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.
The failure of trusts to hit targets to reduce the number of long stay patients – a flagship NHS England target – represents a major headache for system leaders. A significant cultural shift to engender clinical buy-in and real investment is needed, or the dial won’t shift, argues James Illman
Just a week after NHS England launched a comms campaign centred on cutting the numbers of long stay patients in hospital, new research has suggested almost 90 per cent of trusts will miss their targets on this agenda.
The CHS Healthcare research, published this week, repeated the question posed by an HSJ investigation in February: how are trusts performing against their individual targets to cut the number of emergency admissions not discharged until after 20 days in hospital, the so-called “super stranded patients”?
Its findings suggest trusts are still falling significantly short of NHSE’s target, first set out last year, to cut the number of super stranded patients by 25 per cent against a 2017-18 baseline.
The CHS study found 114 out of the 131 acute trusts it obtained data for were behind their target as of March 2019. It also found 330,826 patients have been stranded in hospital wards for 21 days or more in 2018-19 so far, and nearly 80,000 operations have been cancelled at the last minute for non-clinical reasons, including bed availability.
The 25 per cent target was meant to free up 4,000 beds ahead of last winter and cut into the circa 18,000 super stranded patients in the system, which effectively meant 36 acute hospitals’ worth of beds were out of action.
The NHSE’s 2019-20 planning guidance then rather ambitiously pledged to raise the bar to 40 per cent once the initial benchmark is achieved, although no date is set for that.
So, why has the system fallen so short? Mounting demand, workforce shortages and the intolerable pressure the system is under are of course playing their part.
But two other issues loom large: organisational and clinical buy-in, and investment.
Rick Strang, an experienced transformation adviser who focuses on emergency care flow, told HSJ his experience across many trusts was that significant work needed to be done to convince medical staff of the clinical case.
He said: “There is a prevailing clinical view [that efforts to cut length of stay are] about freeing up beds to save money and/or avoid opening more beds.
“The true clinical case for this work, despite a lot of the evidence out there, has still not landed in a meaningful way… Therapists and nurses are doing much better, but [the medics], despite some genuine champions in their ranks, appear to be lagging behind.”
He and many of his colleagues believe that, should the NHS get a further cash windfall, it would be best spent on “a huge cohort of discharge and 21 day length of stay coordinators, one on every ward to drive the teams to get over the line are required, given the growing complexity of safe discharge requirements”.
He also warned “the infrastructure and resilience required… simply isn’t there”. It’s hard to push hospital teams to “be more proactive when they know there will be nowhere for patients to go because the social and community care structures aren’t there,” he said.
Other senior improvement leaders from NHSE/I, who wished to remain anonymous, told HSJ they agreed with Mr Strang’s arguments for both the requirement of cultural change and investment.
One senior figure added that, while getting the clinical team support was vital, the most important battle was getting the chief executive on board. Without senior executive buy-in, it’s an uphill battle from the off.
“The chief executive can ensure that it is prioritised over all the other pulls on both clinical and non clinical staff’s time. If [efforts to cut length of stay] are not prioritised, they get a bit lost and don’t go anywhere.”
The source added: “We need to re-frame the conversation and ensure the clinical benefits are better understood and also make sure the doctors get information about the target and performance in a suitable format.
“It’s a very mixed picture out there. But the trusts which are shifting the dial are almost all ones where the chief executive has bought into it and prioritised it.”
The NHS comms campaign launched last week – which promotes ‘Where Best Next?’, a (good) summary of a lot of the existing guidance – is certainly A Good Idea and a step towards securing that wider clinical buy-in.
NHSE said: “NHS doctors, nurses and other staff are being encouraged to ask themselves ‘Why not home? Why not today?’ when planning care for patients recovering from an operation or illness, as part of a campaign – called ‘Where Best Next?’ – which aims to see around 140,000 people every year spared a hospital stay of three weeks or more.
“The campaign will see posters and other information placed in hospitals aimed at different staff groups, encouraging them to take practical steps every day to help get patients closer to a safe discharge – whether to their own home or a more suitable alternative in the community.”
But if NHSE is to “free up more than 7,000 beds” as it pledged last week, it will need to do significantly more work on this agenda.
System leaders need to decide if they are going to genuinely back efforts to cut length of stay with the capital and staffing investment required or not. Paying lip service to the project while ramping up the targets to unrealistic levels will be completely counterproductive and further sap already rock bottom morale.