David Oliver

Organising care at the NHS front line, a report from The King’s Fund, focuses on the logistical barriers to delivering the best care for acutely ill medical patients. Its starting point is the lived experiences of clinical staff based on acute medical units, and general medical and geriatric inpatient wards.

These clinical areas are in the eye of a perfect storm, created by rising emergency attendances, falling bed numbers and more patients stranded in hospital due to increasingly inadequate community health and social care capacity. Acute care staff are often the ‘shock absorbers’ for these system problems – the one place that can never say no, yet often feeling unable to influence solutions outside the hospital walls. Their own morale, retention and engagement can suffer, perpetuating a vicious circle. But are some of the solutions in their own gift?

Too often, within hospitals, there are poor internal processes and systems – a physical environment, equipment, record systems and IT that hamper good care, cause delays and worsen patient flow, care quality and communication. This means highly trained practitioners can spend their time duplicating others’ efforts, chasing information and implementing pragmatic ‘work-arounds’ to counter poor logistics. Such issues feature in many of the essays in this report, which include clinicians’ narratives of the struggle they sometimes face in delivering high-quality care, alongside perspectives from managers, patients and others.

Some of the messages emerging from this work might apply in other clinical areas; so why the focus on acutely ill medical patients?

First, it’s because these patients are driving much of the rise in acute general hospital activity. They are a hospital’s ‘core business’ and they are key to hospital workflow. There are numerous examples from initiatives such as the Royal College of Physicians’ Future Hospital Programme, the Acute Frailty Network or studies from the Health Foundation showing that getting the operational details of patient flow right means ‘win/win’ dividends for patients, their families and care systems.

While hospitals rightly invest effort in assessing and returning patients home from the acute ‘front door’, there is a risk that acute medical wards – which have lower priority in national targets, payment mechanisms, and performance and activity data – will suffer.

Second, the needs of acutely ill medical patients are generally the most complex. Patients are often older, living with frailty, social vulnerability, dementia, multiple long-term conditions, all compounded by acute illness or injury. They are often reliant on multiple services and on family caregivers and are at most risk of disjointed care and poor transitions from hospital.

Third, because their care doesn’t fit so neatly into well-defined pathways, it is inherently multidisciplinary and more reliant on better collaboration and information with teams outside hospital such as general practice, community health or social care services. And it is often at these interfaces that continuity of care, communication and co-ordination can break down and where a lack of single shared records, datasets or whole-pathway approaches cause further fragmentation.

Fourth, it’s because these wards often struggle most with workforce gaps: last year more than 40 per cent of consultant physician posts were unfilled at interview and unfilled rota gaps for senior and junior doctors are endemic. Yet it is clear that hospitals’ largest need is for more ‘expert generalists’. Workforce gaps in nursing and allied health professions are often at their worst on these wards where teamworking is so crucial to good patient outcomes and processes.

Our report identifies a number of ways to tackle these problems and to deliver constructive solutions.

Some solutions sit with national system leaders, for example through adequate funding settlements, workforce planning and recruitment, and more support to retain staff. Early moves towards more medium-term planning, support for new models of care and local interagency collaboration as seen in sustainability and transformation plans may help. But without an adequate settlement for social care and community services, pressures on adult hospital medicine won’t abate.

Many solutions sit with board-level leaders, operational and clinical managers within hospitals. They can help prioritise better logistics and operational functions and give the same attention and status to acute general wards as elective and outpatient work. Crucially, they can create a supportive and permissive environment in which clinicians can apply quality improvement, improvement cycles, the use of data to evaluate and drive change, and continuous learning. To do all this effectively, senior leaders need to be on or in contact with the ward ‘shop floor’ enough to understand operational problems and staff concerns.

Ultimately, the quality of care patients receive and experience in these settings is down to the operational details of service delivery, the leadership culture on those wards and the ability to liberate patient-facing staff to focus on the roles they are trained for.

We should learn from the better examples and embed these lessons in every ward in every general hospital.

• Read our new report, Organisating care at the NHS front line
• Find out more about out work on frontline clinical care in acute hospitals.