Organisational Pressure: Are Hospitals At Breaking Point?

The NHS is facing unprecedented challenges on both an operational and financial level, fuelled by an ever-increasing demand for services combined with limited resources. There is a constant need to ‘deliver more for less’, not helped by reports that NHS providers recorded a record deficit in 2015/16 (1). The strain is being felt across the entire healthcare sector, but most notably in areas such as mental health and community care. With further cuts imposed to social care and public health and the need to deliver £22 billion of productivity improvements by 2020/21(1), it’s no surprise that many organisations and individuals are buckling under the pressure.

“Combined with increasing demands on the healthcare system, these multiple pressures require NHS organisations to change, adapt and innovate on a scale that would make Apple and Microsoft catch their breath.”

Michael West, Head of Thought Leadership at The King’s Fund

The healthcare system has an underlying duty of care for anyone in need of medical assistance, but when demand far exceeds capacity, cracks inevitably begin to show. Medical professionals are being pushed to their physical limits, resources are being stretched beyond reasonable measure, and, yet, if they don’t meet their targets, they face public scrutiny for inefficiency and poor standards of care.

It has been suggested that the organisational structure of hospitals is often resistant to innovation and change. One healthcare professional reported cases of ‘Operational Tunnel Vision’, where, if a problem didn’t impact on their own patients, it was ignored. This insular view means that issues are only ever being dealt with at a micro level, when, in reality, changes need to be happening at a hospital-wide level if they are to have any impact at all.

Michael West, Head of Thought Leadership at The King’s Fund, seems to agree with this sentiment. He said:

“Making change at the level required to meet the current demands on the NHS will require new ways of working at every level: the adoption of new technologies by staff and patients; more research and development; and a major shift in the capacity of organisations to develop and adopt good practice. That will only be achieved if the right organisational conditions are in place.”

Unless the organisation is prepared to identify and address the causes of pressure, it’s unlikely they will be able to effectively manage it and improve conditions for both staff and patients alike.

The Risk to Patients

Organisational pressures often mean that decisions are made from a financial perspective, and not always in the best interests of patient welfare. Choices have to be made which may not be in the best interests of every patient, but the compounding priorities and pressures can be confusing. With only finite resources, healthcare professionals are often put in extremely difficult situations, having to prioritise organisational pressure over the welfare and potential health of patients.

Pressure on beds and infection rates are good examples of this. When hospitals are experiencing high levels of activity and high demand for beds, decisions have to be made concerning the level of cleaning of infected patients’ rooms before another patient is admitted. With rising cases of antibiotic-resistant organisms such as CPE, there is a very real risk that some patients are being put at risk of acquiring an infection whilst in hospital, which could have been prevented.

This view was reflected in a study by Huttner and Harbath (2015), who found that only 27 out of 74 MDRO (multi-drug resistant organisms) were identified as such at ICU admission, suggesting that a significant number of patients acquired the infection during their stay, despite enhanced terminal cleaning procedures.

Numerous studies have indicated that several factors are in play regarding the transmission of healthcare-associated infections (HAIs), commonly considered to be contaminated surfaces in patient environments, shared patient equipment and poor hand hygiene. These three factors are closely related and during times of high occupancy and demand for beds, it is easy to see how standards may slip, processes missed and, with that, the potential for patient infection to occur.

Reactive vs Proactive Approaches

When faced with critical issues such as the outbreak of an infection, hospitals are forced by default to resort to a reactive approach to tackling the problem. Many hospitals rely heavily on on-call decontamination services to help them manage outbreaks and infection risks. Whilst this resolves the issue at hand, it may not necessarily target the root cause of an outbreak. Hospitals end up being trapped in a vicious cycle of jumping from one crisis to another.

Case studies have shown that hospitals that are able to adopt a proactive approach to infection prevention, such as by implementing screening processes for patients on admission, along with enhanced proactive decontamination procedures, have been able to reduce outbreaks, minimise cases of infection and significantly reduce cases of cross-contamination. Over time, the wider healthcare benefits have been evident, such as reduced number of bed days and reduced costs of additional healthcare and medical intervention as a result of patients acquiring an HAI.

NHS Staff Remain Positive in Light of Increasing Pressures

Given the evidence presented so far, you could be forgiven for thinking that staff morale must also be at an all-time low. However, the recently released 2015 NHS Survey paints a very different picture.

This survey was the largest of its kind in Europe and surveyed over 741,000 NHS staff, with 299,000 responses received. The report showed that there has been improved staff engagement, despite intense pressures on the service and widespread negative media coverage. Steven Weeks, Policy Manager at NHS Employers, said that “the increase in engagement levels reflects the high levels of commitment of NHS staff and the sustained efforts by many NHS Trusts to improve involvement over the past year”.

Looking to the future, Steven Weeks also suggests that the sector needs to look at how to spread best practice from improving organisations to those that face the greatest challenges, as well as how to further sustain staff engagement and satisfaction in light of intensifying pressures on the service.

Whilst there is no ‘one-size-fits-all’ approach to the effective management of any healthcare setting, it’s clear that championing the successes of those that have made positive steps forward is critical to helping promote thought leadership, encourage change and ultimately reduce the pressures faced by NHS staff and Trusts.

Hydrogen Peroxide room disinfection – ready for the prime time? Huttner and Harbarth, Critical Care (2015)
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