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London Quality Standards – acute medicine and emergency general surgery


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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

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London Quality Standards – acute medicine and emergency general surgery

  1. 1. NHS LHP poster A1.qxd:Layout 1 12/11/13 11:18 Page 1 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 for further information