In a financial climate which even the most confident of commentators would describe as highly challenging, the pressure on policymakers to find a way of stemming the rise in emergency attendances and admissions is growing ever more acute.
The cap on payments to hospitals whose emergency admissions exceed pre-2010 levels and the push (via the Better Care Fund and the Urgent and Emergency Care Review) to find community-based alternatives to emergency care, are just some of the measures introduced in recent years to curb emergency activity in England.
Yet estimates vary considerably as to how many people who end up in A&E departments could have been dealt with more appropriately in other settings. At one end of the spectrum, it’s been suggested that up to 40% of patients in A&E are discharged without the need for any intervention. At the opposite end, others have argued that most people who arrive in A&E need to be there and that only around 15% could be seen by a GP in the community.
What we do know for certain is that the health service is dealing with more and more people with age related long-term conditions and frailty issues. Many of these ‘core customers’ of our services, as David Oliver describes them, can only be managed appropriately in hospitals when they are ill or injured. Rather than thinking purely about community-based solutions, we need to spend more time reflecting on whether our hospitals are equipped to meet the needs of these older, vulnerable patients.
All this suggests that we shouldn’t become overly preoccupied with strategies aimed at avoiding or deflecting emergency attendance and admissions. Yes, there is a lot more we can do to relieve the pressure on hospitals, but it’s an approach which can only take us so far. As the recent QualityWatch report on A&E attendances indicated, we may be close to reaching the limit as to what we can do with our current A&E capacity. Either we create extra capacity or we find ways of making better use of the capacity we already have.
So where do we go from here? Our Flow Cost Quality programme – which examined the relationship between patient flow, costs and outcomes in two NHS foundation trusts in England between 2010 and 2012 – offers one potential way forward.
The programme enabled the trusts to examine patient flow through the emergency care pathway and develop ways in which capacity could be better matched with demand to prevent queues and improve patient outcomes. As well as achieving a reduction in mortality, the trusts succeeded in reducing length of stay, bed occupancy and readmissions, and improving the overall patient experience. Moreover, once the programme had ended, the trusts were able to sustain the improvements they had achieved.
Key to the trusts’ success was their willingness to spend time examining their own systems in detail, using a range of diagnostic tools, so that they could pinpoint where the constraints and bottlenecks lay and then identify and implement solutions specific to their needs.
Crucially, the two trusts were also able to implement flow concepts systematically across the whole of their organisations, rather than focusing on one department, such as A&E, in isolation. The project teams ensured that every department was involved in and committed to the programme from an early stage, and that improving patient flow was very much a shared, organisation-wide priority.
We would like to see other organisations follow the lead set by the two trusts involved in the Flow Cost Quality programme, but achieving what they’ve managed isn’t easy. You need to have sustained support over time at senior management and board level, and recognise that there are no quick wins or off-the-peg solutions which can be implemented overnight. Organisations need space and time, often up to two or three years, to deliver real change at system level.
With money tight and health care leaders under pressure to deliver rapid results, it can be hard to convince people that the use of such resources is justified. But the long-term benefits of examining flow on a system-wide basis mean that it’s a challenge we simply cannot afford to ignore.
Bryan is a Policy Manager at the Health Foundation