This article was first published on The Journal of mHealth | Read now
The last few weeks have been filled with the news of at least three effective vaccines that could be available to combat Covid-19 by the end of 2020. Meaning that with Herculean mass vaccination programmes commencing in early 2021, we could have the world almost back to normal by the spring. But we still have the worst part of the winter to come and enormous healthcare backlogs and pent up demand waiting within our populations that will need dealing with for the rest of 2021.
Where we are now does not make comfortable reading or point to a benign winter. In the Nuffield Trust’s NHS Performance Summary September to October 2020, there are some portents of a bumpy winter season ahead.
In October 2020, total ED attendances were 1.6 m; a fall of 26% in comparison to the same period in 2019. But, there has been a rise in ambulance incidents (which is notably the reports of when patients have arrived at an ED department but have had to remain on the ambulance due to issues such as no bay availability and staffing in the ED). Moreover, despite the declining numbers of patients attending ED, the 4-hour wait time for patients is almost the same as this period in October 2019 and for the last five months 4-hour performance overall has been deteriorating. Worryingly, numbers of patients waiting greater than 12 hours on a trolley in ED is 75% higher than in the same period in October 2019.
For planned care the news is no better – despite a ramping up of services over the summer of 2020, 4.4 million patients are currently waiting to begin consultant led care, in comparison to April 2020 when the waiting list stood at 4.5 million patients. There are growing waits for all manner of diagnostic tests and procedures, and cancer waits continue to be challenged.
Performance on discharge is also showing signs of strain this Autumn – with increasing numbers of patients who are medically fit but still occupying hospital beds. This despite £280m funding being provided to accelerate ‘discharge to assess’ by paying for the first six-weeks of out-of-hospital care.
There are solid and obvious reasons for the current state of performance: the needs for the streaming of patients into covid and non-covid pathways both at admission and those needing on-going care at discharge. The operational impact of the current second wave of Covid on health services. Indeed, an interesting piece in the HSJ showed that once the number of Covid patients admitted to a hospital hits 15% of total admissions, the provision of planned services is impacted, compounding efforts to recover performance.
But the NHS is resilient and has become skilled at managing services and capacity considering the operational impact of social distancing, planning and time lost due to infection control and prevention (donning, doffing and longer cleaning protocols). Plus, managing the massive impact of covid on the workforce, including staff testing and staff away due to having to self-isolate.
However, my reflection is all the challenges listed above are all the signs and symptoms of challenged patient flow.
In the early noughties, I was a joint head nurse of a regional Critical Care Network and as part of this spent a lot of time being tooled up by the then NHS Modernisation Agency (Proto NHS Improvement) to help change healthcare.
As part of my time working with the Network, I was exposed to all manner of ‘then’ cutting edge thinking on operational management, improvement tools and change techniques. From Understanding Capacity and Demand; the theory of constraints; system thinking and system management – it was here I discovered a new hero, W. Edwards Deming and his TQM approach and the shear madness of the ‘red-beads’ process.
As I look at the numbers and data coming out of NHS England on current performance, three things jump out from my time back in 2003: bottlenecks, ‘carve out’, and variation. In attacking Covid we have created whole new sets of bottlenecks, carve out and added new causes for variation.