This report is the summary output of an intensive piece of work commissioned by NHS London and co-delivered with Transformation Nous over a five-week period. The objective of this work was to understand and quantify the continuing impact of the COVID-19 pandemic, by comparing to a pre-COVID baseline.

Specifically, the work focused on understanding how the operating capacity and efficiency of Urgent and Emergency Care (UEC) in the London region was affected. Critically, it also generated recommendations to mitigate these effects, in preparation for Winter 2022/23.

The study focused on two hospitals, Kingston and Chelsea & Westminster, to generate insights that were transferable across London and other regions.

The initial hypothesis was that the most significant continuing effects of the COVID-19 pandemic would come from protocols to mitigate transmission of the disease itself, i.e., Infection Prevention & Control (IPC) measures and Covid testing regimes (see Exhibit 1).

In reality, the biggest challenge facing hospitals was a disruption to flow out of the hospital and the knock-on effect further down the pathway. This knock-on effect was not linear but amplified closer the ‘front-door’ of the hospital.

A 10% decrease in patients being discharged from the wards, with an equivalent increase in average length of stay (aLoS), translated into a ~15-20% decrease in patients through the assessment units, due to the increase in aLoS. The challenge was most visible in the Emergency Department (ED), where risks to patients became most significant. There was an increase of up to 50% in aLoS within the ED (see Exhibit 2).

This new reality of the UEC is explored in the following sections, in addition to challenges such as mental health within the ED and increasing complexity of site management.

Challenges facing the acute hospitals began at the end of the in-hospital patient pathway. Comparing the months directly preceding COVID-19 to the first few months of 2022, there was a 10% decrease in the number of patients being discharged from inpatient wards. As expected, over the same period the aLoS of patients increased.

All else being equal, aLoS increases should be equivalent to a fall in discharges, as was the case at Kingston Hospital. At Chelsea & Westminster, bed base adjustments over the analysis period, and other factors specific to the site, meant that the increase was smaller at 5%, but still significant (see Exhibit 3).

Analysing patient spells, segmented by length of stay, highlighted the shift in proportions over time. At Kingston, the percentage of patients who stayed in hospital for over 7 days increased from 30% to 34%. These patients have always consumed a large proportion of bed days but now accounted for nearly 80% of bed days (see Exhibit 4).

In doing so, they essentially 'squeezed out' shorter-staying patients, illustrated by Exhibit 4 which shows the number of patients staying under 3 days fell by 11% from pre-COVID levels. The most extreme change was in patients staying over 21 days with 19% more patients falling into this category now, than they did pre-COVID.

There were two main drivers of this trend. Firstly, internal factors related to ward operational effectiveness. Secondly, challenges related to supported discharges and moving patients into more appropriate settings of care.

1. Ward operational effectiveness
   The study highlighted slippage of operational processes on wards, most obviously in terms of board rounds and discharge planning. Both Kingston and Chelsea & Westminster are high-performing Trusts, delivering exceptional care for patients, but there was a need to reinvigorate the relatively straightforward operational elements of this care.
   
   For example, while all elements of the SAFER bundle were discernible during board rounds, they lacked the rigour and energy needed to generate proactive discharge planning such as chasing up delays needed to reduce lengths of stay.
   
   The opportunity was significant, given the cumulative effect of relatively small decreases in aLoS from patients throughout the hospital. But making these changes would require targeted efforts and drive. A fatigued workforce, given two years of ongoing pressure, and limited opportunities to reflect, recharge, and re-build their resilience, were normalising delays where historically they may have been more driven to achieve patient discharges sooner.

2. Supported discharges
   Challenges were exacerbated for patients who required additional support for discharge. Whether it was patients needing intermediate support in their own home (Pathway 1), those needing a short-term rehab and reablement bed (Pathway 2), or those requiring full-time, 24-hour care in a care home facility (Pathway 3), the story was the same. Their aLoS had increased, as it became more challenging to support them out of hospital into more appropriate care settings.
   
   At Chelsea & Westminster, this change was particularly stark if measured from the lowest point reached mid-pandemic when, due to the urgency needed to rapidly create acute hospital capacity, aLoS actually decreased significantly for supported discharge patients. Since then, progress has eroded and as of May 2022, aLoS was up by 50%.
   
   It was the most complex of supported discharges pathways which saw the greatest increase in aLoS. At Chelsea & Westminster both Pathways 1 and 2 saw an increase of over 30% since April 2021, up to 30 days and 28 days respectively.
   
   The reasons for 'exit block' and associated delays were varied but can be meaningfully grouped as:

   • Capacity issues, e.g., care home beds closures due to internal outbreaks of COVID, reduced capacity through staffing issues caused by the pandemic and Brexit, etc.

   • Process issues, e.g., challenging discharge criteria for patients with COVID or those who have come into contact with COVID patients, a return to and worsening of pre-COVID levels of supported discharge bureaucracy and paperwork

The disruption at the back of the pathway was amplified toward the middle, as a lack of available beds on inpatient wards made it more challenging to transfer patients onwards through the hospital.

This was clearly seen in the volume of patients transferred onto inpatient wards which was down between 15 and 20%. Fewer transfers, as well as a drop in patients being discharge directly, contributed to a significant aLoS increase on assessment units which increased by nearly 20% at Kingston (see Exhibit 5).

The time of day that patients were transferred was also indicative of a change to operational effectiveness. At Kingston nearly 50% of patients moved into the main hospital bed base between 8pm and 8am, as they waited for other patients to be discharged, and for a bed to become available (see Exhibit 6).

Impediments to onward flow create delays in availability of beds on assessment units for patients admitted from the ED. It was the bottleneck in this interface which caused the most significant and painful pressure, manifesting in the ED, and generating the greatest risk to patient safety.

Patients remained in the ED for longer than they used to. The aLoS within the ED increased dramatically, up ~20% to ~50% for Type 1 patients (see Exhibit 7).

Given attendances are roughly back to pre-pandemic levels, means that demand for patient care, as measured in patient hours in the department, has increased significantly. At Kingston, total patient hours in the department increased by ~45% between pre- and post-pandemic periods. In the same hospital, comparing the lowest point of activity in 2021 (mid-pandemic) to the first months of 2022, patient hours increased by ~170% (see Exhibit 8).

Unlike other parts of the hospital, the ED had to increase its capacity to meet demand and expand its 'elastic walls' by doubling up cubicles, moving patients into overflow areas, and in extreme cases, caring for patients in corridors. This often led to ambulance delays as they had to queue as they waited to handover.

Congestion in the department severely impacted staff and patients. Most ED process times saw an increase in duration of ~50% (e.g., first seen to discharge time increasing 56%, or referral to discharge increasing 50%). The 'Decision to Admit' (DTA) to admission time for admitted patients saw the greatest increase in delays – up 123% at Kingston (see Exhibit 9).

A useful gauge of the challenge in ED was the number of DTA patients waiting for a bed at 8am; at Kingston, this increased by over 40%, averaging ~16 each day. Against a total of ~63 daily admissions, this meant 26% of the day’s 'admission workload' was already in the department before the day shift had even started – up from ~18% pre-pandemic.

While 26% was not as extreme as other, more challenged, hospitals post-COVID, it was the 'Kingston move' that was significant. This trend was indicative of the new pressures facing EDs in London (see Exhibit 10).

A change in patient attributes added to the pressure articulated by ED teams; patients appeared sicker and more complex than pre-Covid. There were two main drivers of this change.

Firstly, during the pandemic, patients were nervous to use services during COVID peaks because of the risk of either catching COVID themselves or worrying that they would overwhelm those already stretched healthcare services. Patient conditions worsened over time as prevention, diagnosis, treatment, and long-term condition management were undermined.

Secondly, patients found it difficult to book GP appointments, or, at the very least, perceived it to be difficult to do so. In either case the outcome was the same: patients arrived sicker, as they had not received any treatment that might have resolved or mitigated their condition at an earlier stage. An additional effect was that many patients attending ED would have been more appropriately treated in alternate care settings, which could explain why Type 3 attendances have fully recovered to pre-Covid levels unlike Type 1.

In addition, the attitudes and behaviours of patients shifted. Staff felt increasingly unsafe given increasing instances of abuse, aggression, and threats of violence. In fact, Chelsea & Westminster introduced body worn cameras to frontline staff, especially nursing staff, to cut down the number of incidents and better investigate those that still occurred.

The cumulative effect was a 'pressure-cooker' environment in the ED, the root causes of which were not in the direct control of the teams that worked there.

A further source of tension in the ED was the increasing prevalence of severe mental health issues. While the number of referrals actually fell by 5-6% during COVID, the aLoS for these patients increased.

At Chelsea & Westminster, from the pre-COVID period, aLoS of mental health patients increased by 14%, equating to ~7.3 hours. Looking at only the referrals from November 2021, the increase in aLoS was ~40% (see Exhibit 11).

The number of very long-stayers increased most dramatically. Chelsea & Westminster saw a 165% increase in patients waiting between 24 and 36 hours, and ~170% increase in patients waiting over 36 hours (see Exhibit 12).

It was these patients, who would wait in the ED for days at a time and were often familiar faces to the teams on the ground, that most significantly drove pressure upward.

PCR COVID testing of admitted patients could be a constraint on performance in EDs. But this was only the case in hospitals that managed to maintain a relative degree of flow, and which had a strict regimen of testing under which patients were only transferred once results were returned.

Chelsea & Westminster is one such hospital and the study estimated a delay of ~100 minutes was added to the ED aLoS of admitted patients. Removing PCR COVID testing (and constraints on transfer) would have contributed to a reduction in delays for patients and mitigated overall congestion in the department. In an optimistic scenario, estimates suggested up to 12 4-hour breaches could have been saved each day, equivalent to recovering ~30% of the pandemic-driven deterioration in performance.

The slippage of operational processes described on wards also appeared in management of the whole site. Improvements to bed meetings in particular (including using visual tools and leveraging more reliable data) could help mitigate the effect of a more complex site management function, given new challenges of safe patient allocation and increase in the number of relevant stakeholders to be consulted when taking decisions.

All of the factors described above were underpinned and exacerbated by a decline in staff engagement and hence productivity. Staff resilience further declined in recent months, having already eroded to historic lows given the ongoing pressure over the past two years.

A significant risk was the negative feedback loop of lower productivity, increasing the pressure and challenge within the system, and further undermining staff ability and willingness to step-up to this challenge.

From the outset, the purpose of this piece of work was to not only diagnose new challenges to the delivery of Urgent and Emergency Care in London, but also to identify the means of facing up to these challenges.

There were four priority areas to focus on, applicable to London hospitals, and supported by the regional team. It is critical that progress is made in each of these areas before Winter 2022/23.

While it was clear which were the most important areas to focus on, we do not want to be overly prescriptive about specific initiatives. We have ideas and suggestions, but the best solutions will be co-developed at the hospital-level, not stipulated centrally.

1. Address supported discharge challenges

   A concerted effort to address challenges in supported discharge is needed, building on the learnings from the national programme on discharges.
   
   The pandemic actually saw a decrease in the bureaucracy associated with discharge in many places and a return to pre-COVID levels of paperwork and delay would be incredibly challenging given the new constraints to performance.
   
   There also needs to be a system-level conversation to understand and articulate the dimensions of this challenge, learning from our successes and transfer best practice as a coordinated network of organisations, wherever possible.

2. Enhance hospital operational ways of working

   Individual hospitals will have to work incredibly hard to re-invigorate and revitalise the operational processes which drive flow through and out of the hospital. Programmes already exist in some hospitals, but focus and energy is needed to restore grip and control before Winter 2022/23.
   
   This work could focus on:

   • Inpatient operations: Improving board rounds and driving effective MDT discharge planning aligned to SAFER guidelines (for both simple and supported patient discharges)

   • Acute medicine: Increase discharges, reduce medical response times, effective board round delivery

   • Emergency department: 95% non-admitted performance, specialty decision <90 mins, effective 2 hourly huddles in ED, optimise patient usage of the clinical decision unit

   • Real time site management: Manage the timely transfer of patients out of the ED in <4hrs, effective bed and site meetings, live allocation at bed meetings, constant evaluation of hospital pressures and timely corrective action

   • Weekend activity: Increase weekend discharges, create a bed buffer for the weekend, increase usage of the discharge lounge

3. Address decline in staff morale and fatigue

   As staff morale decline underpins and exacerbates the other challenges facing UEC, improving morale underpins, and will accelerate, the improvements in the other priority areas of focus.
   
   The critical factor is reversing the 'command and control' dynamic introduced during the pandemic, where centralised mandates were necessary to move quickly and with synchronicity in crisis.
   
   There is now a need to actively listen to our teams and genuinely understand the challenges they face. We must then work collaboratively to address these issues, fostering a meaningful, action-oriented dialogue that drives tangible improvement.

4. Seize opportunities for admission avoidance

   In addition to enhancing internal ways of working, a significant change is needed to manage the inflows into UEC. The two biggest opportunities come from re-directing activity before it reaches the ED (i.e., working with the ambulance service and community teams to redirect ambulance conveyances to ED alternatives, improving access, and perceived access, to primary care), and once activity does reach the ED, redirecting to new and proven models of care like same day emergency care (SDEC) and pursuing both pull and push initiatives to drive throughput.
   
   While the primary responsibility for delivery will be held by local health and social care teams, as the most able agents of change for their specific sites, these initiatives might be supported as four workstreams in a pan-London approach. This could be achieved by leveraging a 'field and forum' methodology to codify and propagate best practice and learnings, supporting coordination and collaboration between stakeholders.

The challenges described in this document are significant but not insurmountable. While pressure has increased, starting at the back of the UEC pathway, and amplifying toward the beginning, becoming most visible within the ED, a concerted effort at hospital, system, and regional-level can drive the step-change needed to maintain effectiveness over the next few months, into winter, and beyond.

The two most important elements of such an effort will be:

• Working as a system: As outlined above, several system-level actions are required to expedite patient flow into more appropriate care settings. In practice, these system-wide initiatives will be the key drivers in reducing ED congestion and alleviating pressures on both staff and patients. Within this context, the role of system leaders and provider collaboratives is critical.
  

• People: Over the course of COVID, NHS staff have performed outstandingly in extraordinary circumstances. However, given now they are demoralised and fatigued, any hospital improvement effort cannot be perceived as 'one more ask'. Instead, they need to be the solution to their concerns by providing a more effective and systematic way of working, and an opportunity for empowerment.