Delays with patients being discharged from hospitals in Wales is affecting the delivery of safe care
Today, a report has been published by Healthcare Inspectorate Wales (HIW) setting out the findings of a review of patient flow in Wales. Patient flow is the movement of patients through a healthcare system from the point of admission to the point of discharge. HIW specifically examined the journey of patients through the stroke pathway. This was to understand what is being done to mitigate any harm to those awaiting care, as well as to understand how the quality and safety of care is being maintained throughout the stroke pathway.
The review used stroke patients as a case study to understand the risks and challenges that poor patient flow can have on the healthcare system, and specifically the impact on the quality and safety of services. The review has highlighted that across Wales, there are significant challenges which are having a negative impact on the efficiency of patient flow, meaning patients are not always receiving the care they need in a timely and appropriate manner. HIW has made recommendations which include the need for health and social care services to work together more effectively, to tackle these issues and improve the patient journey.
The review began in December 2021 and explores the experiences of stroke patients accessing care and treatment, from a person calling for an ambulance, transfer to hospital, assessment, inpatient treatment, through to discharge. The decision to undertake the review follows poor patient flow being highlighted within our inspection and assurance work, and the negative impact this can have on the quality of services provided.
The review findings reveal consistent challenges caused by poor patient flow throughout Wales, hindering the timely and appropriate delivery of care. These challenges are wide ranging, but primarily stem from the high demand for beds combined with the complexities involved in discharging medically fit patients from hospitals. Unnecessarily long stays in hospital due to delayed discharge can place patients at risk of hospital acquired infections or deterioration whilst awaiting discharge. The bottleneck at the point of discharge has a knock-on impact on emergency departments, ambulance response times, inpatient care, planned admissions and overall staff wellbeing. These challenges are wide ranging; the high demand for inpatient hospital beds combined with the complexities with discharging medically fit patients from hospital, leads to the inpatient healthcare system across Wales operating under extreme pressure.
A key area requiring improvement identified by our work, relates to the need for healthcare services to engage with people, to better understand the barriers to them accessing or choosing from the range of healthcare services available in Wales. The range of healthcare services includes pharmacies, Minor Injury Units, mental health helplines, online NHS consultations, and the NHS 111 Wales service. Ongoing engagement with people about the range of available services may reduce the need for people to attend their GP surgery or Emergency Department (ED) when their health concern is not an emergency.
It was positive to find that patients suspected as having had a stroke, were prioritised for ambulance handover, and transferred into emergency departments promptly in line with the stroke pathway. However, we found that achievement of the Welsh Government 15-minute target for handover of stroke patients was challenging. This target aims to ensure that time critical investigations and treatment are undertaken promptly to ensure the best outcome for patients.
Due to pressure on bed numbers, it was not always possible to move patients to the most appropriate ward or specialty for their care. Patients who are not allocated to the right bed or ward, can at times experience an increased length of stay. This may lead to other complications, creating additional challenges for care teams and adding to the issue of poor flow. A stroke patient who has been admitted to hospital is likely to have a much better outcome if they are treated on a stroke ward.
HIW found good collaborative working between the stroke multidisciplinary teams in relation to patient discharge preparation. However, a key issue which significantly impacts on patient flow and overall patient progress, is the delayed transfer of care and discharge for patients who are medically fit to leave acute care. This can be due to availability of care home beds or social care and rehabilitation therapy provided within the home.
HIW’s review indicates that health and social care services are not operating as effectively as they could be. This inefficiency increases the risk of complications arising from delayed discharge and has a significant impact on the overall health and care system in Wales. However, some positive initiatives and approaches were also identified by our review, and these should be considered across Wales as services attempt to tackle the problem of poor patient flow. For example, in some health boards, a Hospital Ambulance Liaison Officer (HALO) was present during patient flow meetings, to discuss handover delays which had a positive impact in managing the issues associated with delayed patient handovers from ambulance crew to emergency department staff.
As health and social care services continue to face unprecedented demands, with staff working tirelessly to provide safe and effective care to patients, it is clear that renewed efforts are required from the health and social care sector, alongside Welsh Government, to tackle the issue of poor patient flow.
Healthcare Inspectorate Wales Chief Executive Alun Jones said:
‘Improving patient flow improves the patient experience, improves outcomes, and minimises waits and delays.
I am pleased that our work has enabled us to identify areas for improvement, and to highlight areas of good practice. Not just in relation to the stroke pathway, but for all patients. What is crucial now is that all parts of the health and social care sector work together as effectively as possible to address poor flow and achieve better outcomes for patients in Wales.
I want to take this opportunity to thank staff working within health and social care services who strive to provide safe and effective care. Their dedication and commitment provide a strong and positive basis upon which to improve.’