Welcome to HSJ’s Performance Watch expert briefing. Our fortnightly newsletter on the most pressing performance matters troubling system leaders. Contact me in confidence here.
Performance Watch this week analyses the NHS’s progress against its ambitious target to “free up” 4,000 beds by December by shortening the length of stay of patients who have spent over 20 days in hospital after obtaining exclusive internal data on performance so far.
The target resulted from system leaders’ pragmatic conclusion that they could not significantly increase hospital capacity for this winter given staff and funding shortages and the best available option was to optimise existing capacity.
There were 128,448 overnight NHS beds in the first quarter of 2018-19, a number which has fallen sharply over the last decade – it was 144,455 in 2010. Some 101,259 are acute and general beds, which is the relevant number in the context of freeing up hospital beds.
Around 18,000 of the circa 100,000 hospital beds were occupied by so-called “super stranded” patients, those in hospital for over 20 days – the equivalent of 36 acute hospitals, NHS England chief executive Simon Stevens told MPs in May.
System leaders targeted a 25 per cent cut in super stranded patient bed days. They calculated this would free up around 4,000 beds, effectively increasing bed base by around four per cent.
Or put another way, it would add around just under an extra ward per hospital – so the potential gains could make a significant difference to how tough this winter turns out to be.
System bosses from Mr Stevens downwards have rightly repeatedly emphasised it is a key priority. So what progress has been made so far?
NHS Improvement this week refused to release the data, held centrally within the internal NHS “model hospital database”, without a Freedom of Information Act request (which HSJ has since submitted).
Officials argued it would be wrong to release the data as it was unreliable because different trusts are counting LoS reductions differently (this is understandable as it’s not an exact science) and requires further validation.
But hospital bosses can rest assured that despite this, they will still find themselves facing rebuke from the centre if they fall short of their target. Data validation for that purpose often has a lower bar.
HSJ has however obtained some of the national level data. It reveals the following:
On the overall target:
- If every trust hit their bespoke December target for reductions the NHS would overshoot the 4,000 bed official target and hit 4,886. This won’t happen, so some flex is sensible.
- This would cut the number of beds occupied by super stranded patients from the NHS identified baseline of 19,889 to a targeted 14,852.
On performance up to August:
- The system freed up 2,338 beds,12 per cent of the bed base occupied by super stranded patients, in August.
- This would mean a further 2,547, 13 per cent of the super stranded bed base, needs to be cleared by December.
So, the system had freed up around half the December target on paper by August. But it would be misleading to conclude the system is therefore halfway there. Far from it, as performance can go back as well as forwards. HSJ has asked for NHSI for the monthly trajectory targets.
One senior source also warned perverse incentives introduced by the new target could mean LoS for super stranded patients could be going down but at the expense of overall LoS.
Patients at an earlier stage, for example 12 days, could find themselves staying longer as extra attention is placed on patients nearing the 20 day mark.
The other risk is that patients are discharged too quickly to try and avoid a breach.
NHS Providers told HSJ that a sharp focus on LoS, especially on long stayers, was right for patients and the system, but that it would be a “stretch” to meet the December target.
The lobby group said hospitals could make improvements in terms of flow through the system, but that there was “limited organisational bandwidth to invest in re-engineering processes” as winter pressures increase. Community and social care capacity still remained the biggest block to systemic patient flow, the provider group said.
Director of policy and strategy Miriam Deakin added: “Attention and resource [needs to be focused] outside of a hospital’s walls, in the community and in social care to reduce avoidable admissions and enable people to return home more quickly with the support and care they need.
“Trusts will this winter find themselves being publicly held to account on the A&E target, the 18-week and cancer targets alongside the national bodies’ push on length of stay. We need to be realistic about what can achieved in what will be a very challenging winter”.
There is no doubt that cutting delayed discharges of care will also remain a key priority this winter. But it is also worth remembering what Rick Strang, an experienced transformation adviser who focuses on emergency care flow, told me earlier this year when PW first analysed the issue.
“The knee jerk reaction from many in the NHS is that [patient flow issues are] a problem about social care services. Of course, that’s a factor, but the predominant issue is how we manage their inpatient stay within the acute trust itself.”
NHS England told HSJ providers “have already reduced the number of long stay patients in line with the target set out in June, freeing up nearly 2,000 beds as part of a comprehensive plan to help trusts prepare for winter”.
NHSE however declined to comment on what monthly trajectory targets were set for the system or provide any further information. Unfortunately the lack of transparency around the metric makes it impossible to verify if the system is meeting expectations or not.
Whatever the case no provider chief I have spoken to yet has seen the target as achievable but every bed cleared will be welcomed.
UPDATED: Please note this piece was updated at 15:15 on 25 October to include NHS England’s statement which was provided after the piece had gone live.