Seven day consultant present care

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Seven day consultant present care
Professor Norman Williams
Chair, Academy Steering Group
President, Royal College of Surgeons of England


Presentation from the 'NHS services open seven days a week: every day counts' event on Saturday 16 November at The Metropole Hotel, Birmingham.

This event was hosted by NHS Improving Quality and NHS England to share the views and ideas of public, patients, carers, NHS England and health and social care staff on how to improve access to services for patients across the seven day week.

More information at http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx or #7DayServices

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  • In January 2012, Academy of Medical Royal Colleges published its report – the Benefits of Consultant Delivered Care. This report set out a summary of written and oral evidence regarding the benefits and difficulties with a system of consultant delivered care plus an externally commissioned independent review of the literature and commentary on the findings.
    Examples of the benefits identified:
    Rapid and appropriate decision making
    Improved safety, fewer errors
    Improved outcomes
    More efficient use of resources
    The report also noted that, having identified benefits associated with consultant delivered care, that these benefits should be availability irrespective of the day of the week.
  • There is growing evidence relating to the comparison of outcomes from weekday versus weekend care. Currently there are fewer consultants at weekends. No robust evidence (yet) to relate the two, but instinct would indicate there is a link. On that note, the Academy is supporting the NIHR funded research project being led by Julian Bion, Professor of Intensive Care Medicine at the University of Birmingham, which is planning to start in February 2014. This research will evaluate the impact of consultant present care over a period of approximately three years.
  • Illustration of the consultant presence difference – the staff car park on a weekday….
  • And the staff car park on a weekend (Southampton General Hospital)
  • Following on from the Benefits of Consultant Delivered Care (published Jan 2012) and the issues around weekend-related outcomes for patients – in April 2012, the Academy established a project to look at seven day consultant present care – chaired by Professor Norman Williams on behalf of the Academy.
    Driven by patient safety – not a ‘patient choice’ or convenience agenda.
    The project looked at seven day standards already published by individual Royal Colleges, reviewed the available evidence for differences in patient outcomes, and developed three patient-centred standards for all hospital in-patients.
  • Consultants are currently available 24/7 – on-call. Key change encapsulated in this standard: to opt out of a daily review for patients at a weekend – rather than current mainstream practice of identifying any patients that need a bedside consultant review at the weekend.
    This standard does not make any artificial divide between elective / non-elective patients – the deciding factor is whether the individual’s care pathway can be progressed if they see a consultant. If it can – they should see one.
  • And following on from Standard 1 – there is no point in having a consultant review if the decisions taken cannot then be acted upon.
  • This includes the need to be able to act on a decision to discharge a patient.
  • The Academy’s Seven Day Consultant Present Care report recognised that to deliver the three standards there would be significant resource and working practice implications. So a follow up project was established to look at the implications of the standards in more detail and provide implementation guidance.
    This has been led on behalf of the Academy by Professor Norman Williams, with Dr Chris Roseveare as the Clinical Project Lead and Professor Julian Bion chairing the project assurance group.
  • In April a structured questionnaire was developed for each speciality organisation to respond to.
    Early findings were reviewed in June and the report has been built around the survey responses. Over 50 specialty organisations have been involved.
    The report is due to be published on 18 November and will make a further contribution to the growing guidance and debate on how to achieve parity of care across all seven days of the week.
  • For change to actually happen, things need to change locally in Trusts – there is no ‘one size fits all’. This report will provide good ‘conversation starters’ for local clinical and managerial leaders and commissioners to look at their own practices and priorities in making changes to meet the Academy standards.
    There is no absolute answer to how long a consultant review of an inpatient takes – there are many variables – but as a ROUGH guide, the survey returns have indicated around 10-15 mins for a patient known to the consultant. The review will take less time if a patient is already known to the consultant - so rota patterns which optimise continuity of care should be designed to ensure best use of consultant time.
  • Optimal value from consultant weekend presence will be achieved if the consultant is leading a multi-disciplinary team of health care professionals and the required specialist supporting services are available. It takes more than the consultant alone to deliver the care a patient needs and move them along their care pathway.
    Consultant presence at weekends will enable greater coaching and supervision of doctors in training, and time should be allowed for consultants to deliver training as well as service at weekends. However this must not discourage the development of decision making skills in junior doctors.
    There is no point in having a daily consultant-led review if cannot then act on the consequences of the review and take the next steps on the patient’s care pathway. So having availability of the key investigations, interventions, hospital based and community based services is essential. The survey results have given a ‘popularity’ order to interventions, investigations and other services. For example, all specialties require pharmacy and physiotherapy services at weekends and the majority of specialties said emergency surgery is an intervention likely to be needed as a result of a consultant daily review. This sort of information – which will be explained in more detail in the report – will be useful to Trusts looking at which services to address first when looking at seven day provision.
  • Another key finding is the importance of having greater levels of early, weekday engagement and advance discharge planning between patients and their carers, hospital and community-based staff and equipment providers. Doing this will increase the ability to make a safe transfer care from the hospital at the weekend.
    If existing consultant numbers are ‘spread’ over seven days, this will have an impact on the elective care that can be provided. To maintain service levels during the week AND increase weekend presence will need more consultants.
    In fact, the Academy believes that meeting the three seven day consultant present care recommendations will require additional resourcing across the whole healthcare system – hospital, primary and community care.
  • How a Trust meets this resourcing demand will depend on a number of factors (e.g whether consultants are already covering weekends, the flexibility of workplans etc). Moving toward having more consultants with the skills to manage patients across different specialty areas (‘generalists’) will increase the flexibility of the consultant workforce delivering daily inpatient reviews at weekends. This is not about providing cross-cover for full service delivery, where specialty knowledge is critical to patient outcomes, but about optimising the generic ability of consultants to recognise the deteriorating patient during a daily review and instigate appropriate action.
    In terms of resourcing, the Academy’s report identifies factors that will affect the scale of demand and solution approach relevant for each individual Trust. The Academy believes additional investment by Trusts will be needed, but this should deliver longer-term benefits and more efficient practice.
    However, as well as consideration of the situation within Trusts, the Academy, as stated earlier, believes the changes needed are whole system ones. For example, reconfiguration and networks.
    But the whole economic question requires detailed financial modelling so that informed and sustainable choices can be made.
  • So – I hope that describes the Academy’s work in this area and gives you a feel for the Academy report due to be published on Monday.
  • Seven day consultant present care

    1. 1. Seven Day Consultant Present Care Professor Norman Williams Chair, Academy Steering Group President, Royal College of Surgeons of England
    2. 2. The Benefits of Consultant-Delivered Care ‘the benefits of consultant-delivered care should be available to all patients throughout the week …. work should be undertaken by clinicians and employers to map out the staffing requirements and service implications of implementing a consultant-delivered service throughout the week’
    3. 3. The weekend challenge… • Higher case-mix adjusted mortality - new admissions and in-patients • Greater illness severity amongst weekend admissions • Fewer consultants in hospital
    4. 4. Weekday
    5. 5. Weekend
    6. 6. Standard 1 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.
    7. 7. Standard 2 Consultant-supervised interventions and investigations along with reports should be provided seven days a week if the results will change the outcome or status of the patient’s care pathway before the next ‘normal’ working day.
    8. 8. Standard 3 Support services both in hospitals and in the primary care setting in the community should be available seven days a week to ensure that the next steps in the patient’s care pathway, as determined by the daily consultant review, can be taken.
    9. 9. Seven Day Consultant Present Care – Follow up Purpose: to develop a more detailed understanding of the implications of each of the standards for each specialty in order to encourage and assist implementation.
    10. 10. Approach •Questionnaire (10 questions) sent to specialty organisations with inpatients •Responses from 36 different specialties •Followed up results with an additional 14 organisations •Final report reviewed by Academy Council on 13 November 2013 •Issue has high profile: • NHS Services Seven Days a Week Forum • HSJ gathering readers opinion • Sunday Times campaign
    11. 11. The Key Findings •Report framed as a catalyst for local conversations. •Factors such as the specific specialty and whether the patient is known to the consultant impact the duration of a consultant led review. •Assuming the patient is known and looking at the most common durations given by specialties: for 30 inpatients, around six hours of consultant time is needed each day at the weekend to undertake consultant led inpatient reviews.
    12. 12. The Key Findings (cont’d) •Effective multi-disciplinary team working is essential. •Opportunity for coaching and supervision of doctors in training. •Some investigations, interventions, hospital based and community based services are more critical to effective weekend care than others. For example: – laboratory services, radiology, ultrasound and cross sectional imaging – emergency surgery, interventional radiology and therapeutic upper gastrointestinal endoscopy – physiotherapy, occupational therapy, pharmacy – patient transport, access to social care
    13. 13. The Key Findings (cont’d) •Planning in advance for transfer of care. •Delivering consultant present care at weekends is likely to require additional consultant appointments as well as reorganisation of the existing consultant workforce and increased resourcing for community based services; careful job planning is essential to minimise the impact on patient care during weekdays.
    14. 14. The Key Findings (cont’d) •How Trusts might meet this demand will depend on a number of factors, including: – case mix and complexity of patients within a Trust, some of whom may require a high level of specialty expertise – whether consultants are already covering weekends – level of ‘generalist’ skills – the flexibility of workplans. •Possible resourcing approaches: – Invest to save – reductions in morbidity / improved outcomes – Reshaping of services – Greater levels of networked / federated arrangements – Need detailed financial modelling
    15. 15. Thank you www.aomrc.org.uk www.hislac.org

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