Less queues, more care
Research Manager and Head of Health
The winter crisis comes around faster every year – inevitably accompanied by a depressingly predictable response from government. A hurried winter plan, emergency funding announced mid-crisis, and a promise that lessons will be learned for next time.
But the next time always comes and the system is no better prepared. In reality, the winter crisis just captures a peak moment in what is now a universal experience: virtually all hospital visits are characterised by waiting, uncertainty and fragmentation, whether in January or June.
Rather than seasonal pressures, this underscores an ongoing, fundamental crisis for secondary care.
And these experiences come down to one core concept: patient flow. This refers to the movement of patients in, out, and through hospital – and it is foundational to their efficiency and effectiveness.
Many assume that at the core of the perpetual patient logjam is that demand for care has grown faster than the supply of staff and services. But this is routinely discredited by available data. In reality, demand for emergency hospital care has grown quite slowly while the numbers of clinical staff in hospitals has increased substantially. It’s less about numbers, and more about how those numbers are deployed.
Patient flow is, in the NHS’s defence, inherently complex: resources need to be efficiently managed to ensure the right staff and clinicians, diagnostics and treatments are available at the exact time and place they are needed. Managing flow is like conducting a live orchestra, where every section has to stay in sync, and one delay can throw the whole performance off. It is especially complicated in hospitals, where patients are constantly reprioritised based on emergency clinical demand.
Hospitals also co-locate numerous (highly skilled, specialist and cost-intensive) functions in one building, including diagnostics, laboratories, operating theatres, A&E and inpatient wards. This means that in addition to constantly shifting demand, there are endless interdependencies between departments.
But while it may be complex, it is not impossible. And indeed, our paper out today, Ending the patient gridlock, confidently shows that there are endless avoidable bottlenecks in hospitals that preclude patients from flowing seamlessly in and out of the hospital building.
Other industries also process complex and multidimensional flow as routine. Retail organisations use footfall counters, heat maps and queue management systems; supply chains use digital twins to simulate warehouse throughput and delays; and traffic flow analytics is common in transport monitoring. The core technology of real-time data capture combined with predictive modelling is similar across industries. Yet hospitals are unacceptably slow in adopting this technology.
Making the decision to move patients on to the next stage of their patient journey is also needlessly fragmented. As covered in The Times this morning, this almost always comes down to the lack of clinical generalism in the doctor workforce. Our doctors are too specialised, and this means the complex, multi-morbid cases fall between the cracks of traditional hospital medicine, despite making up a large portion of demand.
By contrast, the hospitalist model – long established in the United States – trains doctors to take charge of whole wards of patients whose conditions cut across multiple specialties. With a hospitalist in place, patients could receive a clear, coordinated clinical decision from a single doctor within hours, rather than wait days for four different specialists to weigh in.
And why, we ask, do we admit patients seven days a week but only discharge them five days a week? Weekend discharges are 40 per cent lower than on weekdays, creating a constant logjam at the back door of the hospital. If patients can’t get out, then new patients can’t get in.
By Monday morning, hospitals face a surge of patients waiting to leave – creating overcrowded EDs, cancelled electives, and delays across the system. The backlog often isn’t cleared until midweek, meaning many wards spend the entire week in recovery mode before the cycle repeats.
This does not mean making the entire workforce work on the weekends: just those essential to discharge. This includes pharmacists, occupational therapists, social workers, as well as empowering more nurses to make decisions to discharge.
If we were designing a hospital from scratch today, no one would build it around a workforce that only works Monday to Friday, coordinated by narrow specialisms and cut-off from the technology that could transform care. Our paper offers a blueprint for removing these bottlenecks.