Introduction
In the first instalment of this series we looked at bed occupancy in general, and how it works in psychiatry. This blog will look in more detail at the factors which affect bed occupancy as they may be helpful in understanding the figures later on.
An overview of patient flow
Put simply, there are four key drivers that affect patient flow:
- Demand;
- Capacity;
- Activity;
- Queue.
These factors are commonly known as DCAQ and we will look at each in turn. Some of the definitions have been taken from the Scottish Government resources to healthcare providers.
1. Demand
Demand is the total sum of all requests into the service from all sources. In inpatient psychiatry this could include: Community Mental Health Teams (CMHTs); primary care (GPs); Crisis Teams; the Police; Crisis Hubs; and pretty much anywhere that might make a request for, or identify a need for, inpatient admission.
Gatekeeping and CRHTTs
It is not just those needing inpatient admission and it includes all those who may be perceived to need inpatient admission. This is important because much of the demand for inpatient care may not be the same population that inpatient psychiatrists think the service might be for. Most inpatient services do not have very explicit criteria for service provision, and there is fuzziness at the boundaries.
Let's assume that you have a limited number of inpatient beds and these are being 'gatekept' by a Crisis Response and Home Treatment Team (CRHTT). This is the model for CRHTTs that was developed many years ago (Department of Health, 2006). Since CRHTTs were funded from closing inpatient beds, they were considered to be essential for 'gatekeeping' to inpatient beds:
"It is important that mental health inpatient services and crisis services are joined up locally. It is necessary for a crisis team to act as gatekeeper for all people requiring access to inpatient services or other emergency care. Gatekeeping is an essential component of CRHT." (Department of Health, 2006)
Since they could offer home treatment as an alternative to admission, they could assess whether a patient was suitable for home treatment instead of an inpatient bed, thereby reducing demand for inpatient services.
The research on whether CRHTTs have achieved their core aim (reducing inpatient admission) is broadly supportive, but sometimes contradictory (for example: Barker, 2011; Jacobs, 2011; Stulz, 2020).
However, let's also assume that your CRHTT only has a locum consultant psychiatrist, many experienced staff have left, and it has seen what many CRHTTs in the UK have seen: their ability to provide home treatment has been compromised by the high demand for crisis assessment. This problem was recognised many years ago (Morgan, 2007) and the crisis response component of CRHTTs was recommended to be kept separate from the home treatment pathway, since the benefits of CRHTTs are only delivered when you can provide home treatment instead of hospital admission.
In these circumstances staff often find themselves simply trying to find a bed rather than delivering the higher-risk and more time-consuming process of home treatment. With regards to risk, it was recognised a long time ago that the suicide rate in CRHTTs was becoming higher than that in inpatient wards (Hunt, 2016). This was due to CRHTTs managing an increasingly risky population in line with their core purpose of being an alternative to hospital admission.
However, this increase in risk needs to be understood and managed by the service and without robust leadership and operational management, there is a likelihood that staff become wary of risk and will lower their threshold for admission. So, rather than preventing admissions to hospital it is possible for CRHTTs to increase admissions, since referrals that would not normally be considered for admission (and would receive home treatment) are now being admitted.
2. Capacity
Capacity is all the resources needed to do the work. In inpatient settings it consists of the buildings (i.e. beds and rooms) and also all the staff. If you close bedrooms (due to renovation, for example) or have staff off sick, then your capacity is reduced.
An inpatient bed is best understood as a combination of a physical bed and also the staff needed to provide care. Someone who needs a bed will also need nursing staff to provide care, and if their needs are more intense, they will need more staff. So, not all patients are equal but it is usually possible to average out admissions, beds, and staff to understand what your staffing requirements are.
Delayed discharges
Key things that can affect capacity include 'delayed discharges'. According to the Scottish Government (2016):
"A delayed discharge is a hospital inpatient who is clinically ready for discharge from inpatient hospital care and who continues to occupy a hospital bed beyond the ready for discharge date."
The higher the number of delayed discharges, the fewer beds will be available for new admissions. Reasons for a delayed discharge can include a lack of social care, or other factors needed that cannot be provided by the inpatient ward (such as renovation to someone's property, or white goods). In some cases, someone may be waiting for a nursing home or other specialist placement to be available and until it is, they cannot be discharged.
Delayed discharges in NHS Scotland are slowly increasing and are reported regularly by NHS Scotland. The most recent set of figures is shown below. The big drop in response to the COVID lockdown was created by large numbers of patients being discharged from hospital
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| Delayed discharges - NHS Scotland (April 2023) |
3. Activity
Activity is the work done. In inpatient environments it consists of all the admissions, all the treatment, and the discharges (and everything in between). A number of things can affect overall activity. For example, a ward that has a higher turnover will have more activity: more people can be admitted and discharged.
Length of stay (LOS)
Often, higher turnover is due to a shorter length-of-stay (LOS). This means that more patients can be admitted and discharged in any given period of time. Whilst there is a concern that an insufficient LOS may increase the risk of readmission, in reality most wards will have a variation in LOS without seeing obvious differences in risk of readmission.
Local data would suggest that there is a range of LOS in which there will be no change in readmission, but as LOS gets very short the risk does appear to go up. Of course, LOS varies according to patient need but there are average values that can be used to understand how different wards are managing broadly similar patient groups.
Perverse incentives
It would be rare if such incentives did not exist within complex pathways and LOS is one example. It is easier to understand if we look at two wards, in the same hospital, and consider how individuals are incentivised to behave.
Ward A is led by a substantive consultant psychiatrist (Consultant A). The average LOS of Ward A is four days shorter than that of Ward B, but the risk of readmission after discharge is the same. The rate of incidents in Ward A is no higher than in Ward B so there is no indication that care is being compromised. Since the LOS is shorter, more patients are admitted and discharged.
Ward B is led by a locum consultant psychiatrist (Consultant B). The LOS is longer and fewer patients are admitted and discharged in any given time period. The Ward B consultant is more cautious about discharging patients because they are only a locum and they don't have as much experience.
Consultant A knows they are admitting and discharging more patients and has no hang-ups about not working as hard. They've seen the data and they know that their turnover indicates that they are working harder.
But they are also exposing themselves to more risk since it is very difficult (if not impossible) to predict which individual patients might have an adverse event (such as suicide) during their admission or shortly after discharge. If they admit and discharge more patients, their individual risk is greater as a result of seeing more patients. They also spend more time managing patients who are most unwell (since the total proportion of any admission when symptoms are greatest is higher with shorter admissions than with longer admissions).
The two wards are in the same hospital and managed by the same NHS Board. The notion of each ward admitting from a particular area (or group of CMHTs) has long gone and if a bed is available in either ward, the patient will be admitted there regardless of their GP, area, or CMHT.
Now let's imagine it's Thursday afternoon and both consultants are asked to discharge some patients to free up beds before the weekend. Consultant A knows that their LOS is already shorter than Consultant B and if they discharge patients from their own ward they will have the same number of new (and more unwell patients) tomorrow, and this will affect how much time they can spend with their existing patients. Meanwhile, Consultant B (by making no changes to their current practice) will have no new patients and will have a more predictable day.
Of course, it is the job of both consultants to admit and discharge patients and deliver optimum care in the safest way, but the incentives are not equal. Consultant A is incentivised to work less efficiently because they have already seen that this is a successful strategy for Consultant B.
Such perverse incentives will be familiar to most people in the NHS. If you work more efficiently than your colleagues, you usually get more work. Most high-performing doctors don't mind this most of the time because doing the work is rewarding and there were opportunities for teaching, research, and other meaningful activities. But the circumstances in which the NHS is currently working post-COVID (relentless demand, higher stress and burnout, real-world pay cuts over time, increases in moral injury, fewer opportunities for research) are different. Working in systems where unfairness is a daily lived experience will affect how people make choices about different priorities. If they didn't, we wouldn't be human.
4. Queue
Queue is also known as 'backlog' and is the activity that has not been dealt with. Typically, it will represent those patients who have been admitted elsewhere and need a bed locally, and also those patients who require a bed but have not had one available. They may have been becoming increasingly unwell in the community.
A queue is inevitable when demand exceeds capacity, and there will be work that has been displaced if inpatient services lack the capacity and activity to manage demand.
Queues can also form when activity is displaced. For example, if a CMHT has a high rate of staff absence or lacks consistent medical staff (For example: The Courier, 2023) then inpatient services may end up being the 'provider of last resort' and have to provide aspects of patient care that have not/ cannot be managed elsewhere in the system.
This brings us back to inpatient demand being a proxy for the functioning of all other parts of the mental health system.
References
Barker, V., Taylor, M., Kader, I., et al (2011) Impact of crisis resolution and home treatment services on user experience and admission to psychiatric hospital. The Psychiatrist, 35, 106-110. http://pb.rcpsych.org/cgi/content/abstract/35/3/106
Department of Health (2006) Guidance Statement on Fidelity and Best Practice for Crisis Services. London: HMSO. https://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/assetRoot/04/14/16/73/04141673.pdf
Healey, D. (2023). EXCLUSIVE: Tayside psychiatry vacancies worst in Scotland as expert warns national services ‘unsafe’. The Courier, 24 January 2023. https://www.thecourier.co.uk/fp/politics/scottish-politics/4082341/tayside-psychiatry-scotland-unsafe/
Jacobs, R. & Barrenho, E. (2011) Impact of crisis resolution and home treatment teams on psychiatric admissions in England. British Journal of Psychiatry, 199, 71-76. http://dx.doi.org/10.1192/bjp.bp.110.079830
Morgan, S. (2007) Are Crisis Resolution & Home Treatment Services Seeing the Patients They Are Supposed To See? London: National Audit Office. http://www.nao.org.uk/idoc.ashx?docId=640def6f-837d-4f1e-a3e8-6a62194a30f1&version=-1
Stulz, N., Wyder, L., Maeck, L., et al (2020) Home treatment for acute mental healthcare: randomised controlled trial. British Journal of Psychiatry, 216, 323-330. https://doi.org/10.1192/bjp.2019.31
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