Category Archives: Hot topics

Hot Topic: Patient Flow

A Word version of this briefing aimed at health care professionals is available for LKS staff to share in their own organisations. Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice:

  • Skilled librarians can locate the evidence for different approaches to patient flow. The evidence may not always be accessible through bibliographic databases, but librarians have the skill to locate other sources of evidence such as case studies or reports
  • Library staff can support the publication and sharing of patient flow initiatives, either as published documents or as poster presentations
  • Library services can provide point of care information tools that can speed up the diagnosis and treatment of patients, and that can support junior medical staff to make decisions when there are fewer senior staff available

What does ‘patient flow’ mean?

Patient flow is about the avoidance of delays in transfers of care, from for instance hospital to home or from A&E to a ward. It can also encompass admission avoidance, but this will be looked at in a separate Hot Topic.

One definition is ‘the right care, in the right place, at the right time’.

Why has patient flow become a hot topic?

The majority of delayed transfers are still due to NHS delays (such as awaiting further non-acute NHS care) but the proportion due to social care (such as awaiting a care package in own home) has risen steeply since 2014. In October 2017 there were 170,100 total delayed bed days (3)

An audit by NHS Benchmarking showed that while only 5 per cent of people aged over 65 who are admitted to hospital stay for more than 21 days, that 5 per cent accounts for more than 40 per cent of all bed days (1). Longer stays in hospital are associated with increased risk of infection, low mood and reduced motivation, which can affect a patient’s health after they’ve been discharged and increase their chances of readmission to hospital (3).

When bed occupancy is higher than recommended, it can lead to difficulties finding beds for new admissions, with knock-on effects in other departments such as A&E. (4)

There is also an argument that due to the way the figures for delayed transfers are defined, there are many more cases of patients that could be cared for in other settings, such as forms of intermediate care. (4)

What are the consequences of poor patient flow?

Some of the consequences (2) are:

  • A&E departments become crowded, stressful and unsafe
  • Patients are admitted as ‘outliers’ to wards that are not best suited to manage their care, which may mean they have worse clinical outcomes
  • Ambulatory care services, clinical decision units, even catheter labs and endoscopy units may fill with patients waiting for ward admission
  • Inpatients are shuffled between wards to make room for newcomers
  • Clinical outcomes are measurably worse, particularly for frail older people, who suffer more harm events and may lose muscle tone due to extended periods in hospital beds

What is being done to improve patient flow?

Three approaches for improving flow are: shape or reduce demand, match capacity and demand, and redesign the system.

There are lots of potential ways to improve patients flow that follow one of more of three aproaches, with one of the ideas being tried that of Accountable Care Organisations which bring health and social care providers together to take responsibility for the care for a defined population.

Other suggestions for improving flow in hospitals include (2),(6):

  • Deploying ambulance managers (sometimes termed ‘HALOs’) to help manage the hospital–ambulance interface and release ambulances quicker
  • Co-location of primary care facilities in A&E department to stream patients
  • Using Clinical Decision Units outside of A&E for patients who can be discharged following a short period of observation, investigation or treatment
  • Assessing patients for frailty when they present at A&E so they can begin to receive specialist care and get the right level of support when they are ready to be discharged.
  • Using the SAFER patient flow bundle and ‘Red2Green days’ tools
  • Using lean or Six Sigma approaches to quality improvement 

Further reading and references

  1. NHS Benchmarking, 2017, Older People’s Care in Acute Settings: National Report
  2. NHS Improvement, 2017, Good practice guide: Focus on improving patient flow
  3. King’s Fund, 2018, Delayed transfers of care: a quick guide
  4. Nuffield Trust, 2017, What’s behind delayed transfers of care?
  5. BMJ Quality and Safety, Six ways not to improve patient flow: a qualitative study
  6. The Health Foundation, 2013, Unblocking a Hospital in Gridlock South Warwickshire NHS Foundation Trust’s experience of the Flow Cost Quality improvement programme

Primary audience: LKS staff and their wider organisations

Date last updated: May 2018

Due for review: May 2019

Group member responsible: JC

Hot Topic: Recruitment of Community Nurses

Word version of this briefing produced by the JET Library at Mid Cheshire Hospitals NHS Foundation Trust aimed at health care professionals is available for LKS staff to share in their own organisations.  Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice 

  • While library and knowledge services provide valuable support to community nurses’ practice and CPD, it is more difficult to see how LKS can support their recruitment
  • LKS services may however be in a good position to support the retention of existing community nurses, for example by supporting revalidation
  • Due to the aging profile of the community nursing workforce, it may be a long time since formal study was undertaken, so for those that are looking to do further study more support and follow-up may be required when it comes to using the evidence-base
  • With a heavy caseload, they may not have time to visit the library so there may be a need for outreach to their bases

The problem

  • An aging workforce (Buchan, 1999) (Gaze, 2001) (Parish, 2005) (Ford & Dowler, 2011)
  • Ford (2014) found that since the 2011 Health Visitor Implementation Plan there had been a year-on-year increase in the workforce which had reached 10,382 by May 2014. At the same time the number of district nurses had fallen from 7,813 in May 2010 to 5,586 in July 2014
  • Evans (2016) pointed out that there had been a 48% drop in district nurse numbers between 2000 and 2014 with numbers falling to fewer than 6,000 full-time roles in England.

Why people go into community nursing

  • Community nursing is often seen as a career destination after a period working as a nurse in the acute sector (Buchan, 1999)
  • More mature nurses are attracted by the opportunity to function independently and autonomously (Buchan, 1999)
  • Enjoying community placements (Gaze, 2001)
  • The opportunity to work with families (Gaze, 2001)
  • The opportunity to influence health policy (Gaze, 2001)
  • Being inspired by one’s family and colleagues (Gaze, 2001)
  • Increased initiative (Thurtle, 2005)
  • More autonomy (Thurtle, 2005)
  • Preferred hours (Thurtle, 2005)

What has been done to attract more people?

  • In South Essex – a practice-nurse apprenticeship scheme to train and prepare students for work in general practice (Bishop & Jones, 2001)
  • Fear (2004) describes a 14-week broad-based community experience for pre-registration nurses which was positively evaluated by both mentors and students
  • Pre-registration placements (Robinson, 2004)
  • Rotational programmes for newly-qualified nurses (Robinson, 2004)
  • Schemes to train nurses from other sectors (Robinson, 2004)
  • A rotation scheme for newly-qualified staff nurses run jointly by an East-London Primary Care Trust and a hospital (Abbott, Bryar, & Hostettler, 2005)
  • A final-placement scheme for community-nursing students developed in Walsall Teaching PCT (Doley & Roberts, 2005)
  • Leicestershire County Council and Rutland Community Health developed a return-to-practice scheme with the University of Northampton (Amin, Martin, & Turney, 2010)
  • Nursing students at the University of Bradford joined community teams specialising in smoking cessation, care of the homeless and cardiac rehabilitation (Dean, 2010)
  • University of Cumbria students spend half their placement time in the community (Dean, 2010)
  • ‘Hub and spoke’ programmes where a central mentor allocates students to different placements so they can gain a variety of experiences (Dean, 2010)
  • A return-to-practice programme in NHS East Midlands (Dean, 2010)
  • A collaborative scheme developed between Leicestershire Partnership Trust and De Montfort University in which nursing students were able to undertake delegated care activities independently while working in community practice placements (Brooks & Rojahn, 2011)
  • In September 2008, Yorkshire and Humber Strategic Health Authority involved local providers, local universities and service users in a project that aimed to offer opportunities to third-year nursing students interested in careers in the community at the point of registration (Brown, 2013)
  • In Leicester a framework was developed between practice and higher-education providers which had a remit of enhancing existing community placements (Brown, 2013)

What puts people off going into community nursing?

  • Stringent entry requirements and lengthy education programmes (Meehan, 2004)
  • Salary (Cameron, Armstrong-Stassen, Bergeron, & Out, 2004)
  • A lack of recruitment and retention programmes (Harrison, 2004)
  • Routes into primary care being “complex, confusing and convoluted.” (Harrison, 2004)
  • A limited pre-registration curriculum (Robinson, 2004)
  • Limited clinical-learning experiences (Robinson, 2004)
  • Few clinical-learning experiences available in general practice (Robinson, 2004)
  • Over-rigid content and funding of training programmes (Robinson, 2004)
  • Lack of money for training schemes (Robinson, 2004)
  • Worries about overloading experienced practice nurses (Robinson, 2004)
  • Different perceptions about priorities among GPs (Robinson, 2004)
  • A lack of information about the workforce and evidence about what works (Robinson, 2004)
  • Challenges universities face in getting community placements for their students (Dean, 2010)
  • Misconceptions about unrewarding and unchallenging work, lack of career advancement and a negative working environment (Sheedy, 2011)
  • While (2014) commented that few community nurses were recognised in the mass media or the professional press and that the media more often promoted hospital-based services rather than community ones.


Abbott, S., Bryar, R., & Hostettler, M. (2005). Developing career pathways for new nurses: lessons from inner London. British journal of community nursing, 10(11), 508-512.

Amin, M., Martin, S., & Turney, N. (2010). Evaluation of a return to practice health visiting scheme. Community Practitioner, 83(3), 25-28.

Ashley, C., Halcomb, E., Brown, A., & Peters, K. (2018). Experiences of registered nurses transitioning from employment in acute care to primary health care–quantitative findings from a mixed-methods study. Journal of clinical nursing, 27(1-2), 355-362

Bishop, T., & Jones, J. (2001). Recruitment: working together to support new practice nurses: a practice nurse apprenticeship scheme. Practice Nurse, 22(6), 14-22.

Brown, K. (2013). Community placements for nursing students. Primary Health Care (through 2013), 23(6), 28-30.

Buchan, J. (1999). Nurse till you drop! Nursing Standard (through 2013), 13(13-15), 34-35.

Cameron, S., Armstrong-Stassen, M., Bergeron, S., & Out, J. (2004). Recruitment and retention of nurses: challenges facing hospital and community employers. Nursing leadership (Toronto, Ont.), 17(3), 79-92.

Cho, E. M. (2009). Recruitment and retention in residential care. (MR55205 M.A.), Royal Roads University (Canada), Ann Arbor. Retrieved from Hospital Premium Collection database.

Cowley, S., & Bidmead, C. (2009). Controversial questions (part two): should there be a direct-entry route to health visitor education? Community practitioner : the journal of the Community Practitioners’ & Health Visitors’ Association, 82(7), 24-28.

Dean, E. (2010). Pressure on universities to find more community placements. Nursing Standard (through 2013), 24(52), 12-13.

Doley, B., & Roberts, S. (2005). Managing student transitions into primary care. British journal of community nursing, 10(12), 563-565.

Evans, N. (2016). Picture of a ‘broken’ workforce. Nursing Older People (2014+), 28(8), 8.

Fear, T. (2004). Community placements for pre-reg nurses. Journal of Community Nursing, 18(5), 32-34.

Fear, T. (2016). Developing sustainable placements: nursing students in general practice. Primary Health Care, 26(10), 24-27.

Ford, S. (2014, Nov 12-Nov 18

Nov 12-Nov 18, 2014). Ups and downs in the community nurse workforce. Nursing times, 110, S6-S7.

Ford, S. (2015, 2015 Feb 19). Yorkshire trust shores up community services with overseas nurses.

Ford, S., & Dowler, C. (2011, Jul 19-Jul 25

Jul 19-Jul 25, 2011). 100,000 fewer nurses in 10 years predicted. Nursing times, 107, 2-3.

Gaze, H. (2001). Matching expectations. Community Practitioner, 74(12), 448.

Gordon, C. J., Aggar, C., Williams, A. M., Walker, L., Willcock, S. M., & Bloomfield, J. (2014). A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce? BMC Nursing, 13(34).

Harrison, S. (2004). Routes into primary care ‘complex and confusing’. Nursing Standard (through 2013), 19(3), 7.

Meehan, F. (2004). A gathering of the masses. Journal of Community Nursing, 18(7), 3.

Norman, K. M. (2015). The image of community nursing: implications for future student nurse recruitment. British journal of community nursing, 20(1), 12-18.

Parish, C. (2005). Recruitment needs to double to keep pace with retirement rates. Nursing Standard (through 2013), 19(33), 8.

Robinson, F. (2004). Innovative schemes to recruit practice nurses. Practice Nurse, 28(7), 10-16.

Sheedy, S. R. N. B. M. H. S. (2011). A call to action: dispelling the myths and reducing the negative factors impacting nursing recruitment to long-term care. Perspectives (Pre-2012), 34(4), 17-26.

Thurtle, V. (2005). Why do nurses enter community and public health practice? Community Practitioner, 78(4), 140-145.

While, A. (2014). Where is the recognition of community nurses? British journal of community nursing, 19(11), 570.


Using Hot Topics for searches

Recently I was asked to conduct a quick search to provide some information on Accountable Care Organisations and Accountable Care Systems.

Luckily I remembered the Hot Topics that we have been adding to the MAP over the past year. The hot topic about Accountable Care Organisations, provided a great starting point for the search highlighting some of the key reports and including a useful summary which I could use in my search report.


If you have any ideas for any new hot topics  to be added to the MAP, email us at 


Hot Topics: Neighbourhood Care Teams

A Word version of this briefing aimed at health care professionals is available for LKS staff to share in their own organisations.  Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice: 

  • LKS may need to consider how to provide clinical librarian services to what in effect are ‘virtual wards’
  • Integrated care teams may contain members from social care, housing, and the voluntary sector that have not traditionally been served by NHS LKS, and consideration may need to be given the potential needs of these users so we can provide as seamless a service as possible to all members of the team. At a national or regional level, it would be useful to negotiate funding for NHS LKS to provide services to these groups so that this doesn’t have to be negotiated on an individual LKS basis
  • LKS may need to look at information resources to support social care staff in particular
  • There could be a role for LKS in providing information to service users covered by the care team, as one of the objectives is to support them to manage their own health
  • As with Accountable Care Organisations, as organisational boundaries blur, LKS may be required to adapt their service delivery models accordingly, particularly as care moves increasingly into the community

What are neighbourhood care teams?

Neighbourhood care teams are a specific example of integrated care.

These are usually local teams comprising health and social care professionals, sometimes supported by housing professionals or the voluntary sector, that work with people with long-term or multiple conditions or the frail elderly. The service user usually has access to a case worker or navigator for a single point of access, medical records are usually shared between the members of the team, and members of the team may be drawn from different organisations. Their aim is to support people to remain in their own homes and live as independently as possible, and to avoid unnecessary hospital admissions.

They may also be known as integrated local care teams, locality care teams, virtual wards, neighbourhood teams or similar. Neighbourhood care teams or similar models are a feature of many local Sustainability and Transformation Plans (STPs).

What examples are there of neighbourhood care teams in practice?

The document from NHS England on new care models (1) provides examples of a couple of schemes similar to neighbourhood care teams, namely Fylde Coast Local Health Economy and Stockport Together.

Other examples include:

What’s the evidence for neighbourhood care teams?

A Nuffield Trust report (2) looking at different community interventions including integrated health and social care teams found no evidence of a reduction in hospital admissions, but this may be due to ‘case finding’ identifying previous unmet needs, and any reduction in admissions may only happen in the long-term.

However, there is evidence (3) that co-ordination of care through integrated teams improves patient experience and quality of life, and some evidence that chronic care management models are associated with lower costs.

Further reading

  1. NHS England (2016). New care models: Vanguards – developing a blueprint for the future of NHS and care services
  2. Nuffield Trust (2011). An evaluation of the impact of community-based interventions on hospital use
  3. King’s Fund (2015). Care co-ordination through integrated health and social care teams

Hot Topic: Social Prescribing

A Word version of this briefing aimed at health care professionals is available for LKS staff to share in their own organisations.  Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice: 

  • LKS teams may be asked to try to locate or synthsise evidence to support the commissioning of specific social prescribing initiatives
  • LKS teams, in collaboration with public library services may be involved in the provision of some social prescribing initiatives (such as service-user or staff reading groups, digital literacy training, books on prescription schemes or similar – see the KfH PPI group’s Ideas Bank for more ideas) or in working with social prescribing co-ordinators to signpost to suitable opportunities (many public library services will have directories of community organisations)
  • LKS could work with occupational health teams to have staff referred to particular initiatives run by the library
  • Social prescribing, along with other initiatives in local STPs, may represent a shift away from secondary care and this may have implications for our user base which may become more community-based

What is social prescribing?

It is a means for GPs and other primary care professionals to refer patients to non-medical interventions that can be used to improve their physical or mental well-being. The kinds of options available for prescribing could include walking groups, knit and natter groups, cookery classes, adult learning, volunteering, and self-help reading (the Books on Prescription scheme is an example of social prescribing).

Social prescribing is mentioned in the NHS England document ‘Next Steps on the Five Year Forward View’ and in the General Practice Forward View as a means of reducing avoidable demand, with an aim to work with the voluntary sector and primary care to ‘design a common approach to self-care and social prescribing’ (1). A national clinical champion for social prescribing was appointed by NHS England in 2016.

Social prescribing is a feature of many local Sustainability and Transformation Plans (STPs).

What examples are there of social prescribing in practice?

There are plenty of examples, some of which are listed in the evaluation carried out by the University of York on pages 5-7 (2). The Commissioning Handbook for Librarians provides suggestions for searching for material about social prescribing (3) which will help identify more.

The Rotherham social prescribing service is a very large scheme, and was mentioned in the NHS Five Year Forward View as an emerging model for the future.

What’s the evidence for social prescribing?

A systematic review carried out in 2016 and published in BMJ Open (4) found that there was there was little good quality systematic evidence to inform the commissioning of social prescribing programmes, as did a previous review of 2015 published by the University of York’s Centre for Reviews and Dissemination (2).

There is some evidence that social prescribing schemes can make a difference to outcomes such as quality of life, levels of depression, and reduction in use of health services, and social prescribing schemes show high levels of satisfaction from users and health care professionals. However, much of the evidence is qualitative, is from self-reported outcomes, and is from small-scale schemes. Most studies focus on a particular intervention rather than social prescribing generally(5). Evidence on the cost-effectiveness of social prescribing is limited.

Further reading

  1. NHS England (2017). Next steps on the NHS Five Year Forward View.
  2. University of York. Centre for Reviews and Dissemination (2015) Evidence to inform the commissioning of social prescribing.
  3. The Commissioning Handbook for Librarians (2017) Social Prescribing.
  4. Bickerdike L, Booth A, Wilson PM, et al. Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open 2017;7
  5. King’s Fund (2017) What is social prescribing?

Primary audience: LKS staff and their wider organisations

Date last updated: May 2017

Due for review: May 2018

Group member responsible: JC

Hot topic: Accountable Care Organisations

A Word version of this briefing aimed at health care professionals is available for LKS staff to share in their own organisations.  Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice: 

  • LKS teams may be affected by changes to organisational structures as a result of the emergence of Integrated Care Systems, Integrated Care Partnerships and Accountable Care Organisations (ACOs).
  • There may be an opportunity to deliver evidence and knowledge to managers, commissioners and transformation teams as health care services undergo this change.
  • As organisational boundaries blur and take a ‘whole population’ approach, LKS may be required to adapt their service delivery models accordingly.
  • If healthcare moves away from a competitive structure and towards a collaborative one, there will be many opportunities relating to knowledge management that could support the sharing and dissemination of good practice, innovation and organisational knowledge.
  • LKS will have to consider how the negotiation and procurement of resources needs to adapt to reflect the changes in organisational structures.
  • There is a clear role for technology in supporting the emergence of these news systems that presents an opportunity for digitally enabled LKS.

What is an Accountable Care Organisation?

An Accountable Care Organisation (ACO) or Accountable Care System (ACS) brings together a number of providers (e.g. acute hospital care, general practice, mental health, social care, ambulance services and pharmacies) to take responsibility for the cost and quality of care for a defined population within an agreed budget (1).

ACOs have been proposed as one way of overcoming fragmented responsibility for the commissioning and provision of care in the NHS.  They could in principle offer an organisational structure that draws together previously siloed or competing providers into a network with a shared sense of purpose and financial interest (3).

Next Steps on the Five Year Forward View (5) describes ACOs as “an evolved version of an STP” and states that ACOs “provide joined up, better coordinated care”.  It published the names of nine geographical areas that are likely to emerge as ACOs in 2017/18.

What can we learn about ACOs from elsewhere?

ACOs have evolved recently in the United States and they build on a much longer history of integrated care systems such as Kaiser Permanente and Intermountain Healthcare (1).

In the UK, three ‘Vanguard’ schemes stated their intention to explore the potential of the ACO as an organising structure in the NHS: Northumbria, Northamptonshire and Salford (3).

The first wave of Integrated Care Systems (formerly shadow Accountable Care Organisations) are currently assuming accountability for local operational and financial performance in:  South Yorkshire and Bassetlaw, Frimley Health and Care, Dorset,  Bedfordshire, Luton and Milton Keynes, Nottinghamshire, Blackpool and Fylde Coast,
West Berkshire, Buckinghamshire, Greater Manchester (devolution deal), Surrey Heartlands (devolution deal) (8).

What are the challenges involved?

  • Relationships: Establishing strong relationships between the leaders of participating organisations and the clinicians who deliver care;
  • Technology: Accelerating the implementation of electronic care records to help predict avoidable hospital admissions and to coordinate discharge planning;
  • Finance: New ways of commissioning and paying for services need to be established across traditional organisational boundaries (1).
  • Legal challenge: The proposed  changes to regulations and consultation on the draft ACO contract have resulted in two legal challenges from 999 Call for
    the NHS and JR4NHS. (7)

Further reading

  1. King’s Fund, 2016, Accountable Care Organisations explained
  2. King’s Fund, 2014, Accountable Care Organisations in the United States and England
  3. National Health Executive, 2016, Accountable care organisations: the future of the NHS?
  4. Nuffield Trust, 2016, Accountable Care Organisations: The winners and losers
  5. NHS England, 2017, Next Steps On The NHS Five Year Forward View
  6. House of Commons (2018) Accountable Care Organisations
  7. Kings Fund (2018) Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England
  8. NHS England (2018) Integrated care systems (ICSs)

Primary audience: LKS staff and their wider organisations

Date last updated: February 2018

Due for review: May 2018

Group member responsible: VT