Congestion and safety: home thoughts from abroad

The news for UK hospitals, those they treat and those who work in them, seems grim. Hospital doctors, nurses and Royal Colleges note that hospitals are at bursting point. Robert Francis was concerned that the problems at Mid-Staffordshire could occur elsewhere. Jeremy Hunt suggested that services aim for mediocrity. According to the NHS Alliance, hospitals are dangerous and fewer patients should be admitted.

A visitor from another planet might wonder why we have hospitals. The answer of course is that they do a lot of good, day in and day out. Yet even the best has scope to improve and the Prime Minister has now asked for advice from Don Berwick, President Emeritus of the Institute for Healthcare Improvement. It was reassuring that in his first interviews he supported the good intentions of staff and highlighted the need to improve the system so that staff could deliver to their potential.

There is no doubt that overcrowding is bad for both patients and staff. The care patients receive is less effective, less safe, less timely, less efficient, less equitable and unlikely to be patient centred. In fact, avoiding overcrowding is key to all the dimensions of quality we aim for.

Overcrowding occurs long before 100% bed occupancy. In fact, most services are probably optimal at around 85% of nominal capacity, which needs to consider staffing as well as beds. Running all services at 100% is not efficient: it is inefficient and harmful.

The key to reduced occupancy may not be fewer admissions though – and certainly not if it denies care to those who need it. The most recent OECD figures show that, corrected for population, the UK has similar numbers of doctors and acute beds to the US. The two countries also have similar numbers of admissions to hospital. Where they differ markedly is in length of stay; the US figure being only two thirds of the UK one.

This is not entirely like for like of course. The US makes greater use of rehabilitation in skilled nursing facilities (SNFs), but the UK has better support in the community and more consistent primary care. One of the clear drivers in the US is the insurance market which gives hospitals and doctors a strong incentive to minimise length of stay. Nonetheless they do it, at least as safely as we do and bed occupancy is generally lower (although difficulty getting in-patient beds is still the biggest issue for their Emergency Departments, as in the UK).

To improve care we need a change, but it needs to be the right change. Some of the internal processes that are more common in US hospitals are worth considering…

The first is rigorous focus on discharge from admission. The second is that most medical patients are admitted to a ward under the care of a hospitalist (a general physician working with hospitalised patients), and remains in the same location and with the same doctor until discharge. Time and information are not lost by physical movement or handover between teams, and nor are unproductive work and risk created. Of course there is handover at shift end, but it is clear who is looking after an individual because physicians and nurses sign in and out on electronic systems.

Thirdly, even in academic hospitals, ‘attendings’ (consultants) look after many patients without any trainees. For individual patients, care is therefore direct. On training services, the number of patients per trainee is capped, so experience and training are balanced.

Fourthly, physician staffing patterns are aligned to patient need, rather than historical practice. For example, additional hospitalists may be scheduled in the evening to meet the peak in admissions. Similarly, consultants in hospital and emergency medicine are likely to be present and working overnight.

Lastly, really long waits for discharge are very uncommon. This is not just about ‘delayed discharges’, it is about smooth processes within the hospitals. And I have yet to see patients crowded into a ‘discharge lounge’.

There are probably no two US hospitals with identical models of care, and I am not suggesting that any of this is a cure-all that can simply be transferred to your hospital today. But we do need to recognise that efficiency is an essential part of quality, that it is possible to safely reduce length of stay, and that this has benefits for the individual and the community.

This suggests that the support from the Royal Colleges for the resurgence of the generalist, for continuity of care, and for more direct patient care by consultants, including out of hours, is correct.

To hard working staff this may seem to be asking too much, but not only is it right for patients, it should benefit staff if the result is that they can concentrate on treating patients, not finding beds or other staff members.

Simon is a Quality Improvement Fellow currently spending a year the IHI in Boston, and is Divisional Medical Director, NHS Lothian. www.twitter.com/SimonJMackenzie