Celia Ingham Clark National Director: Reducing Premature Mortality. Slides from Celia's presentation from the 7 Day Services events West Midlands 11th June and East Midlands 12th June 2014

1. Developing and implementing
clinical standards for seven day
services
Celia Ingham Clark
National Director:
Reducing Premature
Mortality
11/12 June 2014

2. National seven day services Forum
• The national Seven Day Services Forum led by Bruce Keogh is
leading the approach to deliver seven day health care services
• It initially focussed on the acute inpatient pathway, although there
is recognition of the need for whole-system change.
• As such, there is alignment with other national work including the
Urgent and Emergency Care review, primary care transformation
and the integrated care programme.
• A clinical reference group reviewed the evidence base and
developed clinical standards for acute inpatients, based on
recommendations from professional bodies.
• The NHS England Board has agreed to the inclusion of these
clinical standards in the standard contract over the next three
years
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3. Seven day services: Why?
• Illness happens seven days a week
• Currently outcomes differ at weekends
• Trainee feedback suggests variable consultant involvement in
acute care out of hours
• Hypothesis that patients admitted at weekends are sicker due to
limited access to primary care
• Importance of “failure to rescue” in defining the difference
between hospitals with high and low mortality rates
• Acute illness can occur at any time and patient expectations are
rising as other sectors (e.g. banking and retail) have moved to
offer seven day services
3

4. Key themes
• There is often inadequate involvement of senior medical
personnel in the assessment and subsequent management of
many acutely ill patients, particularly at the weekend
• Limited access to diagnostic services and allied health
professionals at weekends to establish multi-disciplinary
management plans and facilitate transfer out of hospital
• Poor weekend emergency service provision is associated with an
increased variation in outcomes such as:
• Mortality rates
• Patient experience
• Length of stay
4

5. Cause of the weekend effect - multifactorial
• Variable staffing levels in hospitals at the weekend
• Fewer senior decision makers of consultant level skill and
experience on site at the weekend
• A lack of consistent support services, such as diagnostic and
scientific services at weekends
• A lack of community, primary and social care services which
could prevent some unnecessary admissions and support
timely discharge
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6. In London data shows higher mortality rates for
weekend emergency admissions than weekdays
Total
emergency
admissions
In hospital mortality
following emergency
admission
In hospital mortality
following emergency
admission (%)
Weekday 521,868 16,377 3.14
+0.32
Weekend 159,676 5,531 3.46
The 0.32% difference between weekday and weekend
mortality equates to 520 potentially avoidable deaths
London’s heart attack centres already operate a consultant
delivered service seven days per week and no observed
difference is found in mortality rates in the week and at the
weekend, suggesting where systems are in place to respond
seven days a week, there is a direct effect on mortality rates
6

7. Similarly elective surgical mortality is higher
for weekend admissions
Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics
BMJ 2013;346:f2424 (Published 28 May 2013)
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8. Seven Day Services – What?
• What we mean by Seven Day Services
• Emergency care Must Do
• Urgent care Should Do
• Elective care Could Do
• ? All of the above
8

9. Seven day services: What?
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True emergencies –
where minutes delay
can affect risk of death
• Cardiac arrest
• Ruptured aortic aneurysm
• Acute MI
• Extra-dural haematoma
Services provided
promptly
• Emergency laparotomy
• Fractured NOF (DH 2011 BPT to improve care)
• “hot” cholecystectomy
Routine services
• Endoscopy
• MRI scans
Services not
commonly provided
at weekends now
• Routine elective surgery
• Routine GP consultations
• Contact with specialist nurses
• Routine outpatient appointments
Similar spectrum applies to diagnostics and their reports: FBC, U&E, ECG,
CXR, CT, USS and cardiac echo, spirometry, histopathology
Spectrumofcare

10. Seven day services:
Not ‘should we’ but ‘how far should we go’?
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• Care and services need to shift towards seven day services to
abolish differentials in:
• Patient safety
• Patient experience
• Clinical effectiveness
• Discussions underway: should this also address patient
convenience?

11. 11
Review of literature
and College reports
Develop case for
change
Develop
standards
Commission
standards
Audit acute hospitals
against standards
Follow up with acute
hospitals
Engagementwithkeystakeholders
Development of the London acute care quality
standards

12. London quality standards – overview
• Addressing the variations in service arrangements and patient outcomes
between weekdays and weekends was identified by the NHS in London
as a key priority in 2012/13 and has remained as such.
• Scope of the standards:
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Adult emergency
services (AES)
Paediatric emergency
services (PES)
Maternity
services
Emergency departments
Acute medicine
Emergency general surgery
Critical care
Fractured neck of femur
Emergency departments
Emergency inpatient
medicine
Emergency general
surgery
Specific parts of the
pathway requiring
specialist acute care:
- Labour
- Birth
- Immediate postnatal
care

13. London quality standards: Key themes
• Admissions seen by consultant <12 hours
• Twice daily ward rounds for all acute patients
• MDT plan within 24 hours including EDD
• Timely access to diagnostics and reports
• Timely access to interventions including theatre
• Good information for patients and their carers
• Timely transfer to next place of care
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14. London quality standards:
consultant-delivered care
• All patients seen and assessed by a consultant within 12 hours
of admission
• Emergency admissions to be managed in MAU, SAU or Critical
Care Unit
• Rotas constructed to maximise continuity of patient care
• Access to all key diagnostic services in a timely manner 24
hours a day, seven days a week to support clinical decision making
• Access to Interventional Radiology 24 hours a day, seven days
a week within 1 hour for critical patients
• Access to comprehensive endoscopy 24 hours a day, seven
days a week
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15. London quality standards:
consultant-delivered care
• All health professionals use unitary document for medical record
• EDD set within 24 hours of admission
• All patients on MAU/SAU seen and reviewed by a consultant
during twice daily ward rounds
• All referrals to intensive care should have consultant involvement
• Structured handovers should take place twice a day and at every
handover between consultant teams
Patient experience
• Consultant-led communications and information to patients,
including patient information leaflets
• Patient experience data recorded, analysed and acted on
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16. National approach
The National Seven Day Services Forum established by
Professor Sir Bruce Keogh in 2013 found that:
• Variation in outcomes exists for patients admitted at the
weekend, seen in mortality rates, patient experience, length of
hospital stay and re-admission rates
• Our junior doctors often feel clinically exposed and
unsupported at weekends
• Lack of many seven day services has an adverse effect on
measurable outcomes in each of the five domains of the NHS
Outcomes Framework:
• mortality amenable to healthcare
• quality of care for people with long term conditions
• outcomes from acute episodes of care
• patient experience
• patient safety16

17. Developing national clinical standards
A Clinical Reference Group (CRG) was convened with
representation from patients, primary care, secondary care, social
care and colleagues from Colleges and professional bodies to
develop clinical standards on behalf of the Forum.
The CRG was asked to:
• Establish the clinical evidence base for providing NHS
Services, 7 days a week
• Defining standards of care that will help commissioners and
providers to deliver a consistently high quality acute care
service at all times of the week.
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18. 18
Consultant review within 12/14 hrs
Availability of core MDT
Rapid access to diagnostics
Only 16% of hospitals
review all emergency
medical admissions
within 14 hours of
arrival
Nearly 80% have
5 or more MDT
members during
the week. This is
just 30% at the
weekend
X-ray and CT availability is
consistently high but other services
vary considerably making informed
decision making difficult
Seven Day Services Forum: survey findings

19. Seven Day Services Forum: clinical standards
The CRG developed 10 clinical standards based on the evidence
and recommendations from Royal Colleges and expert bodies.
These follow the patient pathway, apply seven days a week and aim
to ensure:
• Prompt access to consultant review and multi-disciplinary
assessment
• Availability of diagnostics to support decision-making
• Timely treatment and interventions
• Planned, safe and appropriate timing of transfers from hospitals
All standards are based on existing recommendations from Royal
Colleges and expert bodies and will cover the seven days of the
week
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20. Alignment with Academy of Medical Royal
Colleges
The clinical standards are deliberately aligned with the Academy of
Medical Royal Colleges work on consultant-delivered care:
• Consultant involvement: All hospital inpatients should be reviewed by
an on-site consultant at least once every 24 hours, seven days a week,
unless it has been determined that this would not affect the patient's care
pathway
• Consultant supervision: Consultant-supervised interventions and
investigations, and their reports should be provided, seven days per
week, if the results will change the outcome or status of the patient’s
care pathway before the next ‘normal’ working day – this should include
interventions and investigations which will enable immediate discharge
or a shortened length of hospital stay
• Support services, seven days a week: Support services both in
hospital and in the community and primary care setting should be
available seven days per week to ensure that the next steps in the
patient’s care pathway, as determined by the daily consultant review, can
be taken20

21. Clinical standard 1:
Patient experience
• Patients, and where appropriate families and
carers, must be actively involved in shared
decision making and supported by clear
information from health and social care
professionals to make fully informed choices
about investigations, treatment and on-going care
that reflect what is important to them. This should
happen consistently, seven days a week.
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22. 2: Time to first consultant review
• All emergency admissions must be seen and
have a thorough clinical assessment by a
suitable consultant as soon as possible but at
the latest within 14 hours of arrival at hospital
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23. 3: Multi-disciplinary team review
• All emergency inpatients must have prompt
assessment by a multi-professional team to
identify complex or on-going needs, unless
deemed unnecessary by the responsible
consultant. The multi-disciplinary assessment
should be overseen by a competent decision-
maker, be undertaken within 14 hours and an
integrated management plan with estimated
discharge date to be in place along with
completed medicines reconciliation within 24
hours
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24. 4: Shift handovers
• Handovers must be led by a competent senior
decision maker and take place at a designated
time and place, with multi-professional
participation from the relevant in-coming and out-
going shifts. Handover processes, including
communication and documentation, must be
reflected in hospital policy and standardised
across seven days of the week
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25. 5: Diagnostics
Hospital inpatients must have scheduled seven-day
access to diagnostic services such as x-ray,
ultrasound, computerised tomography (CT),
magnetic resonance imaging (MRI),
echocardiography, endoscopy, bronchoscopy and
pathology. Consultant-directed diagnostic tests
and their reporting will be available seven days a
week:
• within 1 hour for critical patients
• within 12 hours for urgent patients
• within 24 hours for non-urgent patients
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26. 6: Interventions
Hospital inpatients must have timely 24 hour
access, seven days a week, to consultant-
directed interventions that meet the relevant
specialty guidelines, either on-site or through
formally agreed networked arrangements with
clear protocols, such as:
• critical care
• interventional radiology
• interventional endoscopy
• emergency general surgery
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27. 7: Mental health
Where a mental health need is identified following
an acute admission the patient must be assessed
by psychiatric liaison within the appropriate
timescales 24 hours a day, seven days a week:
• Within 1 hour for emergency care needs
• Within 14 hours for urgent care needs
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28. 8: Ongoing review
• All patients on the AMU, SAU, ICU and other high
dependency areas must be seen and reviewed by
a consultant twice daily, including all acutely ill
patients directly transferred, or others who
deteriorate. To maximise continuity of care
consultants should be working multiple day blocks
• Once transferred from the acute area of the
hospital to a general ward patients should be
reviewed during a consultant-delivered ward
round at least once every 24 hours, seven days
a week, unless it has been determined that this
would not affect the patient’s care pathway
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29. 9: Transfer to community, primary
and social care
• Support services, both in the hospital and in
primary, community and mental health settings
must be available seven days a week to ensure
that the next steps in the patient’s care pathway,
as determined by the daily consultant-led review,
can be taken
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30. 10: Quality Improvement
• All 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,
seven days a week
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31. Seven Day Services: Implementation
• Year 1 (2014/15) – local contracts should include an Action
Plan to deliver the clinical standards within the Service
Development and Improvement Plan Section
• Year 2 (2015/16) – those clinical standards which will have
the greatest impact should move into the national
requirements section of the NHS Standard Contract
• Year 3 (2016/17) – all clinical standards should be
incorporated into the national requirements section of the
NHS Standard Contract with appropriate contractual
sanctions for non-compliance.
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32. Enablers for implementation
• NHS England Implementation Board and delivery sub-group
• Development of metrics to support the standards
• Clinical Senates support
• NHS IQ to introduce a large-scale transformational change
programme to support the spread of seven day services
• CRG continues to provide expert advice
• In London – ongoing audit of implementation of Quality
Standards, and lessons shared
• Inspection and assurance – CQC hospital inspections to
include assessment of seven day services implementation
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33. The wider context
Recognising relationships with other work including:
• Primary Care Transformation
• Urgent and Emergency Care Review
• Integrated care programme
• Reconfiguration proposals and service change plans
• Productive elective care
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34. Patient perspective
• “I was lucky. Shouldn’t every one of us
have the best chance possible no
matter what time of day or day of the
week it is?”
• Rodney Partington, Patient representative
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