Planning for winter pressures with the backlog at record levels, acute bed shortages and A&E demands still major disrupting factors – advanced, agile capacity planning is vital if we are to avoid fire-fighting throughout the winter.
Although we’re currently basking in the finally arrived summer sunshine, many trusts are starting to plan for winter and for what the increased patient influx will mean for them. Will anything change between now and then? Will the current pressures being seen by ambulance services, ED’s and wards make it seem like last winter never ended?
We are continually bombarded with reports that the NHS has a shortage of beds, which appears to be the case when we compare ourselves against other countries. The latest OECD data*[i] shows the UK has 2.34 beds per 1,000 population, while Germany has 7.82, France 5.73, while Sweden has 2.05.
While beds are clearly a factor for the UK, a combination of other contributing issues include staff shortages, Covid restrictions and emergency departments that are not large enough to manage the numbers attending. Plus, the relentless increase in occupancy rates is resulting in hospitals being unable to maintain effective ‘flow’, with many exceeding 95% in the pre-pandemic period.
During the pandemic, occupancy rates fell due to infection control procedures, rapid discharges, and a reduced demand for services. Data released by the NHS indicates that bed occupancy levels are again increasing in England and are now generally recognised to be excessive.
Winter 2022-23 demands and the backlogs
No one knows yet what Winter 2022-23 will bring. Will it be increased admissions again through Covid, a flu outbreak, higher levels of elderly respiratory and cardiac conditions exacerbated by huge increases in the cost of domestic heating, or norovirus? The list is almost endless, and the risks to outcomes are real and potentially significant.
In addition to the pressures from emergency and non-elective activity, the NHS is striving to clear the backlog of planned elective activity following the pandemic. In April 2022 there were 6.48 million waiting for care, with many waiting over two years for treatment. And treating these patients is the same workforce and the same physical resources. Somehow, we need to manage the continued surge in emergency and non-elective activity.
Insource provides expert analysis and proactive planning
Although Insource can’t eliminate the problems for trusts, we can provide expert analysis to support proactive planning that identifies where and when the critical periods are likely to occur. This gives the organisations time to work up mitigating options to alleviate pressures, rather than being purely responsive in declaring red or black alerts.
While the NHS may suggest anything between 85% and 92% occupancy is ‘optimal’, there is no number that can possibly be correct everywhere, and (to add to the confusion) occupancy statistics are based on midnight or 8AM ‘bed-states’. This is taking a snapshot at a point in time where fewer beds than average would be occupied.
Forecasting predictable and unpredictable demand
At Insource, we use recent activity patterns to forecast predictable demand, and the likelihood of unpredictable demand, over the coming weeks. We then model this data to highlight where the crisis points are likely to occur. Bed occupancy exists to absorb the unpredictable variation in demand, and our model reveals this for each service.
Assigning acceptable risk
We then discuss with operational and clinical leads and decide on the acceptable risks of putting non-elective patients into overflow bed areas (such as elective beds, assessment areas, day-case units), and understand the bed occupancy that is consistent with that. For example, the right occupancy for critical care may be 50% while surgery may be 75% and medicine 85%.
Identifying improvement scenarios
This allows the analysis to identify an initial ‘long-list’ of improvement scenarios to investigate in each bed pool to reduce risks and manage costs. These could include, identification of ‘surge’ bed availability, reduction in length of stay, improve bed turnover interval, admission avoidance, and improvement in integration with community beds and services.
Many of these options will not be unexpected recommendations, but by having the analysis of pressures at a more granular level, it allows for a more targeted and realistic approach in identifying realistic and achievable projects that will help to deliver on the shortfall.
Successful projects include
Successful projects for relieving similar pressures have included:
- Community nursing teams ‘in-reaching’ into acute wards to ‘pull’ patients from hospital beds earlier for management and care at home or in step-down facilities
- Investing in OPAT (Outpatient Parenteral Antibiotic Therapy) resulting in significant bed day savings by providing home treatment rather than hospital-based care
- Frailty assessment units to stabilise patients and return them home for community nursing care returning on a planned basis to outpatient clinics
- Improved System collaboration
Below are larger scale projects that would take time and funding to implement, but even minor changes can be effective in maintaining patient flow:
- Better management of TTO’s (drugs given to the patient on discharge)
- Tracking and chasing of patients waiting for any diagnostic tests or results
- Active management of Criteria to Reside status
- Discharge planning process starting at admission using EDD (Estimated Discharge Date)
While trusts can and will continue to develop schemes to help with winter pressures, resilience over this coming winter will only be achieved through proactive planning and organisations taking a system-wide approach to working in a collaborative manner, leveraging the strengths of all partners across the health and social care system.
See more information on our agile capacity planning solution
 * OECD (2022), Hospital beds (indicator).