CCGs and providers must work together to deliver safer, 24/7 care that consigns higher weekend mortality rates to history, say Steve Kell and Mike Pinkerton
The higher mortality rates for patients admitted at weekends has been documented for at least 20 years, including studies in the US and Canada. Recent data in England has confirmed this is still the case, despite significant improvements in technology and treatment options.
Free healthcare is not enough: it has to be safe. Services should be centred around patient needs, with the focus on continuous improvements in quality. This includes making services available when people need them most: when they are acutely ill.
‘There was a strong emphasis on clinical leadership. Primary and secondary care clinicians co-designed the new systems’
It is essential that commissioners and providers work together to improve safety and reduce variation. Following the reviews by Robert Francis and Don Berwick, it is no longer acceptable to avoid the difficulties this involves. The time has come to make the NHS safe 24 hours a day, seven days a week.
There needs to be a clear focus when discussing seven-day working options. Some advocate the supermarket model − available for all conditions, at any time, with flexibility around the working patterns of the patient. This may be an option in the future with improved technology and staffing, but the NHS faces a more immediate problem.
The initial focus should be on delivering a safe service to those in hospital or who need attention during the traditional out of hours period.
In Bassetlaw, joint working has led to significant improvements in local hospital services and outcomes. As in many areas, the accident and emergency department consultant cover was mainly during working hours, Monday to Friday, and the medical assessment unit worked well during the week but became less effective at weekends, with less consultant cover and fewer patient reviews.
There have been a number of key elements to the improvements we have achieved towards seven-day working. First, there was a strong emphasis on clinical leadership. Primary and secondary care clinicians co-designed the new systems. Patient care and quality was the focus and all were driven to improve the pathways with which they worked.
Second, there was clear, identifiable managerial support, with clear “plan, do, study, adjust” cycles and external validation, where required.
Third, a clear focus on outcomes was important. The case for change was clearly established: improving outcomes including mortality, morbidity and lengths of stay by establishing rapid access to senior decision making, early discharge planning, and increased availability of diagnostics.
‘A number of “new breed” acute physicians have been recruited and there is consultant presence on the unit for a minimum of 10 hours a day, seven days a week’
This vision enabled us to focus on service before capital designs and helped us to agree a contract model, which supported the clinical model and enabled commissioners and providers to share risk.
By establishing the clinical model first, we have been able to redesign anticipated capital works based on staff and patient need.
In addition to primary and secondary care joint working, we established partnership working with groups including social care and community providers. By improving the pathway we aimed to improve efficiency and patient outcomes for all providers.
New model of care
Bassetlaw Hospital now has a new model of emergency medical care based on a new assessment and treatment centre (ATC). A number of “new breed” acute physicians have been recruited and there is consultant presence on the unit for a minimum of 10 hours a day, seven days a week.
Patients requiring admission are assessed at the ATC with enhanced diagnostic access and early discharge or treatment plans established. Staff skill mix and experience has been improved through rotation of senior staff across Doncaster and Bassetlaw sites.
‘Following the introduction of the ATC in Bassetlaw, we have seen a reduction in mortality and a significant reduction in variation between weekend and weekday’
Early access to senior decision makers improves outcomes and hospital efficiency. The “front door” of A&E is vital and we have worked together to improve services in the department, while designing the ATC.
As with many smaller hospitals, senior cover was greatest during the week. The four hour target had recently become a challenge. We have reviewed pathways and staffing within the emergency department, including regular visits from clinical commissioning group nurses and GPs.
As a result of this joint working, we have secured funding for additional consultants, middle grade doctors and nurses, with senior sessions covering Doncaster and Bassetlaw sites. Consultant cover has been extended to seven days.
There has been some investment required. The CCG and the trust have invested in improved services with contracting methods designed to ensure a clinical and patient focus and to reduce the risk to either organisation.
There have also been efficiencies; a reduction in locum staffing and improved efficiency has benefited the trust, while reducing inappropriate hospital stays and joint working with partners has seen efficiencies for the CCG.
Reducing weekend mortality
Following the introduction of the assessment and treatment centre in Bassetlaw, we have seen a reduction in mortality, with the hospital standardised mortality ratio for medical admissions now 93 − there has also been a significant positive reduction in variation between weekend and weekday. Patient and staff satisfaction has been high, with improved unit sustainability and recruitment.
Seven-day working in Bassetlaw remains a work in progress but we have started changes that have had a direct effect on outcomes. There are significant challenges ahead, but we have worked hard to develop transparency between partners, a sense of trust and establish that focusing on patients and clinical models can lead to meaningful change.
‘Future improvements have to include care outside hospital, but we must ensure community services are effective before any potential reduction in hospital funding’
Bassetlaw is a strong community and the changes have highlighted the benefits of local clinical commissioning and service redesign. The national focus on seven-day working by NHS England is welcomed, but solutions are best achieved if they are clinically driven, developed jointly and supported by strong management.
Future improvements have to include care outside hospital. Funding changes proposed for 2015 highlight the risks to NHS contract baselines, but also the need for effective working with partners. If services are to be maintained, we must ensure community services are effective before any potential reduction in hospital funding.
In Bassetlaw, we have established an integrated care board including providers, commissioners and the local authority. This will continue working to improve outcomes for Bassetlaw residents, providing services when they need them most, seven days a week.
Dr Steve Kell is chair at Bassetlaw CCG and co-chair of the NHS Clinical Commissioners Leadership Group; Mike Pinkerton is chief executive at Doncaster and Bassetlaw Hospitals Foundation Trust