Feature / Time for change

03 February 2014

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Seven-day services should raise clinical standards and could make the NHS more efficient, but what are the consequences for providers and how much will it cost? Seamus Ward reports


The NHS should offer its services 24 hours a day, seven days a week, the argument goes, because we live in a 24/7 world. Some supermarkets never close their doors, while other services, including banks, and even public services such as libraries remain open in the virtual world. But while it is said that the public expects to receive services any time of the day or night, there is a more compelling argument for moving the NHS to an open-all-hours culture.

The forum on NHS services, seven days a week, which published its initial findings in December, said there was evidence that in England, as with other health systems worldwide, outcomes are worse for patients admitted to hospital at the weekend.

The increased risk of mortality could be as high as 11% for patients admitted on Saturdays and 16% on Sundays, according to its analysis of more than 14 million hospital admissions in 2009/10. This has been attributed to fewer staff, less consultant support and lack of diagnostic services. Initially, the forum has focused on urgent and emergency care and supporting diagnostics. Given that quality of care, patient safety and efficiency (which is often said to follow higher quality) are the driving forces behind changes in the NHS, this evidence has moved seven-day services from a desirable to an essential development.

There are questions to be answered, not least on cost. The HFMA led the costing work on seven-day working in acute and emergency care and diagnostics on behalf of the forum (see costing box overleaf). It concluded it would add 1.5% to 2% of providers’ overall costs.

NHS England medical director Sir Bruce Keogh set out 10 clinical standards that should be met seven days a week in urgent and emergency care. Each is evidence based and developed with the Academy of Medical Royal Colleges. These would ‘undo more than 50 years of accumulated custom and practice that have failed to put the interests of patients first’, he says, and recommends they be adopted by the end of the 2016/17 financial year (see clinical standards box).

But to remain clinically and financially sustainable, every provider could not offer all services over seven days. Sir Bruce says NHS commissioners and providers should explore new ways of delivering the services by sharing the workload – in networks or collaboratives, for example. Delivery of the standards should be part of the five-year strategic plans being developed by commissioners.



Rewards and sanctions

Sir Bruce recommends the urgent and emergency care standards should be backed by incentives, rewards and sanctions. They should be progressively adopted into the NHS standard contract, with sanctions for non-compliance. In 2014/15, contracts should include an implementation action plan. The CQUIN quality and innovation incentive scheme will be used to encourage implementation (linking payment to compliance with the time for first consultant review standard).

Other incentives could be used, he says – commissioners and local authorities applying to use the Better care fund cash should demonstrate they are addressing service needs at weekends; Health Education England should include a requirement for adequate consultant supervision at weekends in education contracts.

HFMA president Andy Hardy backed the seven-day initiative. ‘Seven-day services are needed not only to improve efficiency, but more importantly to ensure the services we offer our patients are safer, no matter when they are admitted to hospital.

 ‘It’s only right for the public to expect that if they need services at 3am on Saturday, they will get the same services as if it was 3pm on a Wednesday. People live 24/7 lives – how can the NHS justify not being the same?’

But he adds: ‘The fact is, we will not be able to provide all we do now, in all the places we do now, in the future and some big decisions around this will need to be made.’

Foundation Trust Network chief executive Chris Hopson takes up this point, saying seven-day services will be extremely challenging under current service delivery models and resource constraints.

‘As the HFMA notes, this 1.5%-2% equates to a 5%-6% increase in the cost of an emergency admission. Given the systemic underfunding of emergency care already – through the A&E tariff, non-elective marginal rate and non-payment of readmissions – loading further cost pressure on parts of the system that are already under strain is not tenable,’ he says.

The December report highlights workforce issues that must be surmounted if providers are to deliver seven-day services. The increase in the risk of death for patients admitted at the weekend is due to a number of factors:

  • Variable staffing levels in hospitals at the weekend
  • Fewer decisions-makers of consultant level and experience
  • A lack of consistent support services such as diagnostics.

The report also identifies a lack of community and primary care services that might otherwise support patients on an end-of-life care pathway to die at home.

Mr Hopson says addressing these factors will require significant workforce changes, including the recruitment of consultants (in emergency medicine, acute medicine, anaesthesia and general surgery), more junior doctors and a range of other healthcare professionals, such as radiographers, therapists and phlebotomists.

These clinical areas are already suffering shortages. Even with reductions in pay premia for weekend work and changes in shift patterns, it is highly unlikely seven-day services will be cost neutral for providers, he adds.



Emergency lead

British Medical Association chair Mark Porter says emergency medicine consultants are already leading care at the weekends. The BMA is negotiating with NHS Employers and the government on an affordable, practical model to deliver this care while protecting doctors’ work-life balance, he adds.

‘There are no easy solutions, no one-size-fits-all answer. Delivering more care will require a system-wide approach, but the case for seven-day services has been made and the focus now has to be on developing workable models for delivering it.’

Sir Bruce says some providers have taken strides towards making healthcare services more accessible seven days a week. The NHS had to accelerate the pace and spread of these changes, not just in hospitals but the whole NHS system. ‘One part cannot function efficiently at the weekend if other parts don’t,’ he says. ‘If people are to experience genuine seven-day treatment and care, we must look beyond emergency services and beyond the services offered to hospital inpatients.

‘We need to make similar improvements across primary, community health and social services, removing barriers between organisations.’



Primary care push

Indeed, NHS England is already working on seven-day service standards for primary care.

NHS Confederation policy director Johnny Marshall agrees that a whole-system approach is needed. But he warns that financial sanctions against trusts could be counterproductive.

‘We urge NHS England to take this into consideration, and clarify which support measures will be put in place for all providers who will need assistance in their transition to seven-day services,’ he says.

And he echoes other peoples’ view that seven-day services could not be provided everywhere. ‘We know we can do much more to create an affordable system that works in the best interests of patients. Getting real bang for our buck will require some tough choices and will require strong political will and public support.’

The future of seven-day services is tied to the emergency and urgent care review, which itself promises to bring about significant change in care provision. Some providers start from a strong base, having already implemented round the clock care in some clinical areas, but others will have to catch up quickly. The arguments in favour of and the support for it are too strong.  n

The HFMA will hold a one-day conference on seven-day services on 5 March in London. Visit www.hfma.org.uk or further details





Clinical standards

Patient experience
Patients should be given a fully informed choice about investigations, treatment and care, seven days a week.

Time to first consultant review An appropriate consultant should conduct a thorough clinical assessment of all emergency admissions as soon as possible and within 14 hours at the latest.

Multidisciplinary team review These should be carried out for all emergency admissions, unless deemed unnecessary by the responsible consultant. It should be completed within 14 hours and within 24 hours an integrated management plan, including an estimated discharge date, should be drawn up.

Shift handovers These should take place at a designated time and place and led by a senior decision-maker.

Diagnostics There should be seven-day access to services such as X-ray, MRI and CT scanning. Consultant-directed tests and reports should be available within one hour (critical patients); 12 hours (urgent patients); and 24 hours (non-urgent).

Intervention/key services There should be access to consultant-directed interventions on site or through formal networks all the time.

Mental health If a mental health need is identified following an acute admission, psychiatric liaison should assess the patient within one hour (emergency care needs) or 14 hours (urgent care needs).

Ongoing review All high-dependency patients should be seen and assessed by a consultant twice a day. Once transferred to general wards, assessment should take place once a day during a consultant ward round, unless this would not affect the patient’s care pathway.

Transfer to community, primary and social care Support services must be available across the health settings to ensure the next steps in the pathway can be taken.

Quality improvement All staff engaged in delivering acute care must take part in a review of patient outcomes. All healthcare trainees’ duties must be consistent with providing high-quality, safe patient care seven days a week.





Seven-day costs

The HFMA led the work on costing urgent and emergency care and associated diagnostics on behalf of the forum. Its findings are based mainly on work at eight volunteer trusts. Its report cautions that while they represent a fair sample in terms of size and location, they may not be representative of the NHS as a whole as they are all foundation trusts with an interest in seven-day services. The main findings on costs are:

  • The costs of implementation varies across the sample – in the two London trusts sampled, past investment means the standards for those services are already largely being met. In most of the others, the cost of implementation is 1.5% to 2% of total income or, looking at it another way, an extra 5% to 6% on the cost of emergency admissions.
  • The small sample and apparent lower need for investment in London makes it hard to calculate an overall cost for implementing seven-day services across England. And, considering trusts will start from different positions and the system change needed, it is likely that implementation would progress best at varying speeds through local negotiation.
  • Investment at hospitals’ traditional front door – A&E and admissions units with supporting diagnostics – can pay for itself in some trusts by reducing unnecessary admissions and lengths of stay.
  • With the current configuration, investment in seven-day services (after admission) is unlikely to be cost-neutral in most trusts. The HFMA study concludes from its sample that the move to seven-day services appears achievable, but may be too expensive and unsustainable for all hospitals to move all their services to a seven-day model. While reconfiguration could substantially reduce the cost, this has not been tested in the HFMA research.
  • It may make financial sense to ‘sweat the assets’, making greater use of expensive equipment at weekends, but only where activity is growing or it is consolidated across fewer providers.
  • Costs are higher in smaller and more rural trusts and these providers tend to find recruitment more difficult.

The biggest cost driver is the need to recruit more consultants – an unavoidable cost for trusts needing a greater consultant presence at weekends. Other workforce costs varied widely – some trusts expected to recruit more nurse specialists, others no change to nursing.

The study found that reductions in the premium paid for working at weekends would make seven-day services more affordable, but not cost-neutral under the current configuration of services, as most of the cost relates to hiring more medical staff. It also points out that some non-teaching hospitals already have difficulty recruiting medical staff. Seven-day services would increase demand for staff groups already difficult to recruit, such as radiologists and acute physicians, but collaborative working between trusts could help mitigate this cost.

If payment by results rules are applied, the main financial benefit for providers is shorter lengths of stay, but the savings in the sample trusts would not cover the extra costs. Providers said the only benefit for commissioners would be avoiding unnecessary admissions – but to deliver this they would only have to provide a seven-day admissions unit, rather than have the whole hospital running seven-day services.

According to the sample trusts, few commissioners have made seven-day services a high priority. The report says NHS England must consider how to incentivise commissioners and providers to implement the initiative. Some trusts had agreed payment mechanisms outside of PBR to incentivise seven-day services and share the risks and benefits.

While seven-day services are likely to point the service towards greater consolidation of providers, the scope for such moves is greater in urban areas. Additionally, seven-day services cannot be divorced from other policy initiatives, such as the review of urgent and emergency services. The HFMA report says NHS organisations need strategic plans that are clinically and financially sustainable, showing how they will develop seven-day services without increasing the overall costs of healthcare.

Finance staff have a role in facilitating seven-day services, including modelling options, managing financial risks, and working with commissioners to resolve funding issues. ‘If the clinical case for seven-day services is strong, internal NHS obstacles should not be allowed to prevent it,’ says the report.

HFMA immediate past president Tony Whitfield, who led the work alongside HFMA head of policy and research Emma Knowles, says the costing shows the need for changes in the way services are delivered. ‘If we try to carry out all we do currently in hospital, except over seven days, it is going to cost more. The report suggests that if we want to make changes to our system they should be clinically and financially deliverable. That’s going to mean changes to the system, both in the number of locations where care is delivered and in the construction of the tariff that will support a sustainable model.’