It’s true that through 2020 and into 2021, the NHS has evolved. The NHS dealt with the first Covid19 wave by switching all of its focus to deal with the virus and nothing else – rightly so. Post the first wave, the NHS quickly re-established some (but not all) services and activity. In the second wave, the NHS managed Covid19 while maintaining key services and increasing activity, but the ‘Kent’ variant of Covid19 in late November followed closely by Delta and now Lambda is having a profound impact on services. The next few months look challenging.
The next few months
According to the latest performance figures from the NHS, the list of people who have waited greater than 52 weeks for treatment has ballooned from 1,600 people at the start of the pandemic to 300,000. These same NHSE figures show that the overall waiting list has grown to 4.49 million people.
More worryingly and highlighted by the ‘waiting list expert’ Rob Findlay during 2020 there had been a significant reduction in the number of total referrals by up to 30%. In April 2020 that was the equivalent to 50,000 less referrals for treatment in a single month. Estimates say this unreferred demand could be as high as 5,000,000 people and that demand could appear on the waiting lists into next year.
This could mean that when services return to some semblance of normal, the NHS could face a waiting list of 10,000,000+ people waiting for treatment. Danny Mortimer, NHS Confederation, has estimated that to work through the backlog of known and unknown demand may take 10 years.
As the NHS ramps up activity and attempts to deal with this backlog – the first services to be hit will be the diagnostic services, and as the ‘hidden’ 5,000,000 waiting patients begin to be referred, ‘new patient’ outpatient capacity will be at volumes never seen before. By default, the NHS will have to become a 24/7 service.
More money? More staff? Longer hours of services availability? Increased use of the private sector? Well, that’s already factored in. The UK Government has promised £6 billion of extra funding and the London region has begun planning more activity for private providers. But, £6 billion will not go far when spread across all providers, and over 24×7 capacity and outside of the London region. The private hospital sector is based on small surgical hospitals, mostly staffed by people who work in both the private sector and the NHS – so it’s not spare capacity.
Is the answer more NHS beds? More modular buildings in hospital car parks? Pop-up operating theatres? CT Scans-in-Vans? Maybe not. The opportunities and funding resources to fund more capacity in the NHS, are as usual, constrained. Plus, we cannot stream 10,000,000+ plus elective surgical patients into community services.
Firstly, there will be little extra capital funding available outside of the 40+ New Hospital Build programme announced in the Conservative Manifesto in 2019. As we all know, this will be less ‘’new build’’ and more likely ‘’refurbishment”.
Secondly, even if we could build additional bed capacity, how would we staff those beds? As the King’s Fund points out; there are currently 100,000 open vacancies and 1 in 11 posts unfilled in the UK. There is little in the way of short-term spare workforce capacity and the long-term tactics to boost overseas recruitment and manage the perennial issue of staff retention are largely focused on maintaining the healthcare workforce. The challenges do not end there.
For instance, how do you reset and restart services in a hospital sector that has been working flat out for over a year managing the pandemic? Plus, how do you do this when a significant part of your workforce is traumatised after facing two waves of Covid19?
Focusing on the minutes
I think what will make the biggest change will be to make every minute of lost capacity matter. That can only be achieved by bringing in a new approach to operational management. Focusing on the minutes between a bed being empty and reoccupied again; reduce every minute lost between each outpatient clinic slot and recoup every minute lost in the operating room when a case starts late or overruns. This will only be done with a mix of technology and transformation.
We need to realise that services operate in complex ecosystems where each local change can impact positively and negatively on many other parts of a system. Where five rehab beds closed in one organisation due to short term staffing problems might mean 20 more ED breaches a week to another provider. Where two extra sessions of MRI capacity in one provider to meet a backlog can inflate the demand for new outpatient appointments in another. That the Covid19 pandemic has disrupted referral volumes and introduced large scale virtual patient appointments and created the need for NHS providers to cooperate and provide mutual aid.
The new normal
This has to involve the integration of care across networks and systems, while addressing and overcoming the organisational boundaries that still exist. It has to stream and balance activity across acute services, work dynamically with community and social care services, and help patients find services based on their need – without going through the GP.
But, trying to do this without the centralised real time visibility of what that system’s demand and capacity is right now is near impossible. There is no view of a multi-service ‘single-point-of-access’ or the ability to operationally manage and balance patient flow operations across this network. But this is, in fact, the missing first step. You would not build and open a new airport, with all its complexity and all its moving parts, and think about ground operational control and air traffic systems later? In UK healthcare that is exactly what TeleTracking has been doing for over a decade with the NHS.
Creating a regional command centre
To move forward and address the pressing need to provide treatment to large numbers of waiting patients with limited resources safely we need to create a regional patient flow command centre that offers visibility of real time data staffed by senior decision makers that are able to balance activity across the system and create mutual aid.
Centralising operations is not unknown in complex organisational functions. It is common to centralise control in the power industry and other critical infrastructure; in aviation, rail, and road systems, for the emergency services (fire, rescue, ambulance, and policing) and in the military.
Centralisation of operations in a command centre is seen as an essential component to effective working where lives matter. So, centralising operations should be essential for one of the most complex undertakings, health and hospital care.
The benefits of centralising information, data, and decision makers in one place are:
- Creates whole system visibility (to beds, patients, assets and staff workflows)
- Creates live data
- Creates live situational awareness
- Creates command and decision structures for leaders to make choices in real time
- Makes for the effective use of resources (balancing demand against capacity)
- Provides data for improvement and long-term planning.
A holistic patient flow model
Patient flow system technology should be deployed and operated at a regional level and all responsibilities removed for bed management from ward level and made the responsibility of the operational teams. This is to release clinical time that can be redirected into managing patient care while also providing a holistic view of patient flow that allows smooth discharge and admission activity evenly across the day and not in the peaks we currently see in late afternoon.
The management of patient flow should also include the adoption and recording of new data points that support operational improvement – like the time it takes for a bed to be turned around from being vacated to being reoccupied. The time taken from a bed being allocated to a patient and the time they occupied it. This is a new scope of operational flow data not currently possible to record or benchmark.
Over the coming months and years, the NHS will have to make a step change to its operating model and leverage capacity planning solutions that can support Trusts with centralised and real time operations management. To rebalance and achieve this, it will have to work regionally and will require a laser-like focus to ensure that no patient has to wait for the care they need.
About Stephen Boyle
Stephen has over 32 years’ experience in healthcare, beginning his career in nursing with a specialisation in Critical Care as Critical Care Unit Nurse Manager and achieving the designation of a Critical Care Specialist Practitioner in Critical Care Outreach.
Stephen has also worked extensively in healthcare management and healthcare improvement in hospitals, community services and mental health organisations. Roles have included Outpatient Services Manager, QI Lead, and Head of Performance with a CCG.
In the last seven years, Stephen has worked extensively in healthcare IT and has been involved in the implementation and delivery of EMRs, with an emphasis on optimising the clinical impact and benefits. Prior to TeleTracking, Stephen was responsible for developing new ‘cutting edge’ AI solutions with IMB.
Stephen joined TeleTracking as the UK’s Product Specialist and is responsible for clinically leading and supporting Trusts’ early engagement, supporting pre-sales in engagement and solution demonstration.
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