Trusts don’t give themselves breathing space, it is “one in one out”. It is no surprise that bed usage spills over into out of area from time to time.
There are some obvious things to do to control Acute flow and the rest is culture.
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Containment not treatment
I’ve been working with Mental Health trusts for almost 10 years. What struck me early on was how difficult it was to see care pathways in action. I realised that I was actually looking at a containment not a treatment model.
Staff are understandably risk adverse: they work in silos not understanding what colleagues in other teams are doing; record sharing is often poor, especially between psychiatric liaison and community mental health teams; crisis plans are weak or absent; and when something does go tragically wrong staff fear for their jobs and reputation or are consumed by subsequent investigations. So why take the risk!?
I’ve been told more than once if the patient is on the ward “they are safe, it’s the ones in the community that keep me awake”.
Yet clinicians tell me patients don’t get better on a ward and every admission should be purposeful. Equally, how many times have you read patient accounts of inpatient care, that describe how the process was traumatising, if well intentioned?
So, this is our wicked problem start point.
Obvious things
There are some recurring actions that arise from our flow work with Mental Health trusts. You should explore the following to reduce occupied bed day pressure:
- Do you have bed flow grip?
Bed allocations by geographical patch ensure that the bed base is not a buffet; & you need actionable flow metric visibility, e.g. a spike in long stayers will put pressure on beds…so where’s the spike, what’s the resolution & mitigation plan to stay within the bed base?
- Do you really have CRHT fidelity?
Your CRHT team should be the virtual ward, is it really only holding at-risk of admission patients? Is it facilitating early discharge and pulling patients from the ward?
- Containment over treatment?
What proportion of the Acute bed base is consumed by repeat admitters? You will be surprised, how then are you ensuring that crisis plans are robust and being used to guide staff and psychiatric liaison teams from admitting unnecessarily?
- Unnecessary patient moves?
Patient moves restart the treatment clock no matter how well-intended to get a patient closer to home or repatriate from an out of area bed. Typically, one move doubles the spell length of stay.
Culture
Culture is the way we do things around here. So, if you want an organisation that is happy to take positive risk; avoids unnecessary admission; and doesn’t wait for perfection before discharge; my advice would be:
- Provide air cover, senior leadership sets behavioural norms. Staff will not take positive risk if they don’t think their seniors have got their backs.
- Close the pathway clarity gap. Staff hold onto patients because they don’t know or trust how they will be supported elsewhere in the pathway. Mental health support must be responsive to reduce the risk of crisis presentation and thus pressure on the ward front door. Don’t tolerate waiting lists, ensure services are ‘easy in/easy out’ and the interfaces between them are well understood.
- Visibility is key. You must be able to see the extent to which you are delivering orderly step up/step down support to patients. You can then target changes required to meet patient need closer to home with less need for bed days; & importantly assure staff and stakeholders.
But we just don’t have enough beds
We wouldn’t have an out of area problem if we had the acute and step-down beds for our population need, is a common refrain.
Ok, one Trust might have relatively more beds than another, but have you done the obvious and can you hand on heart say you treat and don’t contain?
Conclusion
This is a wicked problem, however, don’t assume it cannot be solved due to a lack of bed capacity.
Studies have repeatedly shown across healthcare settings that the best performers are not those with the most relative resource or the least demand pressure. Take, for example, declining A&E performance. An excellent analysis1 showed that the frequently cited drivers of poor performance of increased attendance, greater complexity and staff shortage were not drivers at all. The driver was a failure to move patients through hospital wards and back home efficiently.
So, if you are going to invest in anything perhaps that should be management capability and process improvement and not the politicians’ answer which always seems to be more front line resource.
1 The A&E crisis: what’s really driving poor performance? Feb-23, Re:State independent think tank
