Ambulances are delayed. GP appointments are delayed. Patients in emergency departments are delayed. Patients who need to move from one hospital ward to another are delayed. Patients who can only be discharged from hospital if there are social care arrangements put in place for them at home – these patients are also delayed. There are delays everywhere in our health and care system. And all these delays are caused by mismatches between demand and capacity. Mismatches which can be measured, using data. But the NHS isn’t measuring these mismatches with enough rigour, despite having more data at its disposal than it knows what to do with. This is a measurement failure. But before we can work out how to remedy this failure, we need to get to grips with the underlying reasons why the NHS is failing in its duty of measurement.
The first failing is that the NHS focuses its measurement attention overwhelmingly on the ‘front doors’ of acute hospitals. This is because it’s the front doors – the emergency departments – where the most visible performance target lives: the government-imposed standard that emergency department patients should be treated within four hours of their arrival. However, even though this target was introduced – twenty years ago – because it was a pretty accurate barometer of whole-system health, and even though most NHS managers know that in order to meet the four-hour target you have to fix things downstream of the emergency department, the measurement focus is still predominantly on the emergency department.
To make matters worse, on the rare occasions when attention does move away from the front door, it leapfrogs straight to the back door, missing out all the interior doors along the way. Those same NHS managers who know there’s a cause-and-effect relationship between delayed discharges at the back door and breaches of the four-hour target at the front door will often go straight to that delayed discharges figure and interpret it as being the sole cause of all their problems. Now – to be fair – that is not an unreasonable conclusion to reach: there is indeed a cause-and-effect relationship here. But this back-door-to-front-door approach taken by managers has two problematic side-effects: first, it makes it easy for hospital managers to blame other agencies (health and social care partnerships, for example) or other factors (‘big picture’, ‘beyond our control’ phenomena like the ageing population, for example); second, it means they don’t bother looking at any of the delays that might occur while patients are passing through the hospital system. The way the cause-and-effect chain reaction actuallyworks is that A (delays in the emergency department) is caused by B (no empty beds in the admitting wards), which in turn is caused by C (no empty beds in the specialty wards, either), which in turn is caused by D (not enough social care capacity). And even that is an oversimplification. But NHS managers often jump straight from A to D, missing out whole chunks of measurable activity and actions that are under their direct influence and control.
But it’s not just that the NHS is focusing on the wrong parts of the system; it’s also inhabiting the wrong time zone. Most of the demand and capacity measurement that takes place in a typical general hospital is ‘here-and-now’ measurement. “It’s 8am on a Monday morning: how many patients are in the emergency department now? How many empty beds are there in the acute medical unit now? How many discharges can we expect before noon today?”
This is the NHS in ‘reactive mitigation’ mode. This is the NHS trying to alleviate its delay problems by tying its hands behind its back and unquestioningly accepting the status quo as a given. It looks at the patients who are currently in hospital and asks: “Can we do anything with these patients – most of whom are in any case close to completing their hospital stays – to discharge them a couple of hours sooner?” So the impact of interventions by bed managers, discharge coordinators and others is constrained by the fact that that they are only being brought to bear on the patients who are already here and who are on the verge of being discharged anyway.
The NHS doesn’t measure or describe its coalfaces in ways that enable clinicians to move into a cooler, more reflective mode of thinking. It needs to move out of the ‘here-and-now’ time zone of reactive mitigation and move into the ‘there-and-then’ time zone that enables ‘reflective improvement’. As things stand, the NHS doesn’t provide clinicians with the data or measurement tools that allow them to look at last month’s discharges and ask questions like: “Is there anything we could’ve done differently to any of those patient pathways? Can we change one or two of those generic pathways to either prevent a few admissions in the first place or to reduce the length of stay of the others?” Those are questions we’ll never know the answer to because they’re questions that are never asked.
And the reason why those questions are never asked is because of the political baggage carried by data and measurement in healthcare. This is the third failure of measurement. Clinicians often complain of data being weaponised against them by managers who use it for top-down performance management purposes rather than for bottom-up improvement purposes. This is an aspect of measurement and data that often gets overlooked – particularly by the data professionals themselves, who are usually so remote from either the clinical or managerial coalface that they don’t sense these political overtones. Data is not a neutral, value-free commodity; when it’s used in an organization, it comes pre-packaged with assumptions to do with authority, performance assessment and control. And if the NHS wants to re-package data with a different set of assumptions (for example: collaboration, service improvement and participation), it’s going to be very difficult to make that switch – particularly if it’s not even aware that the switch is needed. Data somehow needs to be un-moored from its top-down ‘surveillance’ connotations and reinvented so that it can be owned by the clinicians themselves and re-purposed for collaborative improvement. This is not a change of emphasis that the NHS will find easy to make.
All of these three measurement failings – the wrong doors, the wrong time zone, the wrong connotations – conspire to prevent the rigorous examination of cause-and-effect relationships in the health and care system that’s needed. The focus on the hospital front door means emergency department performance isn’t connected to the bed fullness in the next – and subsequent – staging posts. The focus on the ‘here-and-now’ means that there is no time or opportunity for reflection, for looking at what happened last month to see if anything might be changed in order to achieve more impactful, more sustainable improvements next month. And the top-down measurement culture means that data is too often viewed with suspicion and cynicism by clinical staff. There’s no ownership. There’s no buy-in.
This all needs to change if we want to do something about all those delays.
Neil Pettinger is a freelance healthcare data analyst and trainer, specializing in patient flow. He lives in Edinburgh.