By Graham Kendall, Director of The Digital Healthcare Council
The NHS faces monumental challenges around capacity management as it tackles the growing elective care backlog that has soared since the start of the pandemic.
If we are to reverse the seemingly ever-upward waiting list trajectory, we need to make the most of our existing resources and that can only be achieved by embracing strategic digital solutions.
This means we need to develop a holistic approach that embraces system-wide thinking; challenges known blocks to progress; and encourages and supports NHS staff through significant change. Digital solutions will play a critical role in acting as both the glue and enabler to achieve measurable and sustainable improvements.
NHS England’s Delivery Plan for tackling the COVID-19 backlog of elective care published earlier this year rightly placed great emphasis on increasing capacity and the role that digital technologies and integrated data systems must play in achieving more efficient care delivery.
It states: “Many aspects of service delivery in the NHS contribute to capacity, including beds, appointments and how clinician time is apportioned. Digital technology and data systems provide us with the opportunity to release capacity in these areas by allowing us to deliver services in new ways that more efficiently meet the needs of both patients and staff.”
“Greater use of digital technology to assist healthcare workers in completing non-clinical tasks increases the time they can spend caring for patients, which provides a better experience and, ultimately, improves health outcomes.”
“We will also use data to drive improvement within the NHS, through using consistent measurement of performance and working with regions and systems to understand and address the reasons behind performance variation.”
The pandemic highlighted critical issues we already knew had to be faced and galvanised the case for change. So these are welcome statements that crystallise lessons brought into sharp relief during the response to Covid.
While some parts of the country will benefit from much needed new capacity, we need to recognise that there are steps we can take in every local system to make better use of what we already have.
That starts with making more of the latent capacity within existing systems – primary, community and acute – that can be unlocked through better use of data and a thought-through digital-first approach. We must move faster to remove manual, paper-based tasks that can release capacity in the form of time-to-care. And, ultimately, it is critically important for a system-wide approach to capacity management, which must be reflected in more strategic and representative procurement processes. We must make progress on all of these areas if we are to deliver system-wide operational improvements.
On a broad scale, we know that the system has capacity, even when it is very stretched.* The problem starts with lack of system-wide visibility to demand, which varies day-to-day and hour-to-hour. Identifying this “hidden” capacity and then taking action to utilise it requires validated digital solutions that create shared visibility and communicate in real-time the demand in variation.
There is latent capacity across the system, including within triage, bed management, and discharge, so to optimise patient flow across the system it follows we need capacity management approaches that go beyond the acute setting. We need to integrate better monitoring of high risk patients within the community, i.e. before admission, and plan for discharge from the moment of admission, if not before, as well as once patients return to the community with support from primary care. This holistic approach is the only way to minimise avoidable admissions and enhance broader system capacity. For many systems, this will require a step change in approach, but it is absolutely necessary if we are to rise to the challenges before us.
A fundamental part of this challenge is how best to signpost patients through a complex system. It has never been more important to ensure people are receiving the right care, in the right place, at the right time, with the right resources, rather than going through a range of different care providers. While there may be regional variation in the system, the clinical filtering that takes place is essentially – or should be – similar. We need to build that clinical knowledge base and learn from it to improve signposting and outcomes.
Likewise, if we make an intervention, we need to see what the end outcome is, not just based on some theoretical model. There is an evidence base around patient preference and genuine clinical choice, which is really important. Patients who are more activated, i.e. with the skills, confidence and knowledge to manage their own health, tend to experience better health outcomes and care experiences. The evidence also shows that patients who are better informed about their treatment options take a more active role in their own care and are less likely to choose surgery where other options are available. Less invasive treatment of course also tends to be significantly cheaper. So doing the right thing is cost effective; and allows us to focus the use of physical capacity to where it will make the most difference.
It is important to see digital in this context, i.e. as a facilitator to achieve those outcomes rather than as an objective in and of itself.
Historically, the NHS has used procurement frameworks that are focused around narrow point solutions. While these frameworks play a useful role in putting suppliers in front of the market, they often do not encourage system-wide thinking and act as a “quick fix” versus delivering sustainable and scalable change.
As a case in point, there are currently 36 recommended frameworks for digital and IT spend across the NHS. Of these, the ten NHS SBS technology framework agreements cover 1,769 approved organisations. So, while there is extensive choice in how to buy, there is far less information available about how to make wise strategic decisions.
Frameworks tend by definition to offer commoditised solutions, especially when it comes to digital products. Many lean heavily on compliance criteria and leave NHS decision makers to make choices based on long lists of potential functionality, much of which is unlikely ever to be used. Too often, this approach shifts the focus away from outcomes in favour of ticking boxes.
In turn, we risk reinforcing decades of old processes and workflows, without taking time to reflect on the larger strategic objectives, and critically, providing tools that support NHS leaders and front line staff in change management and a new, better, digital way of working.
We need to change this by emphasising what matters. Decisions should be guided by an understanding of how digital solutions improve outcomes; whether and how they are used by their customer; and ease of use, which is fundamentally linked to workflow. We therefore need to inform decision makers by publishing a small number of core metrics focused around utilisation, satisfaction, workflow and outcomes.
Some areas have already made real progress. The emphasis on outcome-focused objectives, for example by Maidstone and Tunbridge Wells NHS Trust, has generated real progress towards achieving sustainable change across the whole system with measurable benefits for staff and patients.
Only by embracing system-wide thinking, publishing evidence to inform decision making and challenging models that are well past their ‘use-by’ date, can we rise to the challenges before us. We must support NHS staff through major changes with tools that enhance rather than hinder operational and clinical efficiency. In parallel and collaboratively, we must create and implement sustainable approaches to support the NHS, its staff, and most importantly, the patients we all serve.
 Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes‐Rovner M, Llewellyn‐Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JHC. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD001431. DOI: 10.1002/14651858.CD001431.pub4.
Top 5 Integrated Care Systems with lowest average ED performance
Top 5 Integrated Care Systems with highest number of cancelled operations
Cancelled Ops sources average per month from Q3 19/20 NHS Statistics.
DTOC Beds sources Feb 2019 NHS Statistics.
Total Beds, ED attendance and performance, Occupancy sources May 2021 NHS Statistics.
Potential Capacity by Integrated Care System
The NHS Digital, Hospital Episode Statistics for England. Admitted Patient Care statistics, 2019-20, extrapolated by TeleTracking Technologies International's capacity released analysis 2017-21.