Likewise, this year we have had Clinical Commissioning Groups making projections for rapid reductions in urgent hospital admissions. Yet, these projections have been made in the face of peer-reviewed evidence that reductions of such magnitude and speed are unattainable, and that even mature integrated care models take several years to deliver.
There is a ‘great white hope’ that shifting care out of hospital will produce quick and “cashable savings” in health economies – again, in the face of considerable evidence that this is a dubious proposition. Most solutions lie in the back-door, in tackling the way patients move around the health and social care systems, not in managing the front door of the hospital.
In the NHS England Five Year Forward View, published last week, there was a welcome acknowledgement that however much we invest in community services or regional centres for, say stroke or trauma, general hospitals will still be required. Rather, we need more fully integrated services that can wrap around people with complex needs to support them to stay at home or leave hospital sooner and that we need more GPs and practice nurses.
We know from the National Audit of Intermediate Care that we currently have far too few places and beds outside acute hospital. The work of the Oak Group describes patients in acute beds who could ‘hypothetically’ be cared for elsewhere, if only that capacity existed. Too often, it doesn’t. Unsurprisingly, it’s hard to keep older people with crises away from emergency departments or get them out of hospital sooner.
Among all of this, there are some simple things that are within the gift of acute hospitals working closely with community partners to solve. Doing these things well can reduce overall bed occupancy, even if average lengths of stay might not fall. Why? Because if we get more straightforward patients home quickly, the case mix of remaining inpatients will be correspondingly more acute or more complex. It’s more important to look at other measures, such as the percentage of patients discharged within 0 to 48 hours, or total bed days occupied by patients who are medically fit for discharge.
The template for this came through loud and clear at the Nuffield Trust’s event on reducing length of stay in hospital, which I presented at earlier this month:
- Having senior decision makers at the front door, seven days a week, until well into the evening.
- A short stay assessment area where older people with frailty or complex needs can be assessed and stabilised overnight if needs be before being sent home.
- Directing patients into the right team and ward for their condition first time around.
- Rapid community response and assessment teams, plus direct phone advice from specialist doctors or nurse practitioners. If someone is seen in a chair in their day clothes, they are far less likely to get swept up into a hospital conveyor belt and “medicalised” than if they arrive on a trolley, are put in a gown and into a bed.
- Placing community teams at the front door to assist a rapid discharge for patients. It isn’t very “patient-centred” to have a team that is only interested in getting people straight back home again if they can chalk it up as “admission prevention”. The principle should be that wherever patients are, once they no longer need to be in hospital, community services help get them out rather than simply responding to referrals and faxes.
- Using real time electronic data on discharge figures, as well as reasons for bed occupancy, to help staff better understand pressure on beds.
In short, acute hospital is often entirely the right place for someone to be when that’s the most effective and cost-effective way to meet their needs. People will continue to need to visit Emergency Departments and Acute Medical Units, however much we invest in prevention. But by focusing on patient movement, rapid turnaround and discharge planning when they do hit the front door, we can impact on bed use far more quickly than we could ever do from admission prevention schemes. Recent studies in Sheffield and South Warwickshire showed that this can be delivered cost-neutrally, with no increase in re-admission rates.
Changing the tariff might help. Changing the way people work is far more important.
Oliver D (2014) 'Over-stretched hospitals: let's improve how patients are met on arrival, not block the front door' Nuffield Trust comment, 30 October 2014. https://www.nuffieldtrust.org.uk/news-item/over-stretched-hospitals-let-s-improve-how-patients-are-met-on-arrival-not-block-the-front-door