Reducing delays and improving outcomes for people

Featured article - 31 May 2019
By Ric Whalley. Director, Newton

By Ric Whalley. Director, Newton

It’s about establishing a person-centred culture and measuring the right things

Jack, 79, was living at home with his wife. He had mild dementia but was functioning well. He did not require any care services. After spending 10 days in hospital with a urinary tract infection, he was declared medically fit for discharge. Following multiple assessments and delays, he was finally discharged, five months after admission, to a nursing home, where he died two months later.

Stories like Jack’s should not happen, yet we all hear them far too often. No one wants these to be happening, and indeed there has been a tremendous focus placed on reducing delayed transfers of care. Good progress has made in many systems – with an 18.2% reduction in the last three years according to NHS England.

Delayed transfers of care, however, are only the tip of the iceberg. Last year, our work on the ground with 14 systems across the country found that 27% of hospital beds (from a total of 10,400 studied) were occupied by someone who didn’t need to be there, far more than the 8% reported delayed transfers of care. Whilst these were particularly challenged systems, the findings and themes are relevant and important more broadly, providing the evidence to show that addressing these challenges requires a person-centred culture, and a systematic approach to measuring the things that matter most.

People first

To best support people like Jack, establishing and maintaining a person-centred culture is key, and will impact how decisions are made, and teams are structured. Our work found that 44% of people were placed in settings providing levels of care that were not the best possible for that individual. Importantly, this is not because practitioners at the frontline are actively making poor or wrong decisions. They are making the best decisions they can, given the pressures and constraints of systems and services that do not always allow the best decisions to be made for the individual.

Manage

All too often, it can be easy to jump to an answer which involves developing new pathways or adding resources. Really, what is needed first is the clarity of data and KPIs to understand root causes, which can be used to support decisions at all levels, and make best use of resources already in place. Whilst the work found that every system had a number of improvement programmes underway, only a few of these were targeting the operational root issues. For those programmes that did target the root issue, even fewer had evidenced measures or KPIs associated with them.

Managing delays requires actions to be taken at multiple levels within systems. Whilst most systems had patient level and senior level governance, the middle level often had a gap. Effective service-level governance (which requires taking actions on themes and trends where particular services are causing consistent delays) was only observable in 3 of the 9 areas. This is particularly important to empowering teams and making timely decisions.

What matters

None of the systems studied had accurate, real-time information on the range of services available and the capacity in them or processes in place for tracking or measuring outcomes. Discharging people to settings not well-matched to their needs can also distort the understanding of the true requirement for resources across the system, and lead to a system not well matched to the needs of patients.

When we did look at this as part of patient case reviews, we uncovered that each time a shift towards home-based services would deliver better outcomes.

What next

Establishing a genuinely person-centred culture lies at the heart of tackling discharge decision-making. But changing the way decisions are taken cannot happen overnight – it takes time and considerable effort to alter entrenched behaviours and attitudes. This is only achievable if the outcomes of decision-making are measured, and the resulting data shared system-wide. Action to reduce delays, which may include shifting provision across the system, can then be taken.

These are very complex issues, but by addressing them, we believe that every system could benefit, and both improve outcomes for older people and reduce the cost of care across the system.

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