Events would suggest our current approach to making decisions in the healthcare system about the annual €25.8 billion budget is flawed, writes Dr Nicola Mountford from MU's School of Business.

    A record amount of money will be spent on healthcare this year, but what will it be spent on? The €2.2 billion committed to an as-yet-unfinished Children's Hospital might give rise to legitimate concerns about where this year's €25.8 billion will end up.

    Spending €25.8 billion requires a series of decisions: from big decisions, such as the strategic decision to build a brand new children’s hospital to seemingly small decisions, such as whether one child in that hospital goes home on a Saturday or the following Monday.

    Consistently high numbers of patients being kept on trolleys suggests that the current approach to making at least some of these decisions is flawed. We just don't seem to be able to make these massive healthcare budgets count where they should.

    Strategic decisions, such as the children’s hospital investment, are fundamental in shaping the course of the healthcare system: these kinds of decisions are usually infrequent, are made by organisational leaders, and are critical to organisational success or failure. But cumulatively, seemingly small decisions, such as whether and when to discharge a particular patient, may add up to a much greater strategic problem for our healthcare system.

    In March 2023, hospital bed capacity was running at a possible deficit of approximately 1,000 inpatient beds in public acute hospitals, contributing to overcrowding issues. These issues are likely to intensify as demand pressures increase due to an increasing and ageing population. Overcrowding is made worse by delayed discharges – where a patient is medically fit to leave but remains in hospital due to a lack of step-down care. Figures indicate that, in 2022, 7,102 patient discharges were delayed resulting in 207,096 lost bed days.

    But who is making these smaller decisions? How are they making these decisions? What gets taken into account and whose voices get heard? In November 2023, the Health Services Executive announced a new rule that seeks to address this issue. It now insists that such patients (who have been pejoratively and controversially referred to as "bed blockers") leave hospital once medically ready – whether they want to or not.

    While there is an urgent national need to reduce delayed discharges, this must be balanced with the rights and concerns of individual patients and their families. Recent research suggests that more inclusive decision-making approaches lead to better funding decisions in healthcare spending. Looking at how much smaller spending decisions are made holds the key to making better decisions at the system level.

    Taken as a group, hospital discharge decisions are fundamental to the survival of our healthcare system - over 23,763 patients were waiting for inpatient care as of late last year. Wouldn’t it be better, then, if individual discharge decisions were seen as strategic decisions and involved the patients more directly? When looked at from the perspective of the patient and their families, they are actually strategic decisions. For them, these decisions are hopefully infrequent, are likely made by their healthcare leader, and they may well shape the course of their life – at least for a time.

    If we treated each discharge decision as a fundamental decision that critically affects the lives of patients and their families, we might adopt a more strategic approach to decision-making. On first reading, this may appear to argue for a more 'corporate’ approach that prioritises financial concerns. On the contrary, however, it argues for a focus on the process by which these decisions are made and, in particular, how the voice of patients and their families is heard and made to count.

    Strategic decision-making processes are characterised by novelty, complexity and open-endedness. Hospital discharge decisions are perhaps considered the opposite of this from the clinical perspective. When we overlook the fact that each individual discharge decision is in fact complex and novel with open-ended repercussions, we risk ignoring how discharge decisions are made at a process level.

    We know quite a bit about ‘why’ such decisions are made. Cost considerations and patient orientation may come into conflict and a particular decision may prioritise one over the other. For example, decisions not to fund particular drugs that will improve the quality of patient lives but which are considered too expensive. We also have learned about the micro-level cognitive processes from the healthcare professional perspective - in other words, what the discharging clinician is thinking when they make that decision.

    But what we don’t know is what happens throughout the process. Decision-making involves three processes: intelligence and information gathering, designing and generating options, and choosing between those options to form a course of action. These three processes can unfold in different orders with twists and turns. We know that more effective decision-making results when we consider a wider range of solutions, consult more people, bring in new types of information, and achieve buy-in from those affected.

    Why is it, then, that patients and their families are very often not consulted in decisions to discharge them from hospital? The role of the clinician in Ireland, and further afield, is highly institutionalised. We look to doctors to make decisions for us about our healthcare. As a society we grant them permission to inform us, rather than consult us, about our own healthcare. Perhaps more attention to the design of decisions and how decisions are made would improve the quality of resulting decisions - from very large decisions such as national hospitals, to very small decisions such as whether one baby should leave the NICU and go home to the care of their family.

    Maybe involving those who have to live or die with the decision would lead to more innovative ideas around discharge practices. Some might go home earlier, some later, and some to a place other than home. Across all of these decisions we may find that we can eliminate the term ‘bed blocker’ from our vocabulary and instead see patients as part of the team, a team with a common goal – a resilient healthcare system that takes care of us all.

    This piece originally appeared on RTÉ Brainstorm