The cost of NHS queueing

QUEUEING. It is something the British have a reputation for. But it is one of the things that is costing Southampton's NHS trust millions of pounds.

Hours, even days, can be wasted, taking up precious space in a hospital bed, while a patient waits in line to see a doctor, to have a test or simply to be told they are ready to go home.

Addressing the issue is one of the ways in which bosses at Southampton University Hospitals NHS Trust are hoping to modernise the service.

Last month the Daily Echo revealed how the trust - which runs Southampton General, the Royal South Hants and the Princess Anne hospitals - is facing a £24m shortfall by next April.

The trust is already £5m in the red, prompting finance chiefs to set a savings target of £15m over the next 12 months, through measures which include a partial recruitment freeze and minimising the use of agency nurses.

But what is the cause of what has been described by trust chiefs as their biggest financial challenge ever?

Over the years a gap has developed between the trust's income and what it spends, principally because the trust is providing services for which it is not being fully paid.

Funding for health care goes direct to primary care trusts who are then responsible for buying the services to meet the needs of the local populations.

Formed in 2000, PCTs are the NHS organisations which deliver healthcare services across the area, including GP surgeries, health centre and community hospitals.

Next April, a national tariff will ensure that all health care providers are paid a set price for each procedure they carry out, based on the national average, and the PCTs will have to pay the full price for any service they need. For most procedures the national tariff is more than what the Southampton trust currently charges.

On the face of it, it is the answer to their prayers.

But in reality it does not solve the problem - it simply moves it, transferring the deficit from the trusts to the PCTs.

"From next April we will be paid more appropriately but the PCTs will be paying more for the same level of service, and will consequently start going into deficit," says Ben Lloyd, director of finance for SUHT.

The root to financial stability across the whole system, he argues, is modernisation - redesigning the service.

"We are all part of the NHS and we have to work together to resolve the underlying financial problem," he said.

The trust is now taking action - to modernise the service and make it more affordable.

Two main areas which are being addressed, explains Mr Lloyd, are 'day case rates' - the number of patients treated and sent home in the same day - and 'length of stay'.

"There has been a shift from what started out years ago," he says

"We are now able to do some things much more quickly."

"There are now certain procedures recognised nationally that should be done as day cases," he adds, giving hernia and cataract operations as examples.

"We monitor that closely.

"Where they can be done as day cases, we do them as day cases. They come into hospital in the morning, have their surgery and are home again by the evening."

Increasing day case rates is good for both the patients and the hospitals, says Mr Lloyd.

"Hospitals are scary places to some people. Most people would rather stay at home given the choice."

And for the benefit of the hospitals, it frees up beds to treat more patients.

"It is a win win situation," says Mr Lloyd.

But it doesn't always work, he adds, as patients may be 'bumped' out of their slot by an unplanned, more urgent, procedure.

As part of the goal to increase day case rates, the Southampton University Hospitals NHS Trust is currently working with the Winchester and Eastleigh Healthcare Trust to develop a diagnostic and treatment centre.

"It will be a centre that is much better at day case rates because it will be staffed just to do day cases," says Mr Lloyd.

He compares the concept to that now instilled in the hospitals' accident and emergency departments, where having one set of staff to deal with major cases and another to deal with the minor cases means that patients are not constantly being pushed further and further down the queue as more major cases come in.

Addressing how long a patient stays in hospital

ONE other key area trust bosses are addressing is how long a patient stays in hospital.

Using a hypothetical patient, Mr Lloyd explained how a stay in hospital can often be much longer than actually required, due to force of circumstances, which clogs up beds desperately needed for others.

The hypothetical patient, he says, might be admitted to hospital after being seen by the accident and emergency department.

Staff in A&E might be concerned that he has an appendicitis, so they admit him.

It may then be several hours before he is seen by the relevant consultant, who then concludes that it is not an appendicitis, but that they would like their colleague to look at him.

So he waits another day. The second doctor then says he wants to him to have a scan, but can't get him in that day.

"That patient could be in the hospital for three or four days, being passed around the system," explained Mr Lloyd.

"We are doing the best we can, but the patient is not being fast-tracked through in any way. They are queuing at lots of different points.

"We are trying to change the pathway of care so we can eliminate the internal queueing within the organisation, so that we do the same for a patient but in a shorter length of time.

"That is great for the patient as they feel good that they are not waiting.

"And it is great for us because we see them treated and out of the door quicker, so we have the bed available to treat the next person who comes along."

The trust is currently setting targets and directorates, identifying areas for improvement in order to reduce length of stay.

Having consultants conduct ward rounds on a daily basis, for example, would ensure that every new patient admitted to a bed from A&E was seen on the day they are admitted, which would potentially save a delay.

Another example where there is a potential for reducing length of stay is when two patients are waiting for the same procedure, with what appears to be the same level of urgency.

But in actual fact, while it won't matter if one is waiting a couple of days, for the other it is the last thing left to be done before they can leave the hospital.

"Which would you do first?" asks Mr Lloyd.

"It is all about prioritising and scheduling."