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 \u2013 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\u2019t 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.<\/p>\n
The first failing is that the NHS focuses its measurement attention overwhelmingly on the \u2018front doors\u2019 of acute hospitals. This is because it\u2019s the front doors \u2013 the emergency departments \u2013 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 \u2013 twenty years ago \u2013 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.<\/p>\n
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\u2019s 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 \u2013 to be fair \u2013 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 (\u2018big picture\u2019, \u2018beyond our control\u2019 phenomena like the ageing population, for example); second, it means they don\u2019t 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.<\/p>\n
But it\u2019s not just that the NHS is focusing on the wrong parts of the system; it\u2019s also inhabiting the wrong time zone. Most of the demand and capacity measurement that takes place in a typical general hospital is \u2018here-and-now\u2019 measurement. \u201cIt\u2019s 8am on a Monday morning: how many patients are in the emergency department\u00a0now? How many empty beds are there in the acute medical unit\u00a0now? How many discharges can we expect before noon\u00a0today?\u201d<\/p>\n
This is the NHS in \u2018reactive mitigation\u2019 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: \u201cCan we do anything with these patients \u2013 most of whom are in any case close to completing their hospital stays \u2013 to discharge them a couple of hours sooner?\u201d 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.<\/p>\n
The NHS doesn\u2019t 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 \u2018here-and-now\u2019 time zone of reactive mitigation and move into the \u2018there-and-then\u2019 time zone that enables \u2018reflective improvement\u2019. As things stand, the NHS doesn\u2019t provide clinicians with the data or measurement tools that allow them to look at last month\u2019s discharges and ask questions like: \u201cIs there anything we could\u2019ve 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?\u201d Those are questions we\u2019ll never know the answer to because they\u2019re questions that are never asked.<\/p>\n
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 \u2013 particularly by the data professionals themselves, who are usually so remote from either the clinical or managerial coalface that they don\u2019t sense these political overtones. Data is not a neutral, value-free commodity; when it\u2019s used in an organization, it comes pre-packaged with assumptions to do with authority, performance assessment and control. And if the NHS wants to\u00a0re-package data with a different set of assumptions (for example: collaboration, service improvement and participation), it\u2019s going to be very difficult to make that switch \u2013 particularly if it\u2019s not even aware that the switch is needed. Data somehow needs to be un-moored from its top-down \u2018surveillance\u2019 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.<\/p>\n
All of these three measurement failings \u2013 the wrong doors, the wrong time zone, the wrong connotations \u2013 conspire to prevent the rigorous examination of cause-and-effect relationships in the health and care system that\u2019s needed. The focus on the hospital front door means emergency department performance isn\u2019t connected to the bed fullness in the next \u2013 and subsequent \u2013 staging posts. The focus on the \u2018here-and-now\u2019 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\u2019s no ownership. There\u2019s no buy-in.<\/p>\n
This all needs to change if we want to do something about all those delays.<\/p>\n
Neil Pettinger is a freelance healthcare data analyst and trainer, specializing in patient flow. He lives in Edinburgh.<\/p>\n","protected":false},"excerpt":{"rendered":"Ambulances are delayed. GP appointments are delayed. Patients in emergency departments are delayed. Patients who need to move…\n","protected":false},"author":2,"featured_media":306956,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[43],"tags":[102,2960,56,54,55],"class_list":{"0":"post-306955","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-healthcare","8":"tag-health","9":"tag-healthcare","10":"tag-uk","11":"tag-united-kingdom","12":"tag-unitedkingdom"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts\/306955","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/comments?post=306955"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts\/306955\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/media\/306956"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/media?parent=306955"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/categories?post=306955"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/tags?post=306955"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}