Local system collaboration to address care backlogs

Birmingham and Solihull’s virtual Elective Care Hub sits across the region’s hospitals, providing ​‘coordination and intelligence about what’s happening on the ground’. 

An operational delivery group of senior strategic, operational and clinical teams from the secondary, community and mental health trusts and primary care oversee the hub. 

This system-wide collaboration has supported two local system innovations that built on work started before the COVID-19 pandemic and were scaled up due to its impact on access to services. 

Jack Bramhall, Programme Lead for the Elective Care Hub, Paul Dias, Consultant Neuroanaesthetist/​Lead for Elective Perioperative Delivery Plan, and Clara Day, Consultant Nephrologist/​Lead for Outpatient and Diagnostic Recovery, shared their learning with Q peer interviewer Ursula Clarke and Q’s Insight Manager Jo Scott.

Watch Jack Bramhall discussing local system collaboration to enhance perioperative care:

Space and capacity for post-operative recovery in critical care intensive therapy units (ITU) and high dependency units (HDU) was a pre-existing ​‘pinch point’. 

Then, during the COVID-19 first wave, access to elective critical care was significantly constrained: ​‘the traditional perioperative pathways we had just didn’t exist anymore,’ Bramhall says.

To preserve critical care capacity while sustaining some elective surgical activity, they developed ​‘extended recovery stays’. 

This is an enhanced model of care to increase safe post-operative care provision for patients needing complex surgery, which was endorsed by the Royal Colleges. 

Further development led to enhanced perioperative care units (EPOCs), part way between a ITU and HDU.

In addition to the elective surgeries backlog, there is growing pressure on staff due to ever-increasing numbers of new referrals to outpatient services. 

This project aimed to use Advice and Guidance (A and G) to minimise this and work with existing skills and system capacity. 

The A and G innovation has required significant changes in ways of working for both primary and secondary care teams as well as changes to data, monitoring, and finance systems. 

The new process has potential, but there are implementation challenges in improving quality and ensuring fair access. Analysis shows fewer A and G referrals in more deprived areas. 

‘In some specialties, there is a lot of backwards and forwards between GP and secondary care and then, ultimately, an attendance anyway,’ Bramhall says.

The team also needs to learn what a good conversion rate looks like for each specialty; they don’t yet have the sensitive data to assess the impact over time on hospital attendance.

The EPOCs have ​“revolutionised” the level of care provided for people waiting for surgery.

Through system-level innovation, A and G referrals increased nearly seven-fold to more than 8,000 per month. 

This has enabled primary care teams to identify more patients that they can safely and effectively support rather than referring them to a long waiting list. 

For secondary care, ​“if that patient does need to be seen, they’ve already done the initial consultation so we’re ready to be treating a condition.” 

More A and G improvements are underway, including work with some of the primary care networks so that specialist primary care teams take on more of the initial referrals.

Developing the EPOCs and implementing A and G have been driven by staff motivation to care for patients and have helped to improve staff experience.

Staff have also been able to enhance their skills.

‘The GPs like A and G because a lot of them find it a learning process and it’s brought the two parts of that care system together,’ Bramhall says. 

For the EPOCs, they are drawing on formalised learning from the pandemic when staff were redeployed to support the significantly increased demand for critical care. 

There is a ​‘reservist hub’ of staff with skills that can be stepped up across the system, which allows for retention of skills within the system. This benefits the local system as much as it does individuals for their career progression. 

The hub is building on cross-system relationships and strategic collaborations across primary, secondary and community care that were developed during the pandemic response. 

Through sharing learning and improving access to and use of data, they are finding better ways of working together in mutual aid and addressing the non-elective demand through enhanced primary care roles.

Collaborative working is helping to reduce silos and speed up decision-making to enable changes at pace to support the elective recovery, while ensuring there is credible clinical leadership and governance to secure staff ownership and motivation.

The hub’s effectiveness benefits from being able to ​‘be efficient and have consensus governance arrangements almost instantaneously with virtual meetings, which has really sped up developing things but also improved the robustness of the process.’

The local system-wide collaboration is enabling improvements in data quality and consistency across the various patient administration system (PAS) and waiting lists, and how data are used to inform strategic decisions. 

A big benefit of the cross-system intelligence is ​‘for everyone across the system to see where the pressures are.’ 

If operations are being cancelled for capacity reasons, the intelligence can reveal where in the system more capacity is needed. 

BSol has also rolled out a consistent ​‘health status check’ process to improve the quality of the data and inform prioritisation. 

They contact everyone waiting for surgery to enable clinical teams to reprioritise and validate their lists. 

The Children’s Hospital has taken this process a step further to take into account all of the different variables, including the social side, to evaluate ​‘the potential impact on later in life if they don’t do their procedure sooner rather than later.’

The pandemic and backlog pressures have created a unique context in which to implement service change. Improvers need to be flexible to embed improvement in such circumstances.

Following the number of changes made at speed during the pandemic, the improvement emphasis has now shifted to a specialty-by-specialty incremental improvement approach: refining, standardising and embedding. 

Watch a recording of Q’s Community Space workshop in September 2021, during which Q member Sophie Bulmer spoke about work at UCL Partners.