Patient flow is the art of integrated care in action

Sebastian Stewart, Service Development Director, CHS Healthcare

It seems every day there is another report released which looks at the patient flow challenge plaguing the NHS, riddling our hospitals and seeping into social care. Each of these reports looks at patient flow from a different angle and diagnoses a new treatment.

Most recently the Royal College of Emergency Medicine made a plea for an additional 13,000 beds noting that 25,000 beds have been lost in the last decade. Reported in the Guardian their view is that these ‘staffed beds’ would “meaningful change and improvement”, which includes a “significant” improvement in A&E waiting times, ambulance response times, ambulance handover delays and a return to safe bed occupancy levels. It recommends opening at least 4,500 of these before winter.

At the same time the government’s programme to build new hospitals has been back in the news due to lack of progress. The hold up being blamed on a lack of funds to push ahead with building.

As we move into a new phase for the NHS, noted for its focus on integrated care, it feels old fashioned to look to beds and hospitals as the solution for our aging and increasingly dependent population. At the end of April according to NHS data there were 12,580 patients who no longer met the criteria to reside waiting in hospital to be discharged. This resonates with the 13,000 beds requested in the report above, but the issue here is complicated – not a lack of beds or staff but a seemingly intransigent issue where people are unable to move from an acute bed to a bed fit for their care needs.

Bed blocking, delayed transfers of care, stranded patients and super stranded patients, no longer meeting criteria to reside, pyjama paralysis – there are so many labels for the challenge of people moving from hospital. The HSJ reported last week that NHS Confed viewed that it was ‘impossible’ to improve delayed discharge at this point. This is a very pessimistic picture which is likely to get worse this winter before it gets better. And of course, this has patients and families at the centre of every delay.  We can’t forget how damaging additional beds days can be for older peoples physical and mental wellbeing.

It can often seem that the NHS is stuck between short term fixes, often driven by unreliable funding, and long-term solutions that are tantalisingly out of reach.

New funding, new buildings and new staff are all unlikely to transpire in the near future so we have to look at how we can create space and flow within existing parameters.  The potential impact integrated care can have for hospital discharge is a nirvana which I hope acts as a clear measure for their success. We stand ready to support with the design and implementation of new pathways and innovative care solutions.

In the meantime, our view is that there is a middle ground which involves a focus on driving connections and creating permanent new work-flows within the existing parameters. We work with over 60 trusts in England and we see the challenges faced by staff day in and day out.  We know that dedicated discharge support for patients as soon as they are admitted drives flow. We know that removing the burden of discharge coordination from clinical teams will create space and flow, we know that there is untapped flow sitting with the trusted assessor model. There are initiatives that can be put in place now to make a difference but they have to be embedded as standard, not just temporary fixes, which as soon as they stop let delays build back up.

Helping people out of hospital into care is often underestimated. It sounds like it should be easy but it is the art of integrated care in action. It connects clinical teams with care homes, with families, with rehabilitation, with pharmacists, with primary care and all of this happens at pace and while each piece of the puzzle is moving. For too long hospital discharge has been a problem to be solved as a reaction to difficulties as opposed to a driver for change in how we design and deliver care.