London Quality Standards – acute medicine and emergency general surgery NHS England Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013 More information about this event can be found at http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx

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London quality standards –
acute medicine and emergency general surgery
The case for change
London Health Programmes, on behalf of all
commissioners in London, developed quality standards
to improve the quality and safety and reduce the
variation found across acute medicine and emergency
general surgery services in the capital.
Reviews by the National Confidential Enquiry into Patient
Outcome and Death and reports from Royal Colleges
identified that the provision of acute medicine and
emergency general surgery services can vary significan
tly. Patients do not always get the same high standards
of care they need, particularly over the weekend.
These reviews have common themes: there is often
inadequate involvement of consultants in the
assessment and subsequent management of many acutely
ill patients, junior doctors are often practising without
adequate supervision, and variations in outcomes and
mortality rates exist between routine working hours
and out-of-hours care.
Who was involved?
The work was clinically-led. Through an application
process, over 30 clinicians were appointed to form
multi-disciplinary clinical expert panels covering the
full geographical spread of London and a range of
clinical disciplines. A patient panel was also formed
to inform all developments.
Each clinical expert panel worked in conjunction
with the relevant Royal Colleges, professional
representative bodies and the London Deanery to
review current service provision and develop the case
for change. There was also close co-operation with
the London-wide GP Clinical Commissioning Council.
Current and future commissioners were represented
on the programme board.
London’s emergency admissions
The NHS London 2011 Survey of Acute Trusts
found that many hospitals were not meeting best
practice recommendations for the provision of
acute services and highlighted marked variation
across London’s hospitals in working patterns for
acute medical and emergency general surgical
care. This variation increased overnight and at
the weekend.
Variation in outcomes
Outcomes for patients in London varied considerably
across different hospitals. A variety of outcome
measures provided an indication of the quality of a
service and enable comparisons between services
across London:
■
Depending on the hospital, length of stay for
patients admitted as an emergency with respiratory
disease was two to three times as long.
Acute medicine and emergency general surgery
services need to deliver a safe and consistently high
quality service for patients seven days a week.
However, progress towards this had been piecemeal
and out-of-hours cover remained particularly fragile.
■
Four in every ten patients were re-admitted
within 30 days of their original admission,
compared with just 1 in 10 patients re-admitted to
the best performing trusts.
This meant that services in London were not
consistently delivering the safe and high quality
emergency care that patients expected.
There was also variation in outcomes between weekday and weekend admissions. London data showed that the probability of dying as a result of many emergency conditions was significantly higher if
the admission was at the weekend, compared to a weekday. If the weekend mortality rate in London was the same as the weekday rate there would be a minimum of 500 fewer deaths a year.
Reduced service provision at weekends is associated with this higher mortality rate.
In-hours and out-of-hours working
Consultant physician hours on-site
14
Consultant surgeon hours on-site
12
10
10
8
8
6
6
4
4
2
The recommendation is for consultant physician presence at hospitals for 12 hours per day, every day of the week. Variation existed
between London’s hospitals in the number of hours an admitting consultant physician was expected to be on-site and the situation
worsened on the weekends. This variation was also seen across emergency general surgery services.
12
2
0
0
London hospitals
London hospitals
Monday - Friday
A lack of senior involvement
Delays to both consultant review and a lack of senior involvement
in patient care have been linked to poor patient outcomes.
Working patterns should be set up to support early involvement
in the care of emergency admissions and consultants should be
freed from other clinical commitments and elective duties whilst
on-take. There was stark variation across London between
weekdays and the weekend in the number of emergency
admissions that were reviewed by a consultant within 12 hours.
Additionally, less than half of consultant physicians and
consultant surgeons were always freed from other duties.
Consultant review of emergency medical
admissions within 12 hours
Weekday
Saturday - Sunday
Weekday London average
Consultant review of emergency surgical
admissions within 12 hours
Weekend
Weekday
Weekend London average
Do consultants undertake any other
duties whilst on-take?
Weekend
Consultant physicians
Consultant surgeons
10%
23%
29%
16%
24%
3%
28%
26%
38%
Always
46%
48%
Very often
Sometimes
52%
No
Always
Very often
77%
25%
Sometimes
Sometimes
No response
48%
Yes
29%
26%
52%
London quality standards and audit of acute hospitals
London quality standards
London quality standards, based on clinical evidence, national
recommendations and best practice were developed to ensure
that all acute medicine and emergency general surgery services
provide care that is safe, and of consistently high quality for
patients across London, seven days a week. These would be
services that improve patient outcomes.
Meeting these standards will ensure that there is no difference in
the quality and safety of these services provided on weekdays
and weekends, or between and within hospitals; could save a
minimum of 500 lives; and improve emergency
care and outcomes for patients treated in the capital.
The London quality standards were included in 2012/13 acute
commissioning intentions – hospitals providing acute medicine
and emergency general surgery services must comply with the
standards in order to continue to be commissioned.
Audit of acute medicine and emergency
general surgery standards
All acute hospitals in London were audited against the agreed and
commissioned acute medicine and emergency surgery standards
between May 2012 and January 2013. Audit teams comprised of
clinicians – from within and out of London – clinical commissioners and
patient representatives. The audits aimed to assure commissioners that
hospitals were compliant with the standards and patients were
receiving high quality and safe care, or help them to find solutions for
providers that were unable to meet them. A full report of compliance
was produced for each provider of these services in London.
Audit results
All hospitals recognised the value of meeting the standards and clinical
leaders at the hospital visits highlighted that the audit was useful in:
■ reinforcing the importance of meeting the London quality
standards;
■ focusing teams on prioritising efforts to address gaps
identified; and
■ developing approaches to monitoring delivery and ongoing
achievement of the standards.
Many hospitals have recognised that compliance with all of the
standards may mean a significant change to the way services are
provided at a local and at a cluster/network level.
Percentage of standards met across London’s acute hospitals
3%
Key findings of the audit include:
■ No one hospital has met all of the standards.
Met
■ No one standard will remain unmet by April 2013 by all
hospitals, demonstrating significant scope for shared learning
and service redesign.
47%
50%
■ Many hospitals have made significant efforts to change practice
to achieve the standards and some have robust plans in progress.
■ The audit findings show a positive journey of improvement
but the majority of hospitals still have significant progress to
make to ensure standards are in place consistently across seven
days of the week.
Initial results show that improvements had been made in working
practices including early consultant involvement for patients
admitted acutely, consultants freed from elective commitments
whilst responsible for emergency admissions, extended day
working and multi-disciplinary input, as well as improvements to
patient experience through provision of information and capturing
and acting upon patient experience data.
Plans in place
Not met
4%
3%
50%
Acute
medicine
47%
44%
52%
Emergency
surgery
A compelling case for change was essential as a lever for implementing the standards and strong clinical leadership was vital. Compliance with the London quality standards will aim to ensure that all acute medicine and emergency
general surgery services provide care that is safe, and of consistently high quality for patients across London, seven days a week. These would be services that improve patient outcomes. Strong clinical leadership and wide
stakeholder buy-in and engagement allowed this programme to be delivered.
Contact england.serviceredesign@nhs.net for further information