Crispin Simon on what can be learnt from the private sector to reduce the chronic problem of delay in the discharge of patients.
At the end of December I completed a term as a non-executive director of the NHS Trust Development Authority, following a term at Imperial College Healthcare NHS Trust; and I’d like to express my thanks to the many NHS people who contributed to my knowledge and personal development.
People who have enjoyed private sector careers are fortunate to have the opportunities presented by public sector NED roles.
High capacity utilisation
I’d also like to register the observation, as a thirty year private sector person, that although there is a prevailing view that organisational excellence flows from the private to the public sector, I have seen plenty of superior NHS practices – for example in major incident management, the deeply-embedded multidisciplinary culture and much clearer accountability for NEDs. And this happens in the context of NHS trusts’ greater breadth of activities (necessarily) and a higher capacity utilisation (efficient but risky) than most businesses would contemplate.
One of the symptoms of this complexity and high capacity utilisation is the chronic problem of delay in the discharge of patients who are medically ready to leave – Delayed Transfers of Care (“DTOC”). The Sunday Times recently reported that DTCs cost £500 million per annum, and cited examples of leading teaching hospital/foundation trusts, traditionally the elite, reporting more than 100 patients delayed by more than four weeks and individual patients waiting several months.
This has gone on too long. To start the ball rolling, I would make three recommendations – combining approaches that are proven in the private sector and the NHS.
What we can take from the private sector
First, and yes, I’m afraid so, I would recommend that a top-down target be established as a government priority – halving the Days Delayed Transfer of Care, as soon as possible and in any case by the last full year of this Parliament. The dramatic reduction of hospital-acquired infections and almost-elimination of Mixed Sex Wards shows how NHS people can drive improvement when there is prioritisation from ministers.
And halving DTOC would be an unusually motivating and unifying target because it self-evidently improves the patient experience and reduces cost. The 50 per cent number is taken from a Unilever measure for “capacity to improve” – the time taken by a management team to deliver a 50 per cent improvement in whatever is being improved.
And when achieved, a further 50 per cent can be demanded, if required.
We need a greater proportion of NHS targets to be strategic in character
So many of our NHS measures are rightly operational and short term but we can start to draw a useful distinction between standards which must be maintained at all times (eg the four hour wait in accident and emergency) and targets, which could/should imply organisational progress. We need a greater proportion of NHS targets to be strategic in character, and not, as they are now, a set of hyper-sensitive alarms.
This is a good place to start.
Second, all relevant task forces should be challenged to demonstrate how they contribute to the achievement of the DTOC goal. According to Department of Health data, eight out of the 10 possible reasons for a delayed transfer reside with publicly-funded organisations outside a hospital, and at least three of these reasons also lie beyond the remit of the NHS – principally with the local authority.
So, for example, any region operating the Northern Powerhouse healthcare model (delegating healthcare budgets to a super-local-authority), should develop written plans that lock into the NHS DTOC work; and an elected councillor should held accountable for delivery of the plans. The same approach should be taken to eliminating avoidable hospital admissions and re-admissions.
The Integrated Primary and Acute Care Systems (PACS) envisaged in the Five Year Forward View should be similarly challenged to contribute to the DTOC goal. Many NHS organisations have done great work with “Lean” principles (exhibiting walls of yellow “stickies” that map processes in previously unknown detail) but they remain oases of great practice, rather than the NHS standard.
In the long term, marginal improvement in process re-design is worse than no improvement at all. It incurs the majority of the cost for the minority of the possible gain.
Marginal improvement in process re-design is worse than no improvement at all
Third, I would recommend that capital investment budgets be used to back strong DTOC initiatives. NHS capital investment budgets tend to be allocated according to operational, not strategic, priorities (as evidenced by the absence of any reporting of the strategic allocation – eg the proportions committed to replacement, efficiency and expansion) and, as a long term problem, DTOC needs long term solutions.
Bricks and mortar will help.
All this is easy to say and hard to do – but with the equivalent of two hospitals currently filled with patients medically fit for discharge, meeting the 50 per cent reduction goal would be like building a whole hospital for nothing. And then there’s the reduced mobility, falls, infections and avoidable deaths.
As a manager, I think the work is important. As a human being I think that it’s essential.
Crispin Simon, chief executive officer at Rex Bionics