Pulling out all the stops: How a focus on whole-system flow can drive greater collaboration and improve quality | Bryan Jones

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There’s much to gain from improving the way patients, staff, information and resources flow between services and organisations, writes the Health Foundation’s Bryan Jones.

Healthcare today is all about cooperation. Everywhere you look new networks, federations and communities of practice are emerging. 

Acute providers that once had little inclination, or, they argued, the time to look beyond their own walls are forging ties with their primary and community care neighbours. Multi-professional working, once the exception, is now the norm in many parts of the NHS. And innovative ways of capturing and using data from multiple organisations are now being developed. 

All of this activity is helping to improve the quality and safety of patient care. But there is still plenty of work to do. 

Many of these fledging collaborations are still feeling their way and are a long way from being embedded into the healthcare landscape. Overcoming the legacy of 70 years of siloed working within the NHS and professional divides that often go back even further is far from easy. Nor are there any shortcuts or quick fixes: mandating collaborative working, or trying to force the issue through structural change, doesn’t work – this much we know from previous re-organisation attempts.

So what can we do to build on what’s been done to date and galvanise the rest of the healthcare system? One area of real potential is flow, or more specifically, the way in which patients, staff, information and resources flow between services and organisations. 

Patients and staff working at the frontline encounter the effects of poor flow every day. Stark examples of a lack of smooth flow include ambulances queuing outside hospitals, crowded emergency departments, long waits on trolleys for a bed and delayed hospital discharges of frail, older patients. 

All of this waste, delay and duplication is stressful and frustrating for staff and can be devastating for patients and their families and carers. It is also a grossly inefficient use of health service resources and capacity. 

In short, flow is an issue that matters – or ought to matter – to everyone with a clinical, managerial, strategic or support role within the NHS. If we want the still disparate elements of the system to work together, then a focus on flow could have a vital role to play. 

While many providers in England have sought to improve flow in some part of their organisation – by trying to match capacity with demand and tackle bottlenecks – most efforts have been fairly small scale, and many have not lasted. Efforts to improve ‘whole-system flow’, the coordination of all processes, systems and resources across an entire local health and social care community, are, unsurprisingly, much rarer.

Nonetheless, there is plenty of encouragement – and, of course, learning – to take from those bodies that have sought to improve flow on a larger scale. For example, work supported by the Health Foundation at Sheffield Teaching Hospitals NHS Foundation Trust and South Warwickshire NHS Foundation Trust through the Flow Cost Quality programme has delivered sustained reductions in emergency care length of stay, bed occupancy and readmissions, while improving safety and the patient experience. 

One of the most important lessons from the Flow Cost Quality programme is that improving flow is much more than just a technical challenge. Behaviours and relationships matter just as much, if not more. The ability of organisations and networks to foster a culture of learning – one where staff accumulate knowledge and insights and have the licence and support to use them to improve services – is absolutely crucial. 

Another critical lesson is that sustained improvement requires a lot of resilience and hard graft. It takes time and resources to map the system, identify where the constraints are and carry out tests of change. Making the case for change and getting support at each level of the system is equally demanding. 

This is a daunting challenge at a time when resources are tight and the workforce is stretched. So what can local healthcare system leaders realistically achieve in the current climate? 

This question is one that our fringe session at Confed17 will be looking to answer. During our session we will be highlighting a range of flow-related projects and approaches that have been successfully implemented across the UK, and describing a comprehensive new framework for improving whole-system flow that has been developed by the Health Foundation and the Advancing Quality Alliance (AQuA). 

We will also be showcasing some of the insights to emerge from a new cutting-edge project led by the Royal Academy of Engineering and the Royal College of Physicians that aims to better understand how systems engineering could be used to improve design and delivery of health and care.   

We are confident that new thinking and tools to emerge from this work will go some way towards helping local healthcare system leaders grapple with the difficult but critical challenge of improving whole-system flow. 

Bryan Jones in an improvement fellow at the Health Foundation. Follow the organisation on Twitter @HealthFdn

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