following question about the case

1)Discussion of implementation plans and Identify missing information and assumptions you made while analyzing the case

PLZZZZZ HELP ME

CASE STUDY Where should the beds go? Infrastructure planning in NHS England Paul Walley This case looks at the strategic planning in one health community within NHS England, which provides healthcare to the population in England free at the point of access. The case examines the underlying finan- cial structure and the control and measurement systems put into place by central government. It considers the challenges faced by managers focusing on the strategic planning within one hospital system, South Warwickshire NHS Foundation Trust (SWFT), and its aims to meet performance targets whilst maintaining financial stability. SWFT operates within the NHS and hence provides healthcare free at the point of consumption. SWFT's attempts to maintain its emergency care performance from 2007 onwards and the strategy decisions it faced at key points in time are tracked. Background private and third-party providers. A high proportion of the The NHS is funded through taxation, and the HM Treasury money is currently spent on hospital care, but not all in 2014-15 financial year provided 98.3bn- for the NHS Foundation Trusts, like SWFT, are hospitals are directly controlled by NHS England. Hospital England. Eighty per cent of all contact with the NHS is in primary care and 12bn of the total budget is spent on 'independent legal entities and have unique govern- primary care services that provide access to the general ance arrangements. They are accountable to local practitioners (GPs) in local family practices. One of the big people, who can become members and governors. They resource allocation issues is to decide how much money are set free from central government control and are no should go into other services and which organisations longer performance managed by health authorities. As should receive it. The bulk of the money (about 60 per self-standing, self-governing organisations, NHS foun- cent) is given to 209 clinical commissioning groups dation trusts are free to determine their own future. (CCGs). CCGs, each of which typically serves a local popu They have financial freedoms and can raise capital lation of around 250,000, are led by an elected body and from both the public and private sectors within are responsible for the local purchase of mental health borrowing limits determined by projected cash flows, services, urgent and emergency care, elective hospital and are therefore based on affordability. They can services and community care. Local GPs comprise 41 per retain financial surpluses to invest in the delivery of cent of members of CCGs, but other professions are repre new NHS services sented. The CCG's representative body states: From the hospital manager's perspective, foundation Commissioning is about getting the best possible status offers the opportunity to operate like a private health outcomes for the local population, by assessing company in many respects, but within a tight regulatory local needs, deciding priorities and strategies, and framework where many prices for the services it offers then buying services on behalf of the population from are largely fixed by NHS England in a tariff system. To providers such as hospitals, clinics, community health achieve foundation status a hospital has to meet strict bodies, etc. It is an ongoing process, and CCGs must criteria and make a formal application. constantly respond and adapt to changing local circum- As a result of increases in the UK population, increases stances. CCGs are responsible for the health of their in the average age of the population and more patients entire population, and are measured by how much they surviving longer with chronic diseases and degenerative improve outcomes. conditions, the NHS is facing an increase in demand and an increase in the resources (staff time and money) The money is spent by CCGs on a wide range of required per patient. In addition, as scientific knowledge providers, including hospitals, GPs, dentists, opticians, progresses, the complexity and hence costs of treatment This case was prepared by Paul Walley (Lecturer in Operations Management, The Open University). It is intended as a basis for class discussion and not as an illustration of good or bad practice. Paul Walley 2016. Not to be reproduced or quoted without permission. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND are increasing. For example, the cost of new drugs is Secondary care hospitals provide the majority of more increasing due to higher development costs. This has complex surgical and medical procedures within the NHS, often led the National Institute for Care Excellence (NICE), ranging from routine heart operations, orthopaedic treat- which produces evidence-based guidance on treatment ment, cancer treatments, treatment for respiratory condi- and drug effectiveness, to reject recommendation for the tions and emergency care. Partly due to this extensive use of new drugs as they offer poor value for the NHS. variety of care offered, each hospital trust has to report on a series of over 200 performance targets. There are several Measuring performance in the NHS mandatory targets that every hospital strives to achieve: It is clearly essential that a budget, as large and signifi- 1.92% of patients must be seen within 18 weeks of cant as that of the NHS, is spent wisely, with the govern- referral, to ensure their treatment is not excessively ment putting into place checks and balances to ensure delayed. that the system works as efficiently as possible. To assist 2. A 31-day diagnosis-to-treatment target for anyone in this process, a wide range of government departments diagnosed with cancer. and independent bodies are tasked with setting stand- 3. A 62-day referral-to-treatment target for anyone ards, reviewing practice and auditing providers. With over suspected of having cancer. 1600 separate measures collected by different parts of 4. Ac difficile' infection reduction target. the NHS and government, the NHS is probably one of the 5. An MRSA infection reduction target. most measured organisations in the world. The Care 6. A four hour waiting time target for accident & emer- Quality Commission is the independent regulator of health gency (A&E) cases. and social care in England that monitors, inspects and Senior hospital managers have to devise their own regulates services to ensure they meet standards of strategy for the ways in which they achieve these targets quality and safety. Monitor is a non-departmental body whilst maintaining the viability of the organisation in the sponsored by the Department of Health that is 'required longer term. The CCG pays for the care it commissions to support patient interests by promoting the provision of through a system called "payment by results' where healthcare services that is economic, efficient and effec- payment is based around standard tariffs for each type tive, and maintains or improves their quality." (In April of treatment. Every time a patient is admitted to hospital 2016, Monitor was moved to become part of a larger for treatment, or attends A&E, their 'health resource organisation, NHS Improvement, bringing together several group' (HRG) code will be recorded and this dictates how support groups.) The National Audit Office also gets much money the hospital can claim for treating the involved, looking for cost savings in public bodies, patient. The HRG codes are determined by assessment including the NHS. of what work and resources should be used to complete CCGs are guided by the NHS Outcomes framework treatment. A hospital that completes treatment very effi- which specifies five domains of efficiency, effectiveness ciently might make a slight surplus, but one that is a high and safety for organisations to achieve (see Figure 1). cost provider could make a loss. Domain 1 Domain 2 Domain 3 Effectiveness Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Domain 4 Ensuring people have a positive experience of care Experience Treating and caring for people in a safe Domain 5 environment and protecting them from avoidable Safety harm Figure 1 The five domains of the NHS Outcomes framework Source: The NHS Outcomes Framework 2015/16. NHS England, Department of Health 723 WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NES ENGLAND Meeting the four-hour target in South until the A&E staff have the space and time to take over Warwickshire the patients care. This creates problems for the ambu- It can be argued that the four-hour A&E target is the most lance services because ambulances cannot get back challenging of these targets. The hospital is tasked with out to deal with new patients until they have properly discharging or admitting 95 per cent of all patients that handed patients over to A&E. attend A&E within four hours of their arrival. For patients If the patient requires care to be administered in hospital they will be transferred to a ward, and their with minor injuries such as sprained ankles or simple cuts and bruises this should, in theory, be an easy target to care taken on by the on-take clinician rotated to take achieve. Such treatment should take less than 30 minutes the emergencies for that day (or week). The patient may in many cases, but hospitals need to ensure that the then need to be transferred to another specialist. For example, a patient may be initially seen by a respira- medical staff are available and on duty at all times for this tory specialist but they have a gastric problem. Once treatment to take place. The more serious cases such as the patient is stable and no longer needs in-hospital patients suffering heart attacks, car accidents or serious falls present a bigger challenge. Dr Kate Silvester, an care they will be discharged back home to be managed and monitored by their GP or as an outpatient. expert in designing healthcare systems, explains some of For some patients a period of rehabilitation is the challenges for the health community: required and they will be transferred to another 'The A&E waiting time target is a very good indicator of hospital (often called a community hospital) or a the health of the care system in a region as it is nursing/residential care home where this care takes affected by the performance of every single provider place until and if the patient is physically fit enough to and the interaction, coordination and cooperation go home. Community hospital staff, in this case between them. If we take a look at the services needed managed by CCGs, also provides nursing and physio- by an elderly patient, who maybe has had a fall at home therapy services into the patient home. or in a care facility, we can see that they use almost If the patient does not require nursing care, but every part of the local healthcare system. The organi- social care, social care services and funds for privately sations involved could include the local GP, the out-of run nursing homes and residential care are provided by hours primary care system, emergency call numbers the Social Service department managed by the local (999 and 111), the ambulance service, the local County Council which are not part of the NHS. hospital and its A&E department, community hospitals This system goes wrong whenever the flow of and care homes which may take the patient once their patients working their way through this complex, emergency care is over and community support services multi-organisation journey becomes disrupted or the including community nurses, occupational therapists system infrastructure becomes unbalanced. The main and social care. Some of these latter services may be problem occurs when hospital beds become full because provided by the local council or even voluntary groups. of delays to care and discharge. Slow in-hospital Each of these providers may have a number of chal- processes are one cause of these delays. Often there is lenges of their own. For example, general practices are also no opportunity for existing patients to be safely privately owned by a partnership of general practi- discharged into community facilities or care homes tioners whose services are commissioned and managed after their acute care is complete. This leaves no room by NHS South Warwickshire Clinical Commissioning for the new A&E arrivals to be admitted, eventually Group. Since it is very difficult for a small general prac- resulting in "trolley waits" where A&E patients can't tice of 3 to 6 doctors to provide 24/7 care 365 days a even be given a cubicle and they have to wait on trolleys year to their list of patients who are registered with in hospital corridors. Ambulances are then unable to them, an "out of hours" service has to be commis- unload patients because A&E becomes full. This type of sioned. If either access to GP appointments or out-of- crisis still happens surprisingly often as few people hours services becomes difficult this may encourage really understand how to address the problems and patients to simply attend their local A&E department implement solutions. where treatment is "guaranteed" within four hours. When a patient arrives at the A&E department they Figure 2 is a representation of the healthcare system will be assessed by a nurse and prioritised again to that Kate is describing, showing how patients might flow wait in the waiting room. If there is no bed or trolley from Primary Care, through the hospital emergency available for ill patients, then they will wait on the department and hospital wards, to out-of-hospital ambulance's trolley, cared for by the ambulance crew services and back into the care of their GP. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND Hospital Ambulance service WIP ambulances Community hospital Assessment units GP 111 Wards WIP Patientin waiting room Intermediate care services Social care services Patient's home or residential home Key Patient's permanent place of residence General practice: managed as a private partnership, commissioned by the Clinical Commissioning Group (CC) 111: national organisation managed by the NHS Ambulance service managed at a regional level by an NHS organisation Hospital: separate NHS organisation Community Hospital and Intermediate care services managed by the CCG Social services managed by the local county council Figure 2 A typical emergency patient flow (based on South Warwickshire in 2009) Source. Paul Walley Kate Silvester, based on NHS data. Addressing the four-hour wait target to address issues. Figure 3 shows the A&E performance at the trust from April 2007 to the end of October 2013. The The emergency care target has been an intense political chart shows that the SWFT A&E hasn't been able to hit issue since 2001 and remains a problem to the present the 98 per cent target consistently, with a number of day. The complexity of the system reflects the numerous periods over time when the trust suffered significant interventions and re-organisations that have taken place drops in performance. In November 2008, performance in the NHS to achieve the A&E target. Demand into A&E dropped suddenly and dramatically and then recovered in is increasing and patients presenting to A&E often have the summer of 2009, only to fall again in November chronic, not emergency, conditions. Many of the infra- 2011 and thereafter deteriorated with worsening perfor- structure developments such as the relatively new 111 mance particularly in the winter periods. telephone assistance service, the GP out-of-hours The A&E performance was the one target that the services and minor injury units were implemented with trust was failing to meet, so the trust started a major the objective to reduce the demand on A&E and reduce improvement programme in April 2009. The perfor the number of emergency admissions to hospital, thus mance drop in November 2008 was highly significant as reducing the overall cost of the emergency service to the A&E performance is a factor that can affect a hospital's tax payer. However, those patients initially given a low achievement of Foundation Status. Senior managers priority, particularly the elderly, have learnt to go straight consider the achievement of foundation status a key part to A&E if they are acutely ill. Nationally, the emergency of their strategy because of the advantages it provides in target performance has been steadily declining for the being able to raise their own capital for investment, the last few years, resulting in frequent 'winter crises' where ability to reinvest surpluses and less central government the system appears to completely break down. interference. Hence delays to achieving the A&E target To look at the challenges faced by the Chief Executive of were delaying all their independent investment decisions. SWFT in meeting this target it is useful to take a longitu At this time two other critical factors came to the dinal look at the trust's performance and the actions taken attention of the executive. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND 120.00% % ABE attendances 100.00% who are discharged, 80.00% transferred or admitted within 4 60.00% hours of arriving at 40.00% ARE 20.00% 0.00% % seen in 4 hours Target 2007-04-08 2007-08-05 2007-12-02 2008-03-30 2008-07-27 2008-11-23 2009-03-22 2009-07-19 2009-11-15 2010-03-14 2010-07-11 2010-11-07 90-E0-T TOZ 2011-07-03 2011-10-30 2012-02-26 2012-06-24 2012-10-21 2013-02-17 2013-06-16 2013-10-13 Week Figure 3 A&E performance in South Warwickshire NHS Foundation Trust Source: Paul Walley Kate Silvester, based on NHS cata. The hospital standardised mortality ratios allowed to continue. This emotional event was exactly The comparable mortality data was published for all hospi- what was needed to ensure that the clinicians and tals in England, now called rate adjusted morality index managers engaged, perhaps unwillingly to start with, in (RAMI) and produced and published publically by the addressing the delays in their system of care - even private company, Dr Foster. The death rates for all hospi though they still believed that the poor care and flow was tals in England are compared statistically and are indexed due to a lack of resources not the internal working and so that the death rate for the average hospital is equal to scheduling of the hospital, which had been beautifully 100. In June 2009, the executive and population of South observed and monitored by the patient. Warwickshire learned that their hospital's mortality rate for emergency patients was considerably above the 100 average figure. Checks suggested this was not a coding Crisis in September 2009 problem. A&E performance suddenly deteriorated again in Was the mortality high in Warwick due to the delays in September 2009. No-one could understand why as the emergency care system? Were the delays due to a demand was normal for the time of year. An improvement shortage of resources or the very inefficient processes that programme created fortnightly 'big room' meetings in staff had unwittingly created over the years of practice? which clinicians and senior managers from organisations A patient's experience across the local health and social care system were encouraged to attend and learn about changes to the In June 2009, a patient wrote to the hospital CEO with a wider system (not just inside the acute hospital). For detailed and factual account of his experience of being the first time they were given the opportunity to observe admitted with a serious emergency over the Easter bank the impact of these changes on the South Warwickshire's holiday. The CEO invited the patient to talk to the clinical health and social care system performance. staff who had been involved in his care. As the patient At the October 2009 'big room' meeting, the public explained what happened, a member of staff mapped health doctors working for the CCG revealed that a local what had happened to him. This value map showed that 40-bed community hospital in Alcester had been closed he lay in bed for ten days waiting for care which should on 1 September 2009 in order to reduce the CCG's have only taken 34 hours, a crucial part of his care was costs. The remaining residents had been transferred into delayed for five days and he lost one third of his blood other NHS community hospitals or into private residential volume over this time which went unnoticed by the staff nursing homes funded by the patients privately or on the three wards between which he was moved. The through social services. Although this had been part of doctors involved in the care were shocked by the story the CCG's strategy for many years, the focus of attention and after a period of discussion accepted the system had had been on implementation of the physical changes to problems. The patient accepted the public apology by the system and not the impact on the system as a whole. the A&E consultant (whose department had done an From the CCG's perspective, the closure of Alcester's excellent job) on behalf of all the hospital's staff, there community beds was a straightforward decision from a was agreement that the current system could not be financial and strategic point of view. A typical hospital WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND bed costs 400 a day to keep open and even though hospital - in particular the change to the working sched- community hospital beds are usually cheaper, they are ules of all the staff. Junior doctor capacity was pooled often in small facilities where there are no economies of across A&E and the assessment units so patients were scale. In the case of Alcester, the site occupied by these examined and investigated within two hours of arrival, facilities was of tremendous value and its closure also the prioritisation policies abandoned and lead times for facilitated the demolishing of older buildings to be laboratory and imaging investigations were improved. replaced by a brand new 6.8m primary care centre. Senior medical and surgical staff were scheduled in the This was intended to provide better value healthcare with hospital from 08:00 to 22:00, seven days a week, more care delivered in the primary care system and 365 days a year, to ensure that all patients had a clear elderly patients treated at home by an integrated health diagnosis, prognosis and their care plan on their day of and social care' (IHSC) team. This would eventually use attendance. Although these changes didn't impact on the a new delivery concept called the 'virtual ward' where the flow constraint downstream of the hospital, the impact systems and staffing found in a hospital ward are re-cre on mortality was dramatic. Despite the poor A&E perfor- ated in a home setting. The expansion and integration of mance, Monitor recognised the outstanding process the primary care facilities in Alcester would also allow improvements and the impact on mortality and the South further non-NHS activity to be provided at the same Warwickshire NHS Foundation Trust was confirmed in location. This includes private treatments for acupunc- April 2010. ture, trauma counselling, podiatry, hypnotherapy, coaching and sports therapy. The impact of this closure became apparent to What happened between April 2011 and everyone in the big room'. The staff at Warwick hospital November 2012? were unable to discharge any of their patients who having reduced the overburden on the staff and thus required community hospital rehabilitation care, so the improved morale and the mortality rate, the hospital backlog of patients waiting for discharge suddenly and continued to struggle against the constraint caused by significantly increased inside the acute hospital. The flow closing the beds in the community trust without first from A&E reduced - with an accompanying spike in the improving the lead times for the community and social death rate that no one else had noticed because of the care services to discharge patients from all the hospitals way in which these statistics are compiled. in the system to home or to residential care. The change in culture across the organisations repre In April 2011, SWFT took over the community hospi- sented in the big room' was profound. Instead of each tals and services from the CCG, but the social care organisation and department focusing on their own effi- services and funding was still managed by the local ciency and cost, everyone began to realise that they were government. Over the next two years the combined part of a complex interdependent system. A well- teams reorganised themselves around the work so that intentioned change in one part of the system could have all patients who no longer needed hospital care could profound and unintended consequences in another part be transferred either directly to community rehabilitation of the system. In this case, we have a change imposed hospital or a nursing home in which the rehabilitation by central government, implemented by an independent care would be provided. The first six weeks in a private funding body, but the chief executive of the local hospital facility were paid by South Warwickshire NHS Foundation is blamed for the poor A&E performance that happens as Trust. Six weeks is enough time to assess whether a a consequence. patient will recover sufficiently to return home and six The CCG and acute hospital staff all recognised that weeks is the lead time for family and social care to sort they had to increase the bed capacity to cope with the out the finances for private residential care if they can't. increased delays to discharge. Since the community Community services delivered into the patient's home hospital had been sold to the private sector and couldn't were also reorganised and the lead times reduced by be reopened, two temporary wards were built at the acute eliminating the prioritisation policies. In October 2012, hospital and opened just before Christmas 2009. A&E the social care budget was cut and the policies performance improved for one week, and then it deterio- governing social care financial support for patients rated again as these 40 beds filled up. The outflow changed. The impact of this system change is visible in constraint still had not been addressed. Again there was the A&E performance. By April 2012, 7/7 working had the spike in the death rate over the Christmas 2009 been agreed and re-contracted for all staff in the parts holiday period. of the system now managed by SWFT. Figure 4 shows By the end of March 2010, internal policy constraints the last recorded measure for A&E performance and that impacted on mortality were being addressed at the mortality and indicates that A&E flow had improved CASE STUDY Where should the beds go? Infrastructure planning in NHS England Paul Walley This case looks at the strategic planning in one health community within NHS England, which provides healthcare to the population in England free at the point of access. The case examines the underlying finan- cial structure and the control and measurement systems put into place by central government. It considers the challenges faced by managers focusing on the strategic planning within one hospital system, South Warwickshire NHS Foundation Trust (SWFT), and its aims to meet performance targets whilst maintaining financial stability. SWFT operates within the NHS and hence provides healthcare free at the point of consumption. SWFT's attempts to maintain its emergency care performance from 2007 onwards and the strategy decisions it faced at key points in time are tracked. Background private and third-party providers. A high proportion of the The NHS is funded through taxation, and the HM Treasury money is currently spent on hospital care, but not all in 2014-15 financial year provided 98.3bn- for the NHS Foundation Trusts, like SWFT, are hospitals are directly controlled by NHS England. Hospital England. Eighty per cent of all contact with the NHS is in primary care and 12bn of the total budget is spent on 'independent legal entities and have unique govern- primary care services that provide access to the general ance arrangements. They are accountable to local practitioners (GPs) in local family practices. One of the big people, who can become members and governors. They resource allocation issues is to decide how much money are set free from central government control and are no should go into other services and which organisations longer performance managed by health authorities. As should receive it. The bulk of the money (about 60 per self-standing, self-governing organisations, NHS foun- cent) is given to 209 clinical commissioning groups dation trusts are free to determine their own future. (CCGs). CCGs, each of which typically serves a local popu They have financial freedoms and can raise capital lation of around 250,000, are led by an elected body and from both the public and private sectors within are responsible for the local purchase of mental health borrowing limits determined by projected cash flows, services, urgent and emergency care, elective hospital and are therefore based on affordability. They can services and community care. Local GPs comprise 41 per retain financial surpluses to invest in the delivery of cent of members of CCGs, but other professions are repre new NHS services sented. The CCG's representative body states: From the hospital manager's perspective, foundation Commissioning is about getting the best possible status offers the opportunity to operate like a private health outcomes for the local population, by assessing company in many respects, but within a tight regulatory local needs, deciding priorities and strategies, and framework where many prices for the services it offers then buying services on behalf of the population from are largely fixed by NHS England in a tariff system. To providers such as hospitals, clinics, community health achieve foundation status a hospital has to meet strict bodies, etc. It is an ongoing process, and CCGs must criteria and make a formal application. constantly respond and adapt to changing local circum- As a result of increases in the UK population, increases stances. CCGs are responsible for the health of their in the average age of the population and more patients entire population, and are measured by how much they surviving longer with chronic diseases and degenerative improve outcomes. conditions, the NHS is facing an increase in demand and an increase in the resources (staff time and money) The money is spent by CCGs on a wide range of required per patient. In addition, as scientific knowledge providers, including hospitals, GPs, dentists, opticians, progresses, the complexity and hence costs of treatment This case was prepared by Paul Walley (Lecturer in Operations Management, The Open University). It is intended as a basis for class discussion and not as an illustration of good or bad practice. Paul Walley 2016. Not to be reproduced or quoted without permission. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND are increasing. For example, the cost of new drugs is Secondary care hospitals provide the majority of more increasing due to higher development costs. This has complex surgical and medical procedures within the NHS, often led the National Institute for Care Excellence (NICE), ranging from routine heart operations, orthopaedic treat- which produces evidence-based guidance on treatment ment, cancer treatments, treatment for respiratory condi- and drug effectiveness, to reject recommendation for the tions and emergency care. Partly due to this extensive use of new drugs as they offer poor value for the NHS. variety of care offered, each hospital trust has to report on a series of over 200 performance targets. There are several Measuring performance in the NHS mandatory targets that every hospital strives to achieve: It is clearly essential that a budget, as large and signifi- 1.92% of patients must be seen within 18 weeks of cant as that of the NHS, is spent wisely, with the govern- referral, to ensure their treatment is not excessively ment putting into place checks and balances to ensure delayed. that the system works as efficiently as possible. To assist 2. A 31-day diagnosis-to-treatment target for anyone in this process, a wide range of government departments diagnosed with cancer. and independent bodies are tasked with setting stand- 3. A 62-day referral-to-treatment target for anyone ards, reviewing practice and auditing providers. With over suspected of having cancer. 1600 separate measures collected by different parts of 4. Ac difficile' infection reduction target. the NHS and government, the NHS is probably one of the 5. An MRSA infection reduction target. most measured organisations in the world. The Care 6. A four hour waiting time target for accident & emer- Quality Commission is the independent regulator of health gency (A&E) cases. and social care in England that monitors, inspects and Senior hospital managers have to devise their own regulates services to ensure they meet standards of strategy for the ways in which they achieve these targets quality and safety. Monitor is a non-departmental body whilst maintaining the viability of the organisation in the sponsored by the Department of Health that is 'required longer term. The CCG pays for the care it commissions to support patient interests by promoting the provision of through a system called "payment by results' where healthcare services that is economic, efficient and effec- payment is based around standard tariffs for each type tive, and maintains or improves their quality." (In April of treatment. Every time a patient is admitted to hospital 2016, Monitor was moved to become part of a larger for treatment, or attends A&E, their 'health resource organisation, NHS Improvement, bringing together several group' (HRG) code will be recorded and this dictates how support groups.) The National Audit Office also gets much money the hospital can claim for treating the involved, looking for cost savings in public bodies, patient. The HRG codes are determined by assessment including the NHS. of what work and resources should be used to complete CCGs are guided by the NHS Outcomes framework treatment. A hospital that completes treatment very effi- which specifies five domains of efficiency, effectiveness ciently might make a slight surplus, but one that is a high and safety for organisations to achieve (see Figure 1). cost provider could make a loss. Domain 1 Domain 2 Domain 3 Effectiveness Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Domain 4 Ensuring people have a positive experience of care Experience Treating and caring for people in a safe Domain 5 environment and protecting them from avoidable Safety harm Figure 1 The five domains of the NHS Outcomes framework Source: The NHS Outcomes Framework 2015/16. NHS England, Department of Health 723 WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NES ENGLAND Meeting the four-hour target in South until the A&E staff have the space and time to take over Warwickshire the patients care. This creates problems for the ambu- It can be argued that the four-hour A&E target is the most lance services because ambulances cannot get back challenging of these targets. The hospital is tasked with out to deal with new patients until they have properly discharging or admitting 95 per cent of all patients that handed patients over to A&E. attend A&E within four hours of their arrival. For patients If the patient requires care to be administered in hospital they will be transferred to a ward, and their with minor injuries such as sprained ankles or simple cuts and bruises this should, in theory, be an easy target to care taken on by the on-take clinician rotated to take achieve. Such treatment should take less than 30 minutes the emergencies for that day (or week). The patient may in many cases, but hospitals need to ensure that the then need to be transferred to another specialist. For example, a patient may be initially seen by a respira- medical staff are available and on duty at all times for this tory specialist but they have a gastric problem. Once treatment to take place. The more serious cases such as the patient is stable and no longer needs in-hospital patients suffering heart attacks, car accidents or serious falls present a bigger challenge. Dr Kate Silvester, an care they will be discharged back home to be managed and monitored by their GP or as an outpatient. expert in designing healthcare systems, explains some of For some patients a period of rehabilitation is the challenges for the health community: required and they will be transferred to another 'The A&E waiting time target is a very good indicator of hospital (often called a community hospital) or a the health of the care system in a region as it is nursing/residential care home where this care takes affected by the performance of every single provider place until and if the patient is physically fit enough to and the interaction, coordination and cooperation go home. Community hospital staff, in this case between them. If we take a look at the services needed managed by CCGs, also provides nursing and physio- by an elderly patient, who maybe has had a fall at home therapy services into the patient home. or in a care facility, we can see that they use almost If the patient does not require nursing care, but every part of the local healthcare system. The organi- social care, social care services and funds for privately sations involved could include the local GP, the out-of run nursing homes and residential care are provided by hours primary care system, emergency call numbers the Social Service department managed by the local (999 and 111), the ambulance service, the local County Council which are not part of the NHS. hospital and its A&E department, community hospitals This system goes wrong whenever the flow of and care homes which may take the patient once their patients working their way through this complex, emergency care is over and community support services multi-organisation journey becomes disrupted or the including community nurses, occupational therapists system infrastructure becomes unbalanced. The main and social care. Some of these latter services may be problem occurs when hospital beds become full because provided by the local council or even voluntary groups. of delays to care and discharge. Slow in-hospital Each of these providers may have a number of chal- processes are one cause of these delays. Often there is lenges of their own. For example, general practices are also no opportunity for existing patients to be safely privately owned by a partnership of general practi- discharged into community facilities or care homes tioners whose services are commissioned and managed after their acute care is complete. This leaves no room by NHS South Warwickshire Clinical Commissioning for the new A&E arrivals to be admitted, eventually Group. Since it is very difficult for a small general prac- resulting in "trolley waits" where A&E patients can't tice of 3 to 6 doctors to provide 24/7 care 365 days a even be given a cubicle and they have to wait on trolleys year to their list of patients who are registered with in hospital corridors. Ambulances are then unable to them, an "out of hours" service has to be commis- unload patients because A&E becomes full. This type of sioned. If either access to GP appointments or out-of- crisis still happens surprisingly often as few people hours services becomes difficult this may encourage really understand how to address the problems and patients to simply attend their local A&E department implement solutions. where treatment is "guaranteed" within four hours. When a patient arrives at the A&E department they Figure 2 is a representation of the healthcare system will be assessed by a nurse and prioritised again to that Kate is describing, showing how patients might flow wait in the waiting room. If there is no bed or trolley from Primary Care, through the hospital emergency available for ill patients, then they will wait on the department and hospital wards, to out-of-hospital ambulance's trolley, cared for by the ambulance crew services and back into the care of their GP. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND Hospital Ambulance service WIP ambulances Community hospital Assessment units GP 111 Wards WIP Patientin waiting room Intermediate care services Social care services Patient's home or residential home Key Patient's permanent place of residence General practice: managed as a private partnership, commissioned by the Clinical Commissioning Group (CC) 111: national organisation managed by the NHS Ambulance service managed at a regional level by an NHS organisation Hospital: separate NHS organisation Community Hospital and Intermediate care services managed by the CCG Social services managed by the local county council Figure 2 A typical emergency patient flow (based on South Warwickshire in 2009) Source. Paul Walley Kate Silvester, based on NHS data. Addressing the four-hour wait target to address issues. Figure 3 shows the A&E performance at the trust from April 2007 to the end of October 2013. The The emergency care target has been an intense political chart shows that the SWFT A&E hasn't been able to hit issue since 2001 and remains a problem to the present the 98 per cent target consistently, with a number of day. The complexity of the system reflects the numerous periods over time when the trust suffered significant interventions and re-organisations that have taken place drops in performance. In November 2008, performance in the NHS to achieve the A&E target. Demand into A&E dropped suddenly and dramatically and then recovered in is increasing and patients presenting to A&E often have the summer of 2009, only to fall again in November chronic, not emergency, conditions. Many of the infra- 2011 and thereafter deteriorated with worsening perfor- structure developments such as the relatively new 111 mance particularly in the winter periods. telephone assistance service, the GP out-of-hours The A&E performance was the one target that the services and minor injury units were implemented with trust was failing to meet, so the trust started a major the objective to reduce the demand on A&E and reduce improvement programme in April 2009. The perfor the number of emergency admissions to hospital, thus mance drop in November 2008 was highly significant as reducing the overall cost of the emergency service to the A&E performance is a factor that can affect a hospital's tax payer. However, those patients initially given a low achievement of Foundation Status. Senior managers priority, particularly the elderly, have learnt to go straight consider the achievement of foundation status a key part to A&E if they are acutely ill. Nationally, the emergency of their strategy because of the advantages it provides in target performance has been steadily declining for the being able to raise their own capital for investment, the last few years, resulting in frequent 'winter crises' where ability to reinvest surpluses and less central government the system appears to completely break down. interference. Hence delays to achieving the A&E target To look at the challenges faced by the Chief Executive of were delaying all their independent investment decisions. SWFT in meeting this target it is useful to take a longitu At this time two other critical factors came to the dinal look at the trust's performance and the actions taken attention of the executive. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND 120.00% % ABE attendances 100.00% who are discharged, 80.00% transferred or admitted within 4 60.00% hours of arriving at 40.00% ARE 20.00% 0.00% % seen in 4 hours Target 2007-04-08 2007-08-05 2007-12-02 2008-03-30 2008-07-27 2008-11-23 2009-03-22 2009-07-19 2009-11-15 2010-03-14 2010-07-11 2010-11-07 90-E0-T TOZ 2011-07-03 2011-10-30 2012-02-26 2012-06-24 2012-10-21 2013-02-17 2013-06-16 2013-10-13 Week Figure 3 A&E performance in South Warwickshire NHS Foundation Trust Source: Paul Walley Kate Silvester, based on NHS cata. The hospital standardised mortality ratios allowed to continue. This emotional event was exactly The comparable mortality data was published for all hospi- what was needed to ensure that the clinicians and tals in England, now called rate adjusted morality index managers engaged, perhaps unwillingly to start with, in (RAMI) and produced and published publically by the addressing the delays in their system of care - even private company, Dr Foster. The death rates for all hospi though they still believed that the poor care and flow was tals in England are compared statistically and are indexed due to a lack of resources not the internal working and so that the death rate for the average hospital is equal to scheduling of the hospital, which had been beautifully 100. In June 2009, the executive and population of South observed and monitored by the patient. Warwickshire learned that their hospital's mortality rate for emergency patients was considerably above the 100 average figure. Checks suggested this was not a coding Crisis in September 2009 problem. A&E performance suddenly deteriorated again in Was the mortality high in Warwick due to the delays in September 2009. No-one could understand why as the emergency care system? Were the delays due to a demand was normal for the time of year. An improvement shortage of resources or the very inefficient processes that programme created fortnightly 'big room' meetings in staff had unwittingly created over the years of practice? which clinicians and senior managers from organisations A patient's experience across the local health and social care system were encouraged to attend and learn about changes to the In June 2009, a patient wrote to the hospital CEO with a wider system (not just inside the acute hospital). For detailed and factual account of his experience of being the first time they were given the opportunity to observe admitted with a serious emergency over the Easter bank the impact of these changes on the South Warwickshire's holiday. The CEO invited the patient to talk to the clinical health and social care system performance. staff who had been involved in his care. As the patient At the October 2009 'big room' meeting, the public explained what happened, a member of staff mapped health doctors working for the CCG revealed that a local what had happened to him. This value map showed that 40-bed community hospital in Alcester had been closed he lay in bed for ten days waiting for care which should on 1 September 2009 in order to reduce the CCG's have only taken 34 hours, a crucial part of his care was costs. The remaining residents had been transferred into delayed for five days and he lost one third of his blood other NHS community hospitals or into private residential volume over this time which went unnoticed by the staff nursing homes funded by the patients privately or on the three wards between which he was moved. The through social services. Although this had been part of doctors involved in the care were shocked by the story the CCG's strategy for many years, the focus of attention and after a period of discussion accepted the system had had been on implementation of the physical changes to problems. The patient accepted the public apology by the system and not the impact on the system as a whole. the A&E consultant (whose department had done an From the CCG's perspective, the closure of Alcester's excellent job) on behalf of all the hospital's staff, there community beds was a straightforward decision from a was agreement that the current system could not be financial and strategic point of view. A typical hospital WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND bed costs 400 a day to keep open and even though hospital - in particular the change to the working sched- community hospital beds are usually cheaper, they are ules of all the staff. Junior doctor capacity was pooled often in small facilities where there are no economies of across A&E and the assessment units so patients were scale. In the case of Alcester, the site occupied by these examined and investigated within two hours of arrival, facilities was of tremendous value and its closure also the prioritisation policies abandoned and lead times for facilitated the demolishing of older buildings to be laboratory and imaging investigations were improved. replaced by a brand new 6.8m primary care centre. Senior medical and surgical staff were scheduled in the This was intended to provide better value healthcare with hospital from 08:00 to 22:00, seven days a week, more care delivered in the primary care system and 365 days a year, to ensure that all patients had a clear elderly patients treated at home by an integrated health diagnosis, prognosis and their care plan on their day of and social care' (IHSC) team. This would eventually use attendance. Although these changes didn't impact on the a new delivery concept called the 'virtual ward' where the flow constraint downstream of the hospital, the impact systems and staffing found in a hospital ward are re-cre on mortality was dramatic. Despite the poor A&E perfor- ated in a home setting. The expansion and integration of mance, Monitor recognised the outstanding process the primary care facilities in Alcester would also allow improvements and the impact on mortality and the South further non-NHS activity to be provided at the same Warwickshire NHS Foundation Trust was confirmed in location. This includes private treatments for acupunc- April 2010. ture, trauma counselling, podiatry, hypnotherapy, coaching and sports therapy. The impact of this closure became apparent to What happened between April 2011 and everyone in the big room'. The staff at Warwick hospital November 2012? were unable to discharge any of their patients who having reduced the overburden on the staff and thus required community hospital rehabilitation care, so the improved morale and the mortality rate, the hospital backlog of patients waiting for discharge suddenly and continued to struggle against the constraint caused by significantly increased inside the acute hospital. The flow closing the beds in the community trust without first from A&E reduced - with an accompanying spike in the improving the lead times for the community and social death rate that no one else had noticed because of the care services to discharge patients from all the hospitals way in which these statistics are compiled. in the system to home or to residential care. The change in culture across the organisations repre In April 2011, SWFT took over the community hospi- sented in the big room' was profound. Instead of each tals and services from the CCG, but the social care organisation and department focusing on their own effi- services and funding was still managed by the local ciency and cost, everyone began to realise that they were government. Over the next two years the combined part of a complex interdependent system. A well- teams reorganised themselves around the work so that intentioned change in one part of the system could have all patients who no longer needed hospital care could profound and unintended consequences in another part be transferred either directly to community rehabilitation of the system. In this case, we have a change imposed hospital or a nursing home in which the rehabilitation by central government, implemented by an independent care would be provided. The first six weeks in a private funding body, but the chief executive of the local hospital facility were paid by South Warwickshire NHS Foundation is blamed for the poor A&E performance that happens as Trust. Six weeks is enough time to assess whether a a consequence. patient will recover sufficiently to return home and six The CCG and acute hospital staff all recognised that weeks is the lead time for family and social care to sort they had to increase the bed capacity to cope with the out the finances for private residential care if they can't. increased delays to discharge. Since the community Community services delivered into the patient's home hospital had been sold to the private sector and couldn't were also reorganised and the lead times reduced by be reopened, two temporary wards were built at the acute eliminating the prioritisation policies. In October 2012, hospital and opened just before Christmas 2009. A&E the social care budget was cut and the policies performance improved for one week, and then it deterio- governing social care financial support for patients rated again as these 40 beds filled up. The outflow changed. The impact of this system change is visible in constraint still had not been addressed. Again there was the A&E performance. By April 2012, 7/7 working had the spike in the death rate over the Christmas 2009 been agreed and re-contracted for all staff in the parts holiday period. of the system now managed by SWFT. Figure 4 shows By the end of March 2010, internal policy constraints the last recorded measure for A&E performance and that impacted on mortality were being addressed at the mortality and indicates that A&E flow had improved