There is a growing realisation that an increase in the provision of community-based care can affect the overall productivity of the health and social care system through a number of distinct ways:
The provision of community bed-based services. Our own work in the community environments has demonstrated that the total amount of disruption and delay is often much greater in a community hospital than expected. The community sector can make massive inroads into helping the acute sector through, firstly, reducing its own lengths of stay in community beds and ensuring 100% bed availability and, secondly, by working much closer with the acute sector to ensure timely discharge into the correct place of secondary care without delay.
Prevention There is common agreement across both the acute and community sectors that a percentage of emergency admissions could be avoided if there was a greater emphasis on community-based supervision of care for the more vulnerable and elderly population.
Offloading There is further evidence and examples of innovative practice which demonstrate that some types of care traditionally carried out in an acute setting can now be more effectively delivered either in the community or in a hub-and-spoke partnership between the acute and community providers.
Care closer to home There is a view that care provided in the home or closer to home is highly beneficial, particularly for the frail and elderly as well as those patients with long-term multiple needs. In these instances, home-based care removes the stress of moving the patient to a hospital environment, often in an emergency. The patient is also able to take more of a proactive and personal role in their own care and decisions about their care.
These points have created a general direction of development, which is reinforced by the high percentage of total healthcare costs that are currently tied up in the acute setting. However, without an initial improvement in productivity within the community system, it will not be possible to have an impact on the overall system without significant upfront investment. As a result, it is important to understand not just the advantages but also the operational challenges of improving and providing more community-based care.
The community healthcare system
Community-based care is divided into two different types of patient flow. Similar to the acute sector, part of community-based care is delivered through a bed base in community hospitals. A second, larger part, is the provision of community-based services that do not require a bed base. The logistical challenges and opportunities for improvement in each part are discussed below.
Bed-based care: the logistical challenges
An analysis of any community hospital will quickly reveal that there is a very wide spread in the length of stay.
This is partly caused by the wide mix of patients using this common bed base but it is also caused by the comorbidity of patients. In a community or acute hospital setting the most commonly described currency of capacity is beds. This is because beds are a resource whose availability directly influences access to care, patient flow and improvement opportunities. It is often the case that when a surge in demand occurs, the loudest cry is for more beds. When bed availability is a problem one immediately sees queues forming and rapid deterioration in the quality and timeliness of care. Management attention is then often diverted to manage the multitude of negative effects that result. On the one hand, management is under pressure to open and resource more beds while on the other hand they feel pressure to close beds to keep the finances under control.
This means that removing the unnecessary disruption and delay in this part of the system is not just key to improving productivity of the community bed base but also for improving the overall flow through the whole health system. Typically the average length of stay will be between five and ten times the average length of stay in the acute sector, and so an improvement in this area can have a major impact on overall patient flow across the whole system.
Community services: the logistical challenges
At the highest level, the objective of community-based services is similar to that of bed-based hospital services: to deliver high-quality, timely and affordable care. However, from a logistical perspective, the two systems are very different. There is not one resource group (such as beds) that has such a controlling influence on the overall performance of the system. Instead, when under pressure, many resources are stretched simultaneously and each resource is asked to cover more and more patients. A more dominant effect in this environment is a greater deterioration in service levels and frequency of patient review. This results in a more differentiated deterioration in the quality and timeliness of care; a deterioration that everyone who works in the system is fully aware of but somehow, it seems, finds it more difficult to directly measure.
Geography is another factor that differentiates the community services setting from the bed-base setting. Geography makes it difficult to gain economies of scale and soak up variations in demand through shared resources. The reality is a system that has many services being provided through many, relatively small, dedicated resource pools, geographically distributed across the region.
In such a situation where there is not a dominant controlling resource it is even more difficult to understand the current performance of any one part or of the overall system. It is also extremely difficult to measure current productivity or evaluate the size of the improvement that is possible. This often results in a plethora of dashboards measuring the performance of each and every service, making it almost impossible for senior management to really understand how the whole system is performing. Unlike in the hospital setting, where when there is a surge in demand the cry for more resources is relatively focused, in the community services setting when there is a surge in demand, everyone, everywhere seems to be crying out for more resources. In the community services setting, management attention can easily become very fragmented and it is often the case that strategic and operational decisions have to be made without a full understanding of the size of the impact of these decisions on the whole system. With the growing pressure on finances and demands to improve productivity, it becomes almost impossible to answer the important and increasingly urgent question:
'Of all the areas I could improve, which one will have the greatest impact on the performance of the system as a whole?'
One often sees managers relying on less tangible ways to check how the system, or any part of the system, is performing. For example, if volumes increase by, say, 5%, and the service immediately falls into crisis then it is often assumed the system must be near to full capacity. However, if volumes increase by 30% and service levels remain the same then maybe service levels could have been much higher or resources reduced.
A further differentiation point between bed-based and community services is that in the bed-based setting the logistical focus is on discharging patients. For example, when a patient has multiple treatment requirements and you have successfully treated two of the three requirements you do not free up your key resource (the bed) until you have solved the third requirement. In the community services setting this is often not the case: each illness may have independent completion dates and this has major implications on how to measure and improve performance. For an individual resource, the key question is to know:
'Of all the treatment plans for all the patients I could follow next,
which one should I follow next?'
The choice is much greater in the community services setting. The traditional analogy of a chain and a weakest link breaks down and what we have is more of a mesh being pulled in many different directions. Equally, finding the weakest link in this mesh of multiple chains of varying lengths being worked on by many different and different types of resources appears not so easy.
The core dilemma
Before the community sector takes on the challenge of improving the productivity of the whole system, we have to ensure we understand how to introduce a process of ongoing improvement within the community sector itself.
With the downward pressure on budgets across all parts of the health and social care system, community-based care, just like everywhere else, finds itself between a rock and a hard place. Its objective is not only to be an ever-flourishing healthcare provider in its own right, but to also take a more dominant role in improving the system as a whole. This requires providing higher quality and more timely care for the current patient pool and an increasing capability to positively impact the system as a whole. It is clear why there is such a strong call to add more front-line resources and in parts ‘pump prime’ the broader role. However, affordability remains a key requirement now and in the future, and the financial pressures start within current budgets and current pressures to reduce their own front-line resources thereby demonstrating improved productivity before there is any major further investment in offloading the acute sector.
Diagram 1: Core conflict
In this instance, the consequence of choosing one side of the conflict over the other is clearly unacceptable. Trying to create a compromise between the two is the worst choice of all: this could create chaos, not just within the community system but, as the community tries to have more impact across the whole system, the damage could be transmitted across the whole system.
We already know that saving money by closing beds in one part of the system can make the finances of that part of the system look better but there are often unintended negative ramifications to patient flow across the whole system. Equally, cutting back on services that prevent hospital admissions or failing to take actions to improve patient flow across the whole system can have a devastating impact elsewhere.
Criteria against which any solution should be judged
Any solution must simultaneously:
improve the quality, timeliness and affordability of the provision of community-based care both in community hospitals and community services
enhance the community care provider’s ability to improve the quality, timeliness and affordability of care across the whole system
achieve results in a rapid timescale
achieve results without putting at risk the current fragile state of each part and of the system as a whole
achieve results without simply asking staff to work harder
achieve results without requiring major upfront investment or waiting for a long time for the return on that investment.
An approach based on the Theory of Constraints (TOC)
The guiding principles are:
A patient-centred, clinically led approach is an essential element of the way forward.
Improving patient flow through all pathways simultaneously is the primary objective.
A focused process of ongoing improvement to balance patient flow is vital.
Removing local performance measures is essential when improving any chain of activities. It becomes non-negotiable when improving multiple interacting chains of activities.
Outlined below are the practical steps to deliver this approach
For each patient create a clinically-based expectation for the timeliness of their care need. In the community bed-based setting this is a simple planned discharge date and in the community services setting this should not only take account of the timeliness of the completion of the care but also, in some instances, the frequency of delivery of the care.
Use the proven TOC-based time-buffer management principles to:
identify and remove the causes of disruption and delay within each service in a rapid timescale
identify and remove the causes of disruption and delay between the acute and community sector in a rapid timescale
transfer these gains in ‘free capacity’ into higher quality and more timely care by removing backlogs and freeing up front-line staff to treat patients rather than manage the queues
identify and exploit those opportunities where an integration of resources would create the fastest improvement in performance for the system as a whole. In community bed-based services this should be driven by reducing the total length of a patient’s stay across both the acute and community bed base. However, in the community services environments it is the identification of resource integration opportunities that is key. This is because of the apparent complexity and the geographical distribution of the provision of care in the community. In our experience time-buffer management and a TOC-based analysis is the only way to identify and exploit these key leverage points and rapidly improve the performance of the system as a whole.
Provide the basis of a throughput-based measurement system that will enable management to understand the performance of both the bed-based and service-based parts of the system and the system as a whole; in particular, to be able to answer the following key questions:
'How well is the system performing and what opportunities remain to improve the performance of the system?'
'Of all the things that could be changed, what should be changed?' (Identifying those few key areas that will have the biggest impact in the shortest timescale.)
'What are the necessary and sufficient changes that should be implemented and how do we avoid any unintended negative outcomes both within the community setting and across the whole system?'
'How do we gain commitment and agreement to the above?'
Educate and coach clinicians to take the leadership role in the delivery of the above changes. This is a vital ingredient in ensuring the approach remains patient-centred and sustainable.
Conclusions
Community-based services have a vital role in improving the quality, timeliness and affordability of care for those patients currently treated in the community. It also has the potential to deliver a breakthrough in productivity across the whole health and social care system by indirectly impacting the productivity of the more resource- and capital-intensive acute sector.
To ensure an outstanding start to a major initiative it is vital that the first substantial actions result in immediate substantial benefits across the whole system. Improving the length of stay in the bed-based community hospitals is an excellent place to start as it simultaneously improves the productivity of this part of the system and the system as whole.
Improving the performance of the community services setting requires a different mindset to that in the bed-based environment. This complex web of interconnected activities and resources makes identifying what to change a challenge.
The secret to a breakthrough is to understand that the inherent simplicity can be accessed by adopting a ‘whole-patient-centred’, clinically led approach combined with an approach that uses timeliness of care and the TOC time-buffer management process as the starting point of a system-wide analysis and the foundation of integration activities.
The core of a breakthrough is to simplify the perceived complexity and focus on those few critical areas that are causing the most disruption within the community sector and across the system as a whole. We can then utilise those areas to improve the performance of both the community sector and the whole system.