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NHS - Seven Days a Week

Professor Sir Bruce Keogh, National Medical Director released a paper outlining a proposed shift in the current NHS working practices.

A summary of some of the key points can be find below:

There is a problem

Data for mortality rates, patient experience, length of hospital stay and re-admission rates showed a

significant trend of negative outcomes for patients admitted to hospitals at the weekend across the NHS in England.

Why make changes?

The reduced level of service provision on the weekend has been shown to be linked with poorer outcomes for patients admitted to hospital as an emergency.

Junior doctors feel unconfident and unsupported at weekends, and hospital chief executives are worried about clinical weekend cover.

"It also seems inefficient that in many hospitals expensive diagnostic machines, laboratory equipment and pathology laboratories are underused, operating theatres lie fallow and clinics remain empty, while access to specialist care is dogged by waiting lists and general practitioners and patients wait for diagnostic results."
- Professor Keogh 2013

Multifactorial aetiology for weekday-weekend variation

There is no definitive reason for variation between weekday and weekend. Rather there are consequences of multi-factorial that are likely to give rise to variation:

  • Fewer onsite consultants providing experience and clear decision making
  • Variable staffing levels
  • Lack of diagnostic and scientific services
  • Lack of supporting community and primary care services

When should changes be implemented by?

Improvements in clinical outcomes and patient experience at weekends should be seen by the end of 2016/17.

Recommendations

There is no ‘one size fits all’ answer to introducing seven day urgent and emergency care services - local solutions will need to be found.

1Patients (and where appropriate families and carers), must be actively involved in decision making.

This must be supported by clear information to make fully informed choices about investigations, treatment and on-going care that reflect what is important to them.

2Emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant at the latest within 14 hours of arrival at hospital.

3Emergency inpatients must be assessed for complex or on-going needs within 14 hours by a multi-professional team, unless deemed unnecessary by the responsible consultant.

An integrated management plan with estimated discharge date and criteria for discharge must be in place along with completed medicines reconciliation within 24 hours.  

4Standardised handovers: designated time and place, with multi-professional participation and the relevant in-coming and out-going shifts led by a competent senior decision maker.

Documentation, communication and handover processes should be reflected in hospital policy.

5Access to diagnostic services and Consultant reporting.
• Within 1 hour for critical patients
• Within 12 hours for urgent patients
• Within 24 hours for non-urgent patients

6Consultant-directed interventions must be available either on-site or through formally agreed arrangements with clear protocols.

For example: critical care, interventional radiology, interventional endoscopy and emergency general surgery.

7Where a mental health need is identified in an acute admission the patient must be assessed by psychiatric liaison:
• Within 1 hour for emergency* care needs
• Within 14 hours for urgent** care needs

8All patients on the AMU, SAU, ICU & other HDU areas must be seen and reviewed by a consultant twice daily.

To maximise continuity of care consultants should be working multiple day blocks.

Newly transferred acute patients should be reviewed on a consultant ward round once in 24 hours.

9Support services, both in the hospital and in primary, community and mental health settings must be available.

To ensure that the next steps in the patient’s care pathway, as determined by the daily consultant-led review, can be taken. 

10All those involved in the delivery of acute care must participate in the review of patient outcomes to drive care quality improvement.

The duties, working hours and supervision of trainees in all healthcare professions must be consistent with the delivery of high-quality, safe patient care.

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