Feature / Magnificent seven

Seven-day services are now on the NHS to-do list and trusts are working out what it will mean for them and how much it will cost. Seamus Ward reports

December’s seven-days forum report and the subsequent NHS England planning guidance confirmed a big shift in the way the health service will offer urgent and emergency care. Once implemented, no longer should someone admitted on a Friday night face waiting until Monday to see a specialist. Nor should a patient medically fit for discharge on a Sunday afternoon have to sit tight until the ward round the next morning.

The NHS is seeking to understand what the initiative means as it looks to migrate to seven-day services over a three- to five-year period. In some ways, it is clear: the NHS seven days a week forum says emergency and urgent care, and supporting diagnostic services, should be available seven days a week. But, as the forum’s report and HFMA costing work for it point out, trusts are starting from different positions.

For now, seven-day services does not mean offering routine outpatient appointments out of hours. Some hospitals will have to invest in services during the week, never mind the weekend, to meet the 10 clinical standards laid down by the seven-days forum. The HFMA found the move to seven-day services would cost between 1.5% and 2.5% of total income, depending on the type of organisation and how many services were already operating on a seven-day basis.

Some trusts have already invested in services to meet local need. But gaps remain, whether they be diagnostic labs closed at weekends or therapists not available. It is clear more staff will be needed, particularly senior hospital doctors.

Chesterfield pilot

Chesterfield Royal Hospital NHS Foundation Trust launched its seven-day service project in January. It is one of 13 early adopters named by NHS Improving Quality as pilot sites. It follows the trust’s earlier work on patient flow for non-elective medical patients. This was adapted to examine costing of seven-day services for emergency patients and diagnostics, featured in HFMA costing work for the seven-days forum.

HFMA director of policy Paul Briddock was the trust director of finance when the patient flow work was carried out. He says this work was partly about seven-day services, but it also encompassed avoiding unnecessary admissions and discharge as soon as clinically appropriate.

The trust held a series of workshops with clinical staff to work through the seven-day forum clinical standards for surgical and orthopaedic patients. ‘We looked at the additional medical staffing needed where we weren’t compliant with the standards during the weekdays as well as the weekends,’ he says.

The cost of extending seven-day services across the whole trust included recruiting about 24 consultants. ‘We found it would require an investment of £4.5m, or 2.4% of our overall income. However, we did not model further savings, as we had with the non-elective care, which paid for itself.’

The Chesterfield pilot has two parts. The first involved investing in senior decision-makers in A&E and its emergency management unit, which receives referrals from GPs. Six consultant staff (whole-time equivalents) were recruited and hours for these clinicians were extended into the evenings and weekends.

The second part focused on services to patients admitted at weekends. This meant increasing access to diagnostics, including radiology, CT scanning and ultrasound, and therapies. Physiotherapy and occupational therapy was also made available at weekends.

Hospital pharmacy input on the wards was extended at the weekend so patients could get their discharge drugs, and supernumerary discharge coordinators were introduced to the wards to maximise discharge.

‘Overall, this cost around £1.4m and we found, on the back of improving patient flows and avoiding unnecessary admissions, there was a significant reduction in average lengths of stay,’ Mr Briddock says. ‘In normal circumstances, this would have meant 30 fewer beds, saving £1.8m, though we invested £1.4m leading to an overall saving of £0.4m. But we were not able to release beds because non-elective activity grew.’

The trust found that non-elective activity growth matched the reduction delivered by the patient flow project. The patient flow work theoretically reduced the trust medical bed requirement from 330 to 300, but rising non-elective activity meant 30 beds were needed.

‘If we hadn’t done the patient flow work, we would have gone up to 360 medical beds,’ says Mr Briddock. ‘But in the end we could keep it steady at 330. So this saving is really about cost avoidance.’

Wrightington, Wigan and Leigh NHS Foundation Trust is another early adopter site. Seven-days leader Sir Bruce Keogh has said the trust could provide lessons to others on their financial approach. Its director of finance and informatics Rob Forster says: ‘We have concentrated on a value approach,’ . ‘I come from the car industry, where the emphasis is to get the most bang for your buck. That’s how we have approached seven-day services.’

The trust believes that operating over seven days can improve quality and reduce costs across the health economy. ‘You can reduce admissions and avoid hospital-related infections and excessive lengths of stay,’ Mr Forster says. ‘We believe there is a value proposition here, but it is a continuum. At one end, the hospital is open 24/7 with full services, but the problem is that is not affordable as a whole and thus not best value for money. At the other end, it’s open five days, but people are not ill just between 9am and 5pm, Monday to Friday, so that’s not value for money. Our value proposition is somewhere in the middle and our pilot aims to find the optimum point.’

Need for research

Mr Forster believes there is a need for an academic study to assess and verify the benefits of investing in seven-day services. Savings could be found by ensuring patients are in the correct wards as this is known to reduce length of stay. ‘You can also get reduced lengths of stay simply by having more senior personnel on site, seeing the patients,’ he continues.

‘Junior staff tend to err on the side of caution, which is what you’d want, and possibly keep people in hospital, when an experienced consultant might not. There are big savings to be made potentially. This is all about having the experience in place that allows you to take cost out of the health economy as a whole.’

While savings are possible, initially seven-day services will be a pressure. ‘It’s almost a double whammy for the hospital,’ adds Mr Forster. ‘To do the right thing, you need to invest in senior personnel for longer and at weekends. We believe that will cost £2.1m. But if we get the outcomes we believe, there should be fewer people admitted and our income will reduce.

‘It is definitely the right thing to do for patients and the health economy as a whole. We are committed to it, but as a provider we have to cover the cost and our income is reduced. Over time we might be able to reduce our beds, but the income will stop before we can take beds and staff out, as we can only do this when it is proven safe to do so.’ He says the trust is discussing with its local clinical commissioning group how the investment will be funded, but he feels this may fall under the better care fund in 2015/16.

Mr Briddock says tariff rules can present a barrier to seven-day services. ‘We had long discussions with our commissioners about these additional 30 beds as they would be paid at the 30% marginal rate but, given the positive work we had done in reducing and dealing with the effect of emergency admissions, commissioners agreed they would pay for the activity at full tariff using [the other 70% of] the funding. Commissioners and providers have to work together as payment mechanisms don't always facilitate changes in service delivery models.’

Transformation agenda

The move to a seven-day service is part of the overall transformation agenda, he adds. The trust has asked what services are sustainable – in some cases down to subspecialty level – in the evenings and weekends. ‘This work is really challenging as we can’t continue to do all the things we are doing on a 24/7 basis. This will lead to a lot of networking and partnering arrangements so the range of services will be provided across a health economy.’

Mr Forster hopes his trust’s pilot can show that seven-day operation increases quality and reduces costs as a whole and that activity is led by demand rather than supply. The trust is focusing on ensuring emergency and urgent care patients get the same level of care at the weekends as during the week. The largest element of this work will be recruiting nine consultants so there is more senior medical cover at the weekends and longer each day – this will make up 60% of the extra cost. It is also investing in services such as diagnostics and back-office support, including IT.

It already offers services across seven days, including MRI scans, pharmacy and an ambulatory assessment area. ‘We are not starting from a standstill, but we are planning to move to the next stage.’ This means a consultant-led A&E service between 8am and midnight during the week and 8am to 9pm on weekends. Its seven-days pilot, which begins in the new financial year, will include more consultants on site in A&E and the trust medical assessment unit, supported by more junior doctors and physiotherapy staff. Diagnostic support will be expanded, with radiology, CT scanning and ultrasound available seven days a week. And IT support will be available throughout – Mr Forster says IT problems can be one of the key frustrations for staff if they occur out of hours.

‘We think it’s important to be honest and say it’s unaffordable to run a hospital 24/7 at the same level and it’s not needed. Between midnight and 6am most people are asleep and most patients have different requirements for safe care. The main factor for us is where do we invest to ensure that anyone who becomes unexpectedly ill receives as excellent a service at night and at weekends as during the week.’

Seven-days services for urgent and emergency care are coming to the NHS, but are only one strand of a transformation agenda that includes service reconfiguration, the review of A&E, better care fund and beefed-up primary, community and social care sectors. There is a lot to do and little additional cash to do it.