Understanding patient flow in hospitals

The aim that 95% of patients attending A&E should be admitted,
discharged or transferred within four hours is one of the highest
profile NHS targets, yet it is being consistently missed across
England. Although the target can be over-emphasised, struggles
in meeting it are associated with deeper problems in the capacity
to move patients into hospital wards. This briefing draws on
theories about congestion to look at why this has become more
difficult in the hospital setting, and what can be done about
it. It looks at ongoing changes driving pressure on bed space,
including mortality, the squeeze on bed space during years of
austerity, rising numbers of patients with multiple conditions, and
delayed discharges. It also looks at the solutions available short of
actually building enough beds to restore free space, and suggests
managers should focus in particular on the minority of longstaying
patients who account for a majority of bed use. Given
the variation during the day, and with an increasing number of
patients leaving in a matter of hours, it urges the NHS to invest
in IT and management systems that can track and deal with the
need for beds and patient movement in real time.
Acknowledgements
This work has been informed by many people who have worked with the authors
and informed their thinking. We thank Kate Silvester and Paul Walley for their ideas
and contributions. We are grateful to Monitor (now NHS Improvement) and GE
Finnamore for sponsoring seminars that contributed to our thinking, to Paul Smith for
his analysis of Hospital Episode Statistics data, and to Andy Cowper and Mark Dayan
for their significant editorial input and guidance.
Many of the themes that this report explored were triggered by conversations on the
frontline of hospitals that the lead author has worked in. In particular, we thank Laura
Allen, Bob Gregory, Paul Younge and Jude French for their valuable insights, and Phil
Martin for extracting the data that has illustrated them.
This work was made possible as a result of North Bristol NHS Trust agreeing to
Sasha Karakusevic’s secondment to the Nuffield Trust and continued use of Dr Foster
Intelligence tools.
Hospital Episode Statistics data © 2016, re-used with the permission of the Health &
Social Care Information Centre. All rights reserved.
Find out more online at: www.nuffieldtrust.org.uk/publications