Local system collaboration to address care backlogs

Birmingham and Solihull’s (BSol) virtual Elective Care Hub sits across the region’s hospitals,1 providing ​‘coordination and intelligence about what’s happening on the ground’. It is overseen by an operational delivery group of senior strategic, operational and clinical teams from the secondary, community and mental health trusts and primary care. This system-wide collaboration has supported two local system innovations: improving enhanced perioperative care pathways; and implementing Advice and Guidance (A&G) to reduce unnecessary new referrals into secondary care. 

Both projects built on work that started prepandemic and were scaled up due to the pandemic’s impact on access to services. The improved cross-system relationships and strategic collaboration developed as a result of the pandemic response were enablers. 

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

Space and capacity for post-operative recovery in critical care units (Intensive Therapy Units (ITU) and High Dependency Units (HDU))) was a pre-existing ​‘pinch point’. ​‘Then during the COVID first wave, access to elective critical care was significantly constrained… the traditional perioperative pathways we had just didn’t exist anymore.’ To preserve critical care capacity while sustaining some elective surgical activity, they developed ​‘extended recovery stays’, an enhanced model of care to increase safe postoperative care provision for patients needing complex surgery, which was endorsed by the Royal Colleges. Further development led to enhanced perioperative care units (EPOCs)2 , 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. To minimise this and work with existing skills and system capacity, ​‘instead of [patients] being referred and sitting on our outpatient waiting list, we go through the A&G process and where appropriate the secondary care clinician provides advice [to the GP on] how they can potentially manage that condition in the community’. This has required significant changes in ways of working for both primary and secondary care teams, and changes to data, monitoring, and finance systems. The new process has potential, but there are implementation challenges in improving quality and ensuring fair access.

They need 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; and their analysis shows fewer A&G referrals in more deprived areas.

The EPOCs have ​‘revolutionised’ the level of care provided for people waiting for surgery:

This system-level innovation, driven by COVID constraints, has helped to address a pre-existing capacity issue for post-operative recovery. A&G referrals have increased from around 1,200 per month in April 2019, to around 8,300 in June 2021, enabling primary care teams to identify patients 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&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&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&G] because a lot of them find it a learning process and it’s […] brought the two parts of that care system together’. 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.This benefits the local system as much as it does individuals for their career progression: ​‘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.’

The Hub is building on collaborations across primary, secondary and community care that were transformed during the pandemic. With shared oversight of challenges and centralised funding, they are better able to address the issues underpinning backlogs. Through sharing learning, 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 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 we are having to cancel for capacity reasons [we understand] that’s where we need to generate capacity in the system.’ BSol has also rolled out a consistent ​‘health status check’ process to improve the quality of the data and inform prioritisation, contacting 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 and… the social side about 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.

Given the number of changes made at speed during the pandemic, now the improvement emphasis has shifted to a specialty-by-specialty incremental improvement approach,5 ​‘refining what we’re doing… to standardise pathways… then embedding that into the process… and tak[ing] it forward to keep everybody on board of the value of this process.