Having the correct capacity in healthcare is crucial to delivering an effective timely service as discussed in a previous blog on restoring healthcare. Understanding the true demand (not just the waiting list) and how it matches to the capacity available is core to planning a service in a timely, clinically appropriate and patient focused way. This can be determined based on physical facilities, workforce capacity and service capacity. Previous blogs have looked at understanding the data and the human capacity. The COVID-19 pandemic has exacerbated the already chronic condition of prolonged waiting times in elective care and waits in emergency care and admission. We have seen challenges to all types of capacity – Physical (e.g. beds), workforce (intensive care staff), service (e.g. PPE). Some of the backlog has occurred because services have completely stopped but others have been because of a mismatch of the availability of physical services, workforce and service capacity. The official data for England is available here.
In the last few weeks, we have also seen hospitals where the outpatients clinics have not had full waiting rooms and patients are seen quickly and effectively. How have some hospitals achieved this?
In this blog, we will look from the perspective of a patient referred to an orthopaedic team for chronic knee pain requiring a knee replacement, to illustrate issues and provide some potential digital solutions that are already in use in some parts of healthcare or in other sectors.
My journey might currently look like this:
- It takes me several weeks to get a GP appointment
- I am reluctant to book an appointment with the GP because of my perception of the many phone calls and long delays in the system
- I book an appointment with the GP for my long-standing pain but must compete with daily urgent cases to get an appointment with my own GP
- GPs lose time to increasingly lengthy referral forms
- GP referral to first outpatient appointment delayed by 4 weeks
- My referral delayed due to technical problems
- My referral is “lost” as it is sent to the wrong specialty
- Service requirements have changed, leading to a bounce-back needing re-referral by my GP
- The hospital has chronic long lists, but my GP is unable to refer to another hospital close by with shorter lists
- Outpatient review and additional investigations needed
- Significant wait times due to poor utilisation/organisation of available clinic space
- Clinic frequency reduced from 3x week to once a fortnight due to other pressures, but I cannot be moved from that waiting list without going back to my GP
- Imaging and investigations not pre-ordered and so are only determined after my first visit and held up due to back log or system issues, so I need multiple visits to the hospital
- Follow up appointment to arrive at a diagnosis and decide on treatment options
- My follow up appointments are delayed because they prioritise new referrals
- Investigations and follow ups not joined up, needing further appointments, only some of my tests are available, so I need yet another appointment
- Follow ups lost to the system requiring me to phone up to chase up on my appointment
- The start of treatment
- Delayed admission letter leading to letters arriving after the admission date or so soon before that I cannot rearrange work and home commitments
- Admission delayed or cancelled at short notice due to ward capacity issues
- Theatre capacity underutilisation leading to discharge and re-admission
- Follow up appointments following treatment
- Delayed to accommodate new patients and first follow up patients leading to post-operative patients having follow up delayed beyond the recommended follow up period
- I attend ED or UCC for post-operative queries
At each of these steps there is the mismatch of capacity, workforce and resources. Clinics can sit empty because the staff is not available while another specialty has staff but no clinic space on that day. Fixed room or bed allocation leads to inflexibility. This in turn can lead to decreased resilience when a surge of activity happens. Disparate systems and processes across widely varying health systems leads to a plethora of information but a lack of understanding or clarity.
Trying to understand the true capacity and waiting time for care pathways, elective admissions and bed capacity has always been a dark art. This problem is more prominent than ever in the context of the ever-changing environment of the current COVID-19 pandemic. But the creation of COVID-secure intensive care beds, while maintaining urgent elective and emergency care, has shown it is possible to rapidly transform hospitals wholesale, to meet a rapidly changing crisis. Inter-hospital co-operation and shared resourcing has been a significant factor in enabling the resourcing and staffing needed to fulfil these surge beds. Some hospitals were able to surge critical care capacity by over 300%.
Taking the lessons learned from the pandemic into the “new normal”, how do we create a new empowered health service within the current system to expand our capacity and improve our flexibility long term? Take the above example again. But instead of waiting more than 12 months for treatment, the patient can be seen, treated and discharged in less than 3 months; we can create a more robust and more streamlined health system.
So how could we ensure that there is physical space for the clinical activity required?
- Unified digital systems
- a. Connected care systems pull patient data from the cloud across healthcare organisations to reduce the administrative burden on care staff and increase their availability for direct clinical care.
- Resource management systems will automatically ensure that results are reviewed as soon as available and free physical space by avoiding multiple clinic appointments (often caused by results not being available or further tests being required).
- More consultations are undertaken virtually so that physical space usage is improved.
- Predictive analytics continuously update the capacity model to ensure that varying demand is met. For example, the number of joint replacement clinics may be predicted by the number of first presentation to the GP with knee pain a year before. The concept of annual business planning is replaced by a more flexible approach based on mathematical modelling of actual and predicted demand.
- GP appointments unavailable for 4 weeks
- Systems allow the patient to see where there is a space available and to choose between travelling a further distance, the timeliness of the appointment and the specific clinician they see
- Patient is offered an augmented digital consultation to review, diagnose and refer at an earlier date
- GP referral to first outpatient appointment
- All referrals including community referrals through a unified national or regional system that electronically links patient details, clinical history and lists key details needed for referral.
- Automated referral systems ensure the correct investigations are undertaken prior to the appointment
- Automated prioritisation of cases can offer the patient timelier care by knowing where capacity is available
- If a resource is no longer available (e.g. staff sickness, estates issues) then the patient can be automatically reallocated an appointment and other dependent resources reallocated.
- Outpatient appointments and investigations
- Specialists work cross site and therefore are not restrained by physical capacity of one location. Digital enables them to have all the information they require at any location.
- Similarly for investigations, patients can opt to have their scans and tests done at a different location at an earlier time in the knowledge that it will be available to the clinician wherever they are located.
- More one-stop clinics are enabled by predicting the resources required for that presenting complaint using AI analytic.
- The start of treatment
- Hospital systems flex capacity to move patients to appropriate beds sooner to expedite speciality care and reduce stay durations.
- Smart theatre scheduling coupled with real time bed locations and AI powered facilities management enables patients to be transported and treated more effectively.
- Follow up appointments following treatment
- Follow up protocols start immediately out of theatre based on predefined follow up and rehab needs to book outpatient appointments, physio follow up and order any equipment required – these are all booked automatically
- Wearable devices and home-based gait analysis allow more therapy to be monitored and administered remotely. AI analysis of the data can enable automated feedback to the individual during their recovery, maximising their opportunities for self-care and decreasing the need to attend a clinic
The need for bigger, better, smarter facilities is obvious. However the underlying message is clear; to integrate all healthcare systems from primary and community care to tertiary care starting with cloud connectivity, APIs, green IT and rationalisation of systems across the country.
When was the last time you fundamentally reviewed a whole pathway and challenged traditional ways of thinking? What if we truly adopted a user-based design, focussing on making the journey as simple as possible for the patient? How do you find out what digital transformation might improve your patient’s experience and outcomes?
What if we did something radical? What if we designed whole healthcare ecosystems from the ground up? Can we use architectural innovations, digital twinning and knowledge of space management from the retail and entertainment sectors? Can we create modular and adaptable hospitals and treatment centres? A hospital that can be modified in a matter of hours to suit the changing health needs of the population. How would this look, and how will we ensure that we are adaptable to the health needs of the future? Will this leading-edge innovation enable us to create a system that is resilient and future-proof?
We would love to hear your views on smarter digital approaches to the utilisation of physical space in healthcare to enable after the pandemic.
David Shier is a Management Consultant & qualified, surgically trained Doctor at Capgemini Invent with a focus on strategy, innovation, operational design and productivity.
Matthew Cooke is Chief Clinical Officer at Capgemini. He spent most of his career working in the NHS as an emergency physician and was the National Clinical Director for Urgent and Emergency Care.
David is a Management Consultant & qualified, surgically trained Doctor at Capgemini Invent with a focus on strategy, innovation, operational design and productivity.
Matthew is Chief Clinical Officer at Capgemini. He spent most of his career working in the NHS as an emergency physician and was the National Clinical Director for Urgent and Emergency Care.