There's an Einstein quotation that I love: "No worthy problem is ever solved within the plane of its original conception." I love it because it explains why we struggle to solve the problem of patient flow.
All our attempts to improve patient flow in the NHS have been within the plane of its original conception. We've been trying to solve the problem at the individual patient level: "Let's see if we can discharge Mr Smith a day earlier than planned so that we can free up an extra bed in Ward 9."
This is the operational plane. And our attempts to improve patient flow within this operational plane have failed.
If we are to properly grasp the nettle of patient flow, we need to grasp the nettle of bed occupancy. An inpatient specialty operating at—for example—98% bed occupancy will need to transform itself into a specialty that operates at—say—90% bed occupancy.
And if we are to grasp the nettle of bed occupancy, then we will almost certainly have to grasp the nettle of length of stay, too. Individual specialties will likely need to reduce their average length of stay if they are to reduce their bed occupancy.
But this—I think—is when we encounter a language problem. Or it might be a culture problem. Or it might be that we're just in the wrong 'plane of conception'.
I have this hunch that when we ask the question "Is it possible to reduce length of stay?" of a consultant in a bed-holding specialty in an acute hospital, they hear: "You want me to discharge Mr Smith a day earlier than planned."
Whereas what we actually mean is more along the lines of: "Has the specialty as a whole got a plan to reduce its average length of stay from x.x days to y.y days?"
I think this misinterpretation (between the operational 'here-and-now' of Patient X and the strategic 'there-and-then' of all the patients) might be at the heart of our failure to improve patient flow.
That's why Einstein's quote is so relevant. The plane of patient flow's original conception is 'the operational here-and-now' of Patient X. But we won't solve patient flow within that plane. We need to move to the plane of 'the strategic there-and-then' of all the patients.
[27 August 2025]