For our latest interview, we spoke with Alcidion’s chief medical officer Paul Deffley and Amanda Thornton, healthcare consultant and previous portfolio director for Lancashire and South Cumbria Health and Care Partnership. Paul and Amanda shared their thoughts on patient flow, including examples of successful projects, practical tips for NHS organisations preparing for winter, and what ‘great’ looks like.
To begin, we asked Paul and Amanda to share a little of their background and experience.
Paul: I’ve worked as a doctor in the NHS for 20 years, across various hospital roles. I’ve worked as the medical director and chief clinical information officer for an emerging ICS and I’ve long had an interest in digital transformation, specifically the human factors associated with successful digital deployment. I would say I’ve had a kaleidoscope of experience, from provider to commissioner to vendor, in trying to create the right solutions and the right ecosystem for solutions to land and make a real difference. I’m also a graduate of the NHS Digital Academy Masters from Imperial College London.
Amanda: I’m a humanist by background and a psychologist. I don’t consider myself to be a digital leader, I consider myself to be a leader who is digitally savvy. I left the NHS last April after 30 years and I’m now working as a consultant psychologist. In the last seven years, I’ve worked with an ICS in various roles; I was CCIO for a number of years, but during COVID, I was moved onto any relevant portfolio of work that needed doing. I was responsible for many projects which required me to have visibility over real-time information from across the whole system, in order to be able to do my job well, but when I went looking for that information it wasn’t where I needed it to be. So I’ve ended up becoming a very passionate advocate for patient flow. I’ve learnt a lot from partners like Alcidion about what good looks like.
Patient flow: projects and successes
Paul: We’ve successfully deployed our flow solution on top of the Cerner EPR programme in East Lancashire, creating real-time availability of bed information across the trust and allowing staff to understand where the bottlenecks and challenges are. Critically, it means they’ve been able to escalate that data to operational and site teams as and when they need it, so that they can make meaningful decisions about those challenges. It prevents a situation where you have really experienced, senior people spending a vast amount of time chasing data.
We’re also rolling out our flow solution in South Tees, where they previously had a manual flow system in place with an enormous whiteboard that was updated twice a day. We’re live across the medical assessment units through to elderly care and discharge out into the community. We’re getting some great metrics back – it’s demonstrating a colossal improvement in emergency department discharge, in understanding what people are waiting for in order to discharge, and in creating that real-time trust wide view of capacity and challenges within the system.
What do we mean by patient flow, and how does it tie into national directives?
Amanda: The favoured rhetoric is that it’s about getting a patient from A to B, usually in the context of an acute hospital, preferably with as few delays as possible.
More recently, there’s been a lot more emphasis, ideas and frameworks developing around site management and flow. If patient flow is often seen through the eyes of the patient, then site flow takes it up a level in terms of using more tools to look holistically at your whole site. Now we have the ICSs sitting in a very privileged position across a whole geography with the potential to mobilise lots of different data and intelligence about their places, so we can talk about whole system flow too. It’s about trying to keep people well as priority number one and keeping people out of hospital as priority number two, but when they do come into the system, we need to look at the whole in-patient journey as well as onwards care. Alcidion are working very closely on this, mapping how their resources can connect to the strategic command centres that are now a requirement in the ICSs.
Paul: I think it’s important to remember that patient flow is a problem that we see through different lenses, whether it’s a patient having a poor experience of the health service or a clinician seeing people backing up in ED, or unable to move on from a bed that is needed for somebody else due to poor flow. Then there’s the other issue that faces organisations – we’ve been trying to do this with pseudo measures for years. But because we haven’t had the data, we haven’t been able to monitor impact. That real-time data across the system is the thing that truly unlocks the challenges we face around flow and how we can make a difference.
Why is patient flow so important?
Paul: Historically, when patient flow becomes challenging, one of the only levers the system has is to turn off elective care. It’s the only tap we have control over, really, when it comes to the flow of patients into acute trusts. But it means that elective care starts stacking up in the background, and that means delays, harm whilst people are waiting, repeat presentations in primary care. Flow is so important because we need to move on from that mechanism by which we can create some breathing space. We need genuine flow systems that collate real-time data across multiple organisations; it can’t just be focused on acute trusts, because anyone working in an acute trust will tell you that the solutions to their flow challenges sit beyond the walls of their organisation. One of the main reasons that the ICSs were created was to facilitate system response – we need acute trusts to be supported by primary care, by public health, by local authorities.
Flow is vital because if we don’t get it right, people’s experience of care is at best sub-optimal. At worst, it could be harmful. We have to get a better grasp on it than just turning the elective care tap on and off.
Amanda: It comes back to the national directives. The two major priorities for the NHS at the moment are to recover the urgent and emergency care performance, to recover the elective waiting list. With demand coming through the front door at a three percent increase with each year, the only thing you can do to tackle this is to optimise your flow.
From a leadership perspective, you also need to be able to ensure your team that flow is optimised, that best practice is best practice. Recently, NHS national leaders have been exploring the evidence around the core features that improve patient flow – the factors that, when you apply them together, should generate the most optimised patient flow possible. Having information in real-time is one of them; another is having embedded frameworks or patient storyboards so that clinicians and bed assigners know exactly where a patient is on their journey. Alongside that, there are a range of tasks that are important but don’t normally receive much attention, like making sure that a cleaner can be triggered as soon as a bed is empty. 16 trusts have been selected to receive investment into those features, this side of winter. As it stands, no hospital in the country has all of those things in place, so there is work to be done, and a real opportunity.
It’s important to recognise that it’s not just about digital. I’m supporting some of the 16 trusts with their business case for this investment, and in many cases they are being written by the chief information officer as though it is digital-only. These new moneys need to change processes, leadership and culture as well as systems.
How can NHS organisations improve their readiness for winter?
Paul: Firstly, there needs to be an awareness of what digital tools are available to support flow. Organisations and leaders need to ensure familiarisation with the benefits and opportunity around digital solutions, and it needs to be framed around the change management aspect. Digital is an enabler, but in order to get best success from it, you need to change your processes and work in a different way. Taking teams through that process is how you unlock the benefits.
Secondly, organisations need to think about the key elements of real-time data that they need to surface within the system, and focus in on those. Don’t tolerate what you can measure, or pseudo measures. Even within a small data set, what are the key parts of data that tell you what’s going on in your system?
Lastly, think about clinical teams and how you engage with them. How can you create marginal gains to drive them to use the digital tools? How do you make their lives a bit better? That’s how we ensure that engagement is high and data quality is high.
Amanda: Last year, I was responsible for deciding where the ICS winter pressure moneys went. My experience was that I couldn’t intelligently decide where to put that money to help the biggest bottlenecks because I couldn’t see where they were. The data wasn’t available for the ICS. So I’d definitely recommend that people start trying to gather that information now.
Also, for digital teams who have been focusing on procuring an EPR – please don’t make the mistake of thinking that you can wait for your new EPR before you take action on this, because recovery is needed now. There needs to be an understanding of the digital enablers for an EPR, versus the ones you need to optimise patient flow and bed management. They are often different.
Often, working with trusts, I’ve seen over 20 percent of beds taken up by people who are ready to go home but can’t get home. Leadership teams can feel that there’s a spotlight on the trusts and their flow, but what about onward care and the organisations responsible for that? To that, I’d say you need to prove that you’ve optimised your patient flow through the hospital. You need to prove that you are doing everything you can, and if you can prove that but you’re still facing patient flow issues with onward care, then that gives you the backing that is needed to intelligently commission further support.
What does good look like?
Paul: Accessible, real-time tools that are adopted and create a difference, so you have measurable impacts from your flow solution. It looks like the real-time data being driven into the command centres so that site managers spend their expertise where it is needed and the leadership team have the ability to interrogate the information and drive meaningful change at system level.
Then we can enhance that – what does good look like, versus what does great look like? Great is adding smart technology on top of those tools to start predicting problems before they happen. The system learns; it learns to predict what happens and the impact of your interventions. You need an underpinning platform and technology that can start driving those algorithms and smart applications to think for you and surface problems before they actually create that problem.
Patient flow tech: hopes for the future
Amanda: I’d hope to see that ‘good to great’ vision that Paul has just shared. I think ambition and needs in this space will absolutely drive that kind of thinking, and we’ll see AI algorithms all over the platforms, trying to prevent bottlenecks. I think those tools will be expected and well-funded across the NHS.
Paul: I hope we start to see system-wide responses to flow challenges. That will mean digitising parts of our health and care spectrum that are currently still manual, creating mobile solutions that are suitable whether someone works in a care home or in an ambulance trust, and blending the boundaries of traditional care. Imagine if we had resources that could reach into a paramedic system and make a make a decision about a conveyance before it happens – that is where I think we need to be. We need to be thinking about how we contract and procure to allow that system-wide response to flow, acknowledging the breadth of the challenge and the breadth of the response that is required from ICSs.
Amanda: Again, looking back to my position in the ICS last winter; I didn’t have oversight of same-day GP data, or availability of pharmacy slots. That data was not available to me. If you are taking an ICS-wide approach, you obviously need that kind of information.
Also, I understand why acute hospital trusts are the focus for much of the investment are we are seeing at present, but they are just the start of this. We need to recognise all of the NHS-partners offering health and care as critical players across the system.
Finally: if you could give one piece of advice to a chief operating officer looking to improve patient flow, what would it be?
Amanda: To a chief operating officer in one of those 16 trusts selected for patient flow investment, I would be saying: please use this investment wisely, and now. Use it to future-proof digital enablement for your care coordination centre. If you are a chief operating officer in one of the trusts without that funding, I’d be asking how quickly you can get your hands on that money.
Paul: Have a really clear understanding of the problem you are trying to solve. The danger with some of the narrative at the moment is that it focuses on this idea of digital bed management. If a chief operating officer committed to a technology just focused on digital bed management, I don’t believe that they would solving the problem they think they are trying to solve. So I would recommend developing a really close understanding of exactly what the problem is, to prevent that from happening.
Many thanks to Paul and Amanda for sharing their thoughts.
