At Akeso, we are extremely saddened by the current healthcare crisis caused by the unprecedented NHS capacity constraints which is threatening the lives of so many of us this winter.
According to the latest discussions at No10, the Government’s response to this challenge is an improved discharge to medically fit patients that is enabled by solutions such as virtual wards.
Although programmes such as discharge to assess (D2A) and virtual wards are not new, we welcome the recognition that doing the same but (slightly) better is not going to solve the problem this winter, or in fact any winter going forward.
According to the NHS, there are 12,809 patients fit for discharge who are occupying beds which could be available to save lives. In an analysis by HSJ, 7,000 virtual ward beds exist, but only half of them are occupied.
So, what is causing this disconnect and why aren’t virtual wards that are in place delivering results?
We believe that the system is struggling with uptake due to the lack of mechanisms that offer a partnership platform between healthcare professionals, who must continue to care for patients uninterruptedly, and specialist partners that can facilitate discharge programmes and implement functional virtual wards.
Akeso can offer such a mechanism and work with Trusts to deliver improvements to discharge practices and implement technology enable virtual wards. We can enable this by offering:
Demand and capacity analysis to enable care pathway remodelling.
Workforce optimisation and empowerment to support discharge and remote care.
Project management to ensure programmes and solutions offer evidenced results.
Comprehensive guide and methodology which takes a Trust ‘step-by-step’ through business case, implementation, effective management and scaling of virtual wards.
A medically graded virtual ward technology which offers proven discharge results by reducing length of stay of medically fit patients.
We are here to talk and help Trusts and ICSs with a free assessment and actionable plan that can offer results right now!
Together with HSJ and Masimo we’ll be hosting a roundtable which will focus on Virtual Wards and Discharge in March. Watch this space for updates!
There are seven key steps to generating traction and improving the discharge-to-assess pathways. These are a mix of technical development in respect of discharge-to-assess (such as the establishment of agreed patient strata) and the generic challenges of change management (such as engagement, communication, and skills building). The first 3 phases (which are the planning phases) will be broadly sequential but the delivery phases can be run in parallel, as the figure below indicates:
Establish a core guiding coalition: build a small group with representation from the acute, community, and social care teams who will act as the core accountable team. This team will guide the program to ensure time and resources are well spent.
Understand where you are and why, in order to build the local case for change, including:
Maturity model completion: complete the self-assessment complete the self-assessment of the Akeso discharge-to-assess maturity model to show where the current system is already fit-for-purpose and where changes need to be made
Internal analysis on “no right to reside” and other key metrics (such as risk adjected length of stay, and elective and cancer waitlist variation) to give additional local relevance
Define the overall model of discharge-to-assess which best suits your location, given the NHS England guidance, known exemplar case studies, and the results from the maturity assessment, including:
Patient stratification: be clear on which patients fall under the category of relevant for discharge-to-assess and how/when they are highlighted
Workforce models: with community and social care partners, develop a sustainable workforce model which meets local population health needs and is achievable with local resources
High-level process: agree what the high-level discharge-to-assess process is which balances discharge efficacy with clinical risk
Technology aspirations: be clear on where technology will help (with both current and potential future systems)
Launch the program of change: take the time to engage with a broad range of stakeholders to lay out the overall aims of the discharge-to-assess program and how it contributes to the aims of the organisation, including:
Vision expected outcomes, and expected timelines: establish what success looks like from an outcome perspective (for example, number of patients remaining in the acute setting with no right to reside; 7-day re-admission rate
Leadership team & resource: ensure that there is sufficient resource ring-fenced to deliver and manage the work, and that senior leaders are actively supportive
Govern and track effectively: embed discharge-to-assess governance within the existing board and directorate mechanisms to ensure its visibility
Communicate plans and progress
Establish portfolio of work: the maturity matrix and case study examples will suggest a wide range of work to be done. It’s important that any portfolio and phasing is chosen which reflects the need and resources available, including:
Pilot and refine: choose 1-2 specific patient groups or services on which to pilot the design where there is both a clear need and support for discharge-to-assess; learn from these pilots and moderate the initial designs as necessary and remember that “getting it right first time” doesn’t apply in this situation! Learning and adapting is part of the process. To aid this, you may want to instigate regular learning cycles (such as Plan-Do-Study-Act) and daily management meetings
Embed and roll-out: broaden the scope of patients and services for whom discharge-to-assess is available, building on the learnings from the pilots (in 1 or 2 further phases)
Business case development: when investment is necessary, put together a robust business case (using recognised approaches such as the HM Treasury 5-case model)N.B. when engaging in technology-driven change, it is very important to ensure that practices are “digital-ready” before they become digitised so take the time to improve ways of working before the technology is available. It is value destroying to embed poor current practice within a new system. Many organisations, therefore, go through two phases of transformation: pre-tech and post-tech availability
Train, support and reward those involved in delivering this new way of working. The pilots will establish local standard methods and learnings. These should be documented and shared with groups involved in subsequent phases of roll-out. The pioneers who drive the change should be given the reward and profile that it deserves.
Communication progress, learnings, and successes, including regular broad updates and particular highlights. Appreciation of the efforts of everyone involved could be included within monthly and annual recognition systems.
Keeping people healthy and returning them to their usual home after a hospital spell is a key ambition for all those involved in health and social care. There is an even greater imperative to do so given the pressures on the system now (be they workforce, elective backlog or capacity constraints). Discharge-to-assess, enabled by technology is one of the ways in which we can work together to ease this problem. Many organisations are already making this work. We hope that these four articles can encourage more progress for the benefit of citizens and health and social care workers alike.
For a free Discharge-to-assess consultation, please contact us for an initial conversation with our consultants.
As the first article in this series highlighted, too many people are spending too long in an acute setting, well beyond the point of clinical need. One in six beds in these hospitals are occupied by patients who would be much better served in their usual place of residence.
Furthermore, with an elective backlog of almost seven million, one in eight people across England are currently waiting for operations and other types of care, and ambulance response times are at an all-time worse. Unprecedented operational challenges are anticipated for the winter period.
Therefore, it is imperative that post-discharge short-term health and care services increase in capacity, improve in quality and effectiveness, and can support system flow for both urgent and emergency care and elective recovery. Indeed, the new Prime Minister Rishi Sunak has made tackling delayed discharges a key priority and ensuring there is an available workforce in the community to deliver timely care.
To support the safe and timely discharge of patients from hospital and to ensure that people continue to receive the care and support they need after they leave, a wide range of supportive material has been produced grounded in research and practical learnings of existing Discharge to Assess (D2A) models. The Department of Health and Social Care (DHSC), Local Government Association and the Association of Directors of Adult Social Services (ADASS) have all released guidance for organisations and local systems on implementing best practice Discharge to Assess and community support. These include:
Managing transfers of care – A High Impact Change model: Local Government Association (2020)
Hospital discharge and community support guidance: Department of Health and Social Care (2022)
From the various national guidelines, alongside discussions working with a number of organisations and systems around D2A, Akeso has developed a D2A and community support maturity matrix. This helps organisations (for example, acute trusts, local authorities and ICSs) to understand what needs to be in place for D2A to work well. There are 36 factors across 7 different domains which all need to be in place,
The 7 domains, as part of a high-level D2A operating system are set out below:
Key ‘essential’ D2A priorities we recommend organisations focus on, which can be delivered in a phased approach to implementation include:
Short term (0-2 months) Discharge Planning: Setting up consistent processes, ensuring early multi-disciplinary engagement and planning for discharge on admission. This is something that organisations could be progression before winter.
Medium/longer term (2-6+) Integrated Team Working: Potentially has the biggest impact for patients and covers 25% of D2A best practice initiatives. Includes systems optimising workforce capacity acute, community and social care settings, for example from joint team working and a pooled workforce
Medium/Longer term (2-6months+): Virtual Wards: Implementation of a tech enabled virtual ward, would require the appropriate infrastructure, funding and resources to be in place, which has shown to improve patient experience and nursing and clinical workforce productivity
As set out in the D2A operating model, D2A priorities would need to be underpinned by robust leadership and governance, and vitally, the appropriate D2A system-wide culture.
Using this framework, we have also developed a more detailed assessment matrix which allows any organisation to assess their current level of maturity against these factors. Details of what “best practice” looks like across these different factors are shown below.
D2A and Community Support leading practice
We recommend that, as an organisation continues to develop its D2A capability, it uses this D2A maturity matrix to inform the programme of work that is required. To request Akeso’s D2A maturity matrix, and if your organisation requires any support in implementing D2A best practice initiatives, please contact Mike Meredith.
In addition, based on the D2A maturity matrix, Akeso have put together a short D2A survey for D2A leaders, Organisations and system leaders. Organisations and systems completing the survey will receive a tailored benchmarking report against their peers.
The next article in this series will focus on how technical innovations, for example tech enabled virtual wards, can improve patient experience and discharge effectiveness, followed by a D2A implementation guide.
When the new Health Secretary, Therese Coffey, was appointed she detailed her priorities for the NHS. These were A, B, C, D, or in other words, ambulances, backlogs, care, and doctors and dentists.
Critical to the current challenges facing the health system is the ability to create and ensure bed capacity. Currently, one out of every six beds are taken up by a patient who no longer requires it. Furthermore, without this bed capacity, it will be impossible to deliver the ambitions of NHS England’s CEO Amanda Pritchard’s around recovery, reform, resilience, and respect (her “4 Rs”).
With an elective backlog of almost seven million, one in eight people across England are currently waiting for operations and other types of care, and ambulance response times at an all-time worse. Unprecedented operational challenges are anticipated for the winter period.
One of the Government’s responses to this problem is the new Discharge to Assess (D2A) programme. This aims to discharge a greater proportion of patients when they no longer require the direct support of an acute bed. They may require further care but can have their longer-term care and support needs undertaken in a more appropriate setting. Four pathways have been established within this D2A programme. They are summarised below.
As in any production flow environment, effective and efficient flow of D2A requires a balance of push and pull on the Hospital and Local Care Organisations respectively.
Reasons Behind Delayed Transfers of Care
Before looking to implement solutions to enable the D2A programme, it is imperative to understand the current and historic blockers to discharge. Analysis of delayed transfers of care data highlights these blockers as well as historic performance. Since 2010, there has been a 75% increase discharge delays measured by the increase in volume of additional hospital days resulting from delayed transfers of care.
Due to COVID, and the subsequent operational pressures, DTOC data is no longer published by NHS Digital. In 2019/20, there were 1,600,000 additional hospital days generated by delayed transfers of care.
The most common reason for these delays was the lack of capacity within the residential or nursing care home setting (ARNHP) accounting for a quarter of all delays. The two next greatest discharge blockers were the need to wait for a care package (ACP, 21%) and the need to wait for further non-acute care (AFNAC, 18%). Both of these blockers can be theoretically readily addressed by the discharge to assess programme. However, the ability for systems to combat the greatest blocker, a lack of capacity within the residential or nursing care home setting, in regard to D2A programmes should be carefully considered.
Current Discharge Performance
National data shows that current discharge performance across England varies widely and is significantly below NHSE’s target of discharging half of those with no right to reside, with an average discharge performance rate of 43%. This equates to almost 3,000,000 instances over nine months where a patient was eligible for a discharge but remained in hospital. Or, in other words, 12,000 patients everyday remain in hospital when they should be discharged.
Furthermore, London is the only region achieving a discharge rate of half of patients who are eligible at 53%. All other regions are below this threshold. The South West and North West regions have both been operating at an average discharge rate of 34%. In fact, London is the only region performing stronger now than in winter 2021.
Analysis at an ICB-level portrays a similar message; performance is widely variable. On one hand, the highest performing ICS, Northumberland, Tyne, and Wear achieved an average discharge of 73%, whereas the lowest performing ICS, Birmingham and Solihull, achieved 17%.
Only 14 of the 44 ICS’s achieved an average performance rate of above 50% (full details of discharge performance by ICS can be seen within the appendix). Moreover, the South West region were the only region not to have an ICS currently meeting this target.
We further analysed discharge performance in terms of acute trust type which identified no significant trend. With exception for multi specialist trusts, performance follows the same profile. Regarding the scale or of Trust, suggesting that the economies of scale for large acute trusts, or the localised focus of smaller trusts, are not factors in discharge performance.
When looked at Trust level, there is again wide performance variation. The top-5 performing Trusts average ~78% discharge performance, whereas the bottom-5 Trusts average ~16%.
Responding to the discharge problem
Analysing the top and bottom-5 trusts in greater detail, it is apparent that Trust from all regions and types feature at both ends of the spectrum. The question, therefore, is what does this tell us about how providers can better respond to their discharge problems?
In answering this question, it is important to acknowledge that the analysis clearly points to this issue being universal. That is to say that discharge performance is not seemingly affected by geography, locality, Trust type or provision, or indeed by system, evidenced by wide ranging variation with ICS’s. The responses to the problem can therefore not be generic in line with the above factors. They must be organisational specific, in line with providers individual caseloads, models of care, and local leadership.
Various supportive materials, based on research and practical learnings from existing discharge-to-assess models, have been produced to encourage the adoption of discharge-to-assess principles in health and social care settings, in an effort to reduce the number of patients in acute settings with no right to stay.
All of this material has been summarized by Akeso into one useful framework. The next article in this series will focus on this framework designed to help ICSs and other organizations better understand what D2A requires in order to be successful.
 Akeso analysis of NHSE reported Delayed Transfers of Care, 2010-11 to 2019-20 – Number of Delayed Days during the reporting period, Acute and Non-Acute, for NHS Organisations in England by the type of care that the patient was receiving. https://www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/delayed-transfers-of-care-data-2019-20/
 Akeso analysis of NHSE reported Covid-19 Daily Discharge Situation Report – All patients for 29 November 2021 – 30 July 2022. This data contains all inpatients 18 and over, including critical care and COVID-19 positive patients, but excluding paediatrics, maternity, and deceased patients. This includes data for acute trusts with a type 1 A&E department. Mental Health Trusts, specialised Trusts (including Children’s and Women’s Trusts) are not in scope of this collection.
Even before the pandemic began, demand for diagnostic services of all types were rising and, in some cases, outstripping capacity. Covid-19 has exacerbated this problem, deepening the diagnostic backlog with knock-on effects for cancer and elective care.
However, it has also demonstrated what is possible. Seemingly complex changes were implemented at a pace not seen before, transforming services within a matter of weeks to ensure they continued during lockdowns, whilst incorporating Covid-minimisation measures.
Although the challenge of catching up with the diagnostic backlog is a steep one, it presents similar opportunities to deliver much-needed long-term change in diagnostic services.
Reshaping diagnostics for the new normal
The challenges created by Covid-19 are ongoing and require new and sustainable solutions. Standard diagnostic pathways have remained the same for many years, despite the fact they are often inefficient both for the NHS and its patients.
But the drive to develop a system that harnesses new ways of working and new technology has already begun. This includes more than 40 new community diagnostic centres that are currently being rolled out by NHS England and set to provide around 2.8m scans in their first full year of operation. Situated in a range of settings from local shopping centres to football stadiums, they are designed to give patients more direct access to the full range of diagnostic tests closer to home.
Crucial to the success of many of these initiatives, will be the relationship between the community and acute services. The transition to integrated care systems (ICS) will help to create this, but a truly interconnected system will still require wider change.
An independent review of diagnostics services for NHS England recently outlined the key components of a new service delivery model. This article explores some of its recommendations and the barriers Trusts need to overcome to achieve them.
What could the future of community diagnostic services look like?
There are three key models to transforming community diagnostic services.
Optimal care pathways
Building on established pathways through existing community support, such as pharmacists, opticians, and phlebotomy services, is one model of delivery that realises the benefits of a greater separation of acute and elective diagnostics.
This provides patients with quicker and more convenient access to care closer to home or work, whilst relieving pressure on acute sites. Telephone and virtual consultations are also expected to play a much larger role in diagnostic services in the near future.
Optimising these established pathways brings a range of challenges which Trusts need to consider, including:
Financial arrangements – Ensuring the commercial arrangements are cost-effective and attractive for the commissioner and the service provider, is important in order for services to run smoothly. A comprehensive activity forecast and tested commercial model is critical.
Care boundaries – Optimising care pathways should involve eliminating the boundaries that still exist in the care system. The transition to an ICS model will play a key role here. As will an effective commercial arrangement that gives the patient true flexibility and choice on where they receive their care in the community.
Collaborative working – Integrated care requires collaboration on all fronts. Often parity of esteem or an assumption of vested interest builds barriers between professionals. Ensuring clinical professionals are engaged and introduced at an early stage will help alleviate this.
Public perception – With the introduction of any new service model, comes the requirement for change management. Fear of a patient backlash often deters Trusts from doing this, but regular patient engagement and feedback is vital.
Social value – An area of increasing priority, the service provider should demonstrate how they will aid recovery of the local community and economy through employment and training, as well as community support.
Community diagnostic hubs
There is an opportunity to develop new diagnostic service models outside the existing Healthcare landscape that are more responsive and innovative, such as community (or remote) diagnostic hubs (CDHs).
They provide a one-stop shop for patients requiring potentially life-saving diagnostic tests closer to home. As noted earlier, centres that deliver this kind of service are already being rolled out and have begun combatting the impacts of Covid-19.
Their numbers and the services they offer are set to grow over the next five years in a bid to reduce the pressure on acute care. In the near term, non-invasive diagnostics are the most viable, but with developments in technology and practice, there will be an increase in more time-consuming, invasive diagnostics in the community.
As part of this initiative, Akeso & Co has supported leading specialist Trusts to implement CDHs in recent months. There are several key challenges to consider during this process to ensure a successful implementation:
Strategic vision and scope – Fully define the strategic objectives for the hub before implementation. This will inform the scope and operating model as well as support timely decision making and evaluation.
Patient need – Identify who the hub’s patients will be and what their needs are. Every aspect of the service model and patient pathway must be built around this.
Project management office (PMO) – Robust planning from the outset is critical to the success of the project implementation. With involvement from multiple stakeholders, capturing dependencies at each stage will not only ensure the Project is delivered on budget, but also prevent surprises further down the line.
Resourcing – Identify and engage with the right people early on. Collaborating with clinical and operational people across the organisation, who have the right expertise and experience to implement a new service model will avoid potential setbacks.
Capacity modelling – Model patient activity across the whole patient pathway. Capacity within the CDH must align with the Trust’s internal capacity. This may be dependent on the capacity to book patients’ assessments and follow-up consultations.
Service resilience – In light of Covid-19 ensure the safety of patients and service resilience by reviewing patient flow and infection control.
New diagnostic technologies
Innovation is advancing rapidly in areas such as genomic testing, point-of-care testing and the use of artificial intelligence for imaging, endoscopy, and wearable devices. These have the potential to transform the service diagnostic hubs can offer.
Historically Healthcare providers have been slow to adopt new technological innovations. That is why it is important to explore the most effective way to introduce them. Here are some considerations to bear in mind:
Clinician uptake – Clinicians need to be encouraged to trust the integrity of new technology and move away from established processes.
Patient awareness – Patients must be supported to understand and adopt new technology. Striking the right balance between a face-to-face and digital service is vital.
System interoperability – New systems and equipment will need to exchange information seamlessly. Clinical data comes in a variety of formats and terminology, which means standardised catalogues will need to be developed for complete interoperability.
Safety – Safeguards must be put in place to ensure data compliance, and Healthcare workers are given the time and knowledge to implement them.
Combining these elements will create community diagnostics services that can rise to the challenges created by the pandemic, while also improving patient care.
By considering the key factors mentioned here at the outset, Trusts will be able to successfully implement and operate each element successfully.
As experts in delivering high quality solutions to the Healthcare sector, Akeso & Co has a track record of supporting Trusts to do this in a way that develops the effective diagnostic services of tomorrow. To find out what we offer, get in touch at email@example.com
Akeso & Co supported Homerton University Hospital Foundation Trust (HUHFT) in the design and implementation of a Scan4Safety Programme and Inventory Management System (IMS). Captured in a detailed business case, the initiative is set to drive significant operational efficiencies and improvements to patient safety and care.
Homerton University Hospital Foundation Trust (HUHFT) is a major NHS provider of acute care in the London Borough of Hackney. With services spanning 75 locations across East London, including approximately 450 beds, 11 wards, three day-surgery theatres and six main operating theatres, HUHFT has a complex set of services and supporting supply chain.
Following a thorough opportunity assessment, a number of challenges were identified with regards to the current operations, accumulating in clinical time wasted, health and safety risks, as well as opportunities for cost improvements.
Some of the key challenges identified include:
Inefficient and inconsistent supply chain processes across wards and departments
Lack of visibility and control of inventory levels due to limited reporting capabilities
Segmented spending on products and consumables across wards and departments
Limited traceability of theatre implants through the supply chain to procedure due to manual processes
Strained working relationships between clinical and material management staff
To address the challenges identified, the project recommended HUHFT would benefit significantly from a Trust-wide IMS to improve inventory management and achieve patient-level costing. We supported HUHFT through a three-phased approach from business case development through to successful implementation.
Phase 1) Secure investment through a robust business case
With the support of key HUHFT clinical and operational stakeholders, we developed a compelling business case and secured the required backing to proceed to procurement. Through a detailed appraisal of the potential qualitative and quantitative benefits and risks, it was identified that implementation of a trust-wide IMS could deliver £1.4m in benefits over the next five years, from an initial £469k one-time investment.
Phase 2) Source and partner with the optimal provider
Following a route to market assessment, we facilitated a phased procurement process through a formalised ‘mini-competition’ to assist the Trust in their rigorous selection of a suitable IMS provider. Through taking this approach, we were able to secure an optimal solution balancing system capability and total five-year cost.
Phase 3) Implementation through rigorous PMO and change management
We project managed the implementation of the new IMS and change management of associated processes encompassed within the Scan4Safety programme, reporting to the patient safety board. From the outset, programme governance was implemented to ensure the new system and its related benefits were achievable and sustainable. This involved the recruitment and setup of a programme board of Trust directors, and the chairing of regular meetings and presenting programme updates at Trust-wide Scan4Safety engagement sessions.
The full benefits of the IMS solution will be seen during the next five years but it is already delivering significant savings and process improvements.
The one-time investments equating to £469,000 and subsequent improved processes is expected to generate £1.4m in cost savings, including:
In addition to the projected quantitative benefits, implementation of a Trust-wide IMS is also expected to deliver number of qualitative benefits, including:
A reduction in the likelihood of ‘never events’ thanks to the patient level costing functionality which improves the traceability of implants, surgical instruments and medical equipment.
The release of up to six clinical WTEs, allowing them to re-focus on patient facing activities.
Automated processes, such as Barcode-driven ordering, that drive efficiencies in areas including procurement and recall.
Additional management information insights that enabled further efficiencies.
Increased clinical confidence in supply chain processes.
Compliance with GS1 and Scan4Safety.
What is next for HUHFT?
Following the success of the IMS and Scan4Safety pilot programme, HUHFT will continue to drive adoption of Scan4Safety to extended use cases, including potentially Blood Transfusion Scanning, Pathology samples, eMedicine, and many more.