How silo working is leading to longer length of stay… and what to do about it

Our recent blog, Can’t See the Ward for the Trees, highlighted the declining NHS bed numbers, and in Don’t Pack Your Pyjamas we looked at how many acute beds are occupied by patients that at first sight do not have acute needs.

Now we look at how hospital consultants work together and the impact this has on length of stay. In particular, we focus on the impact of referrals between consultants, and how these silos can be broken down to improve patient outcomes and reduce costs.

There are a lot of internal referrals…

In the hospitals that we have worked with, around 18% of admitted patient spells include a referral to another consultant within the same spell. As these referrals are within the same spell, they do not attract additional PbR tariff income – so there is not a commissioner cost. But they do add to a trust’s costs.

Typically these referrals are linked to longer length of stay. In one trust we have worked with, patients with a single consultant-to-consultant referral had a length of stay more than 8 days longer than patients who stayed with a single consultant. This picture is common across other trusts we work with. In a medium-sized DGH, at any time roughly 50% of beds will be occupied by patients progressing through a multi-episode spell.

There are many reasons for these referrals, some of which are clinically led. But it does raise a question about how organisations are structured and how they manage patient flow.

Most of the referrals happen between ‘specialty’ silos

We have looked at which specialties most commonly go together when patients are referred from one consultant to another. Some specialisms commonly lump together – e.g. geriatric medicine and gastroenterology (see table below).

Figure 1: Pattern of specialty-to-specialty referrals

Percentages show the mix of “destination” specialties, for each “origin” specialty

And this appears to be driven by different communities of consultants

When we dig deeper into the data, we see this is driven by what look like referrals between different communities of consultants. This is shown in the chart below, which uses our Cohorting algorithm to identify the closeness of different consultants (each dot is a consultant and the line is a referral).

But do the internal referrals require an acute bed?

A second question is whether the additional referrals are adding value. This is hard to spot in the data, but one indicator is whether patients are receiving acute interventions during their stay. The chart below shows that most patients (58%) having multi-episode spells don’t have a single procedure after their initial episode.

Whilst the data can only tell us so much, this demonstrates that there are a large pool of patients for whom the additional referrals might be for observation in an acute bed, rather than for receiving additional acute interventions.

Implications for your hospital

The Future Hospital Commission’s report highlighted the impact that specialised wards had on patients needing to move beds and accordingly on patient experience and length of stay. When this is combined with the impact of teams focusing on a single specialty, it creates super siloed working.

Each silo may provide a world class depth of care. But when silos are combined with poor IT and communication channels, they can also lead significantly longer length of stay for patients with complex care needs, hard to diagnose symptoms, or simply misdirected at the start of their pathway. This has an impact on the quality of care for the individual and organisational performance overall.

We have worked with an organisation that has worked hard to break down these silos and they have achieved outstanding performance – meeting both their 4-hour A&E and 18 week RTT targets, and maintaining or improving performance on both measures.

This suggests that a lot of organisations could have a dramatic effect on their performance if they are able to break down the siloed working between specialty teams. This is not easy, but the benefits are potentially huge – given that roughly 50% of acute beds have are occupied by a patient going through a multi-episode spell, reducing their length of stay has a substantial impact.

Failing this, organisations could focus more resources at the start of a pathway so that patients are at least allocated to the right team. E.g. having a MDT within 24 hours of decision to admit.