Rapid bed review finds 'deep rooted behavioural and cultural issues' at Noble's Hospital

Advises against increasing capacity 'without root-cause improvements'

An independent rapid review of overall bed capacity within Noble’s Hospital has found evidence of 'complex issues such as trust, discretionary behaviours, questionable consultant job plans, silo-planning and circumvention of normal governance systems'.

Described as 'deep rooted behavioural and cultural issues' which 'may also be distracting from delivering responsive and efficient services', the reviewer has classed them as 'underlying issues'.

BACKGROUND

The review was commissioned by the Department of Health and Social Care (DHSC) in response to the Medical Staff Committee's (MSC) request to increase inpatient beds in Nobles Hospital back in March.

This followed 'sustained periods of OPEL 4 operating status, which by definition indicates the highest level of risk to delivering safe patient care on a system wide basis'.

As an ‘immediate first step’ the MSC called for the prompt provision of 50 additional inpatient beds; this is something Manx Care said at the time wasn't possible. 

In April, the DHSC Minister, Claire Christian, announced a rapid review would be commissioned.

You can read more HERE.

The review was allocated up to 10 days resource to complete and was led by independent reviewer Peter Gent.

FINDINGS

The overarching theme of the report appears to be that 'opening additional beds without root-cause improvements would most likely result in these beds being filled almost immediately, providing a one-off benefit, beyond which the current position would continue'.

With regards to the Emergency Department (ED), the review found the 'department has no streaming function in place to clinically navigate patients to the most appropriate service for their care needs'.

It currently 'receives patients destined for specialties, urgent care, injuries, minor illness, trauma, un-differentiated majors and resuscitation' and therefore 'poor flow' of patients was evident.

Meanwhile, the current Acute Medical Unit (AMU) 'does not operate as one', with 'no defined pathways or Acute Medicine co-ordinator function to manage patients with a short length of stay'.

There is a 'noticeable pattern' of heightened OPEL status following weekends, and the medical in-patient bed base 'appears to be predominantly occupied with elderly and frail patients'.

In terms of Manx Care's executive team, the review found the 'current members are highly experienced in the challenge of flow and the widest range of best practice initiatives embedded in the NHS', but noted that 'the challenge for this team is taking colleagues with less experience and ulterior motives along the improvement journey'.

It says 'the ability to link what is happening in ED, with expected real-time demand into the AMU and the wards, along with real-time updates on individual discharges will significantly improve upon the current manual system'.

It has highlighted the need for digitisation going forward - something echoed by outgoing Chief Executive Teresa Cope during a recent Tynwald committee appearance.

In terms of culture, the review states: "The culture feels ‘blamey’ and ‘individualistic’ rather than collegiate. Patients being everyone’s common currency provide the compass point for building consistent pathways and processes and establishing ‘single versions of the truth’ to drive the best care possible."

RECOMMENDATIONS

The rapid review makes nine key recommendations:

• The reviewer does not advise increasing the inpatient bed capacity without first optimising the potential of the current capacity, skills and transformation opportunities. Adding additional beds without embedding changes to current practices will not deliver improved flow but will significantly increase costs and introduce additional risks.
• The footfall on ED could be significantly reduced through recommissioning an integrated Urgent Care model to realign lower acuity presentations (too many patients using the ED as an alternative to primary care services), enabling patients to be assessed and managed by the right team for their health issue without avoidable delays. 
• Patients presenting to specialties via ED should go direct to specialty and the current Acute Medical Unit needs to change its operating model to enable this.
• The reviewer recommends re-configuring bed allocation to Medicine, most specifically by reducing the Surgical bed numbers and allocating an additional circa 10 beds to Medicine.
• Bed management systems need digital transformation to link ED, Acute Medicine (or a combined Acute Assessment Unit) and the core bed base with live patient information. This will enable a clearer line of sight on the demand for hospital beds as well as discharge status and progress of discharges at any point in time with minimal manual effort.
• Access to beds and driving flow should be consistently managed and robustly delivered 7 days per week. Defining ‘golden’ patients for discharge, consideration of a discharge lounge area to free beds up earlier and step down to ambulatory care to enable discharges to be brought forward would all help reduce delays in access to beds and improve efficiency.
• Driving more focus on community resilience and admission avoidance, particularly in the frail and elderly groups will help mitigate some of the current demand. There is a wealth of Consultant AHP and Nursing experience who are wholly motivated to supporting the transition of care balance from acute settings to community and patients own homes. Given the predictable rise in the Island’s age demographic, mitigating future pressures both in health and social care services, the reviewer would advise this as a higher priority to invest than simply increasing inpatient bed numbers.
• Planning for discharge from initial arrival is not consistently applied and is essential for maintaining focus on early discharge for the majority of optimised patients. Discharge planning appears not to be consistent and in too-many examples, appeared to come later into the patient’s stay.
• Although not part of the review, issues such as gaps in skills and experience were raised, particularly in non-consultant grade medical staff. This appears in part due to recruitment trends and strategies to fill vacancies. Dependencies on less experienced, non-senior decision-making staff will impact decision making and risk appetite.

FINAL THOUGHTS

At the conclusion of the report, Mr Gent said: "The review was undertaken quickly, involving as many stakeholders as possible. There are a range of other underlying issues that the reviewer believes are influencing service cohesion and delivery and which were not part of the review, but it would be remiss not to allude to them. 

"Complex issues such as trust, discretionary behaviours, questionable consultant job plans, silo-planning and circumvention of normal governance systems appear evident. 

"These are deep rooted behavioural and cultural issues which may also be distracting from delivering responsive and efficient services. 

"My concern for the current Executive Leadership team and future appointees is that Manx Care becomes ungovernable and for key groups of the workforce, there are ulterior motives to building services comparable with modern and more efficient healthcare organisations."

You can find the full report HERE.

Manx Radio has approached the DHSC and Manx Care for interview.

The Health and Social Care Minister Claire Christian declined the opportunity saying she won't give interviews before this month's sitting of Tynwald.

She'll be asked to provide an update on the status of the bed capacity review, and to make a statement, by Arbory, Castletown and Malew MHK Jason Moorhouse when the court sits tomorrow (16 June).