Case Studies

Guy’s and St. Thomas’ NHS Foundation Trust

Guy’s and St. Thomas’ NHS Foundation Trust

Guy’s and St. Thomas’ NHS Foundation Trust banner image

Context and approach

Guy’s and St Thomas’ NHS Foundation Trust (GSTT) is one of the largest healthcare provider organisations in England with over 140,000 attendances passing through its St. Thomas’ site Emergency Department (ED) every year.

The Trust were becoming increasingly concerned about patients presenting with mental health problems in relation to the quality and appropriateness of their journey through the ED pathway. Particularly, issues were occurring which resulted in waiting time breaches, sub-optimal care quality and a higher cost base (often due to the need to ensure one-to-one nursing whilst in the ED). GSTT asked Niche to undertake a capacity, demand and patient flow review to more fully understand the:

  • nature and origin of demand;
  • pathways in, through and out of the ED;
  • options to provide (and commission) new efficient and effective care models for those presenting with mental health conditions;
  • capacity, staffing and financial implications of alternative models to meet service needs, particularly how to achieve a reduction in the current one-to-one nursing spend.

The analysis at a high level is shown below:

We undertook a series of stakeholder interviews with clinicians within the Trust as well as their psychiatric liaison provider and their commissioners. We also observed the ED in action and then built a simulation model across the ED pathway for patients presenting with mental health problems. This model assessed their journey ‘into the ED’, ‘through the treatment pathway’ and ‘out of the pathway’ essentially either home or to an inpatient bed.

What we found

There were several key findings:

  • mental health patients were an increasing element of ED activity and the rise in the absolute and proportionate volume was ‘statistically significant’ in recent years;
  • these patients were accounting for, in relative terms, over three times as many breeches than non-mental health patients;
  • Section 136 activity was on a significant upward trajectory;
  • the pattern of admissions was skewed towards the weekend but ‘drug and alcohol related activity’ was responsible for this (see below);

  • pathways for these clients were sub optimal and there were many opportunities to rectify this by better training, transition protocols, clearer policies and procedures, better observation guidance and enhanced coordination and communication between ED staff and psychiatric liaison colleagues;
  • the ‘nurse specialing’ spend was increasing rapidly both in the ED and on the wards. It was agreed to undertake an option appraisal to consider how to tackle this;
  • there was a need to update the service specification and communication policies between the partners to reflect up to date guidance and the findings from our modelling.

For more information about our capacity, demand and patient flow work and how we might help you.

Contact James Fitton

What our clients say

This was excellent work … and the flexibility that you and others provided to fit around operational teams, was also excellent

Joanne Furley, Director of Operations at Guy’s

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