Images of ambulances waiting outside of accident and emergency departments are alarming, but but in most cases neither A&Es nor the ambulance service are the source of the problem. The root issue lies instead at the end of a patient's hospital journey – where many face a prolonged wait to be discharged from hospital, despite being medically fit to leave.

One in five patients cannot be discharged directly from hospital to their usual place of residence. These patients then, through no fault of their own, often take up bed spaces needed for non-elective hospital inpatients. In short: delays in discharge from a hospital bed lead to spiralling waits in A&E.

Professor Christos Vasilakis, Director of the Centre for Healthcare Improvement and Innovation (CHI2) at the School of Management, is helping NHS Integrated Care Boards (ICBs) to address this issue by using systems and computer simulation to better inform their decisions on where to allocate funding.

He explains:

"What is the sweet spot? We need to ensure that we have enough capacity on discharge pathways so that patients in an acute hospital setting are waiting as little as possible.

"If we have better patient flow then we don't have issues with ambulances queueing up at the front of the hospital and we don't have elective surgeries being cancelled because there are no beds for these patients to go to."

Pathways out of hospital

When patients discharged from hospital in England require ongoing care, they are assigned to one of three 'discharge to assess' pathways. During the six-week period they spend on this pathway, their care is paid for from National Health Service (NHS) budgets.

Two of these pathways involve care in a non-hospital facility such as a care home or community hospital. The third involves a package of support in their own home – regular visits from district nurses or care staff, for instance.

Ensuring that these services are available in the required quantities is a complex task, particularly when at-home care needs to be coordinated.

Christos says:

"Where people have been discharged home with community support, capacity is not defined by someone staying in a bed: capacity is defined by visits. There's also a tapering effect, because you start out with more intensity and over the six-week period this dies down as the patient doesn't need as much support.

"Your resource stock is basically slots in the appointment diary of a care professional that goes around the region to visit patients. This is quite difficult to model."

Improving patient flows

A carer holding the hand of an elderly patient, who is also holding a stress ball — IPACS' modelling is able to account for tapering care requirements.

Christos led a project to develop the Improving the Flow of Patients between Acute, Community and Social Care (IPACS) tool for use by NHS decision-makers. This easy-to-use, open-source tool is available to download for free from GitHub.

IPACS takes into account factors such as:

The rate of patients getting ready to be discharged
How long is spent in follow-on care facilities
The availability and demand for at-home care
Average costs of community care
Acute delay costs per patient per day

The tool then uses this information to produce a report forecasting estimated patient distribution between pathways, amounts of delays and the potential costs of this for a given time period.

It is currently being used by Bristol, North Somerset and South Gloucestershire ICB to plan for winter pressures on healthcare services for the one million people living in this catchment area. Other ICBs are looking to apply the model to their own services, too.

The team were also invited to present the model in workshop sessions for NHS analysts.