trust (Leicestershire Partnership) and Northamptonshire Healthcare NHS Foundation Trust's (Northamptonshire Healthcare) ongoing efforts to grow community care capacity via virtual wards.
Shifting more acute care out-of-hospital and into the community is of course not without risks, particularly around lines of clinical accountability.
Learning to share risk can require a cultural shift. Across Leicestershire Partnership and Northamptonshire Healthcare we saw the importance of communicating the rationale behind delivering more care remotely, increasing inpatient capacity and therefore reducing risk in other parts of the system.
We saw a similar approach to collaboration from Devon Partnership NHS Trust (Devon Partnership) who are lead provider for the South West Provider Collaborative.
Here we saw how sharing data on capacity and demand at a regional footprint level, had allowed a consistent and clear overview of capacity, excess demand and where pinch points were emerging. Using the data, Devon Partnership has been able to manage patient flow across the collaborative network, reducing average length of stay and increasing focus on delivering care in community settings.
Prevention is better than cure
As demand for emergency care has risen, so has average acuity of demand, and length of stay has increased as the health of the population has deteriorated in recent years.
While tackling health inequalities and improving population health requires cross sector action, trusts have an important role to play. Embedding effective preventative models of care that lead to improved health is a long-term task. However, we spoke to the Yorkshire Ambulance Service NHS Trust (Yorkshire Ambulance Service), who have effectively applied population health analytics to manage and identify demand.
Taking this approach has allowed Yorkshire Ambulance Service to develop a clear understanding of which communities are experiencing the worst health outcomes and using emergency services most frequently. They have then been able to begin work with system partners to put effective preventative measures in place.
Looking ahead…
An effective approach to improving patient flow recognises the causes of delays sit both beyond and within the acute sector.
Increasing physical capacity and addressing chronic workforce shortages across the urgent and emergency care pathway are of course vital to improving patient flow, however growing capacity in the community sector and in mental health care is equally vital. That said, increasing capacity is a long-term task that will require substantial investment.
In this report we have seen how trusts have been able to use innovation, system-working, collaboration and prevention to deliver improvements in a context of high demand and stretched resources.
It is clear trusts are well equipped to deliver this, but without the investment to grow the workforce and increase physical capacity across the NHS, progress may be limited, and improvements may not be sustainable.
Improving patient flow will continue to play a crucial role in achieving sustainable recovery across the whole health and care system.
This opinion piece was first published by HSJ.