Practical issues around the implementation of the Academy of Medical Royal Colleges' standards for 7 day consultant-present care, along with the potential impact on training

1. 7 day working:
implications for
emergency services
Dr Chris Roseveare
Co-Chair AoMRC 7 day Project sub-committee

2. The weekend challenge…
Higher case-mix adjusted
mortality
Greater illness severity
amongst weekend
admissions
Fewer consultants in hospital

3. …the benefits of
consultant-delivered
care should be
available to all
patients throughout
the week

4. 7 day working: what do we mean?
• ‘Emergency’ Care:
• ‘Elective’ Care:
• ‘Urgent’ Care:
• Must Do’s
• Could Do’s
• Should Do’s

5. 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.

6. Standard 2
Consultant supervised
interventions /
investigations + 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.

7. Standard 3
Support services both in
hospitals and in the
primary care setting
should be available
seven days a week

8. Sir Richard Thompson
President , RCPL
‘While the RCP accepts this as an
aspirational standard for all physicians,
we believe that this will require service
redesign and may have resource
implications to make this a
comprehensive reality’

9. • Challenges for implementation
– contracts / job plans
– specialism vs generalism
– continuity of care
– costs

10. PART 2
More detailed summary of implications for each
speciality / college
• Staffing requirements?
• Which investigations / interventions?
• Which support services?
Questionnaire to speciality organisations
– Responses from 36 medical specialities
– Further information from 14 other organisations

12. Key messages…1
Most patients will benefit from a daily
consultant review

14. Key messages…2
Duration of consultant review varies
by speciality, but continuity is key….

16. Key messages….3
‘Approx. 6 hours of consultant time
required for every 30 in-patients’

17. Key messages….4
More generalists needed for ‘cross
cover’
– acute physicians
– geriatricians
– general physicians

18. Consultant supervised
Investigation
Proportion of specialties indicating a regular need at
the weekend
‘Top Ten’ specialties 36 survey respondents
Haematology 100% 97%
Microbiology 100% 97%
Clinical biochemistry / chemical
pathology
100% 97%
Ultrasound 90% 83%
Computed Tomography (CT)
scan
90% 78%
Plain radiology 80% 89%
Access to expert imaging opinion 70% 58%
Magnetic Resonance Imaging
(MRI)
60% 56%
Diagnostic upper
gastrointestinal endoscopy
60% 42%
Echocardiogram 60%* 19%*

19. Consultant-supervised
Intervention
Proportion of specialties indicating a regular need
at the weekend (%)
‘Top Ten’ specialties 36 survey respondents
Emergency surgery 70 58
Interventional radiology 50 47
Therapeutic upper
gastrointestinal endoscopy
50 39
Percutaneous coronary
angiography
50 25
Radiological feeding tube
placement
40 31
Haemodialysis 40 31
Bronchoscopy 20 33

20. Hospital based
services
Proportion of specialties indicating a
regular need at the weekend (%)
‘Top Ten’ specialties 36 survey respondents
Pharmacy 100 100
Physiotherapy 90 83
Specialist nurse review 70 61
Dietetics/Nutrition 70 44
Occupational therapy 40 47
Swallow assessment 40 17
Speech & Language therapy 30 31

21. Community
based services
Proportion of specialties indicating a regular need
at the weekend (%)
‘Top ten’ specialties 36 survey respondents
Social care team 90 67
Specialty community care
team
80 58
Real time conversation with
GP
70 47
Electronic communication
with GP
60 50
Real time conversation with
community practice team
60 50
Electronic communication
with community practice
team
50 44

22. Training implications
– Supervision vs autonomy
– Generalism vs specialism
– Consultant numbers / patterns of working

23. •Rapid and appropriate decision making
•Improved safety, fewer errors
•Improved outcomes
•More efficient use of resources
•GP's access to the opinion of a fully trained doctor
•Patient expectation of access to appropriate and skilled
clinicians and information
•Benefits for the supervised training of junior doctors.
Benefits of consultant delivered care…

24. Any thoughts from trainees
about the positive /
negative impact of greater
consultant 7 day working?

25. Autonomy vs supervision
Medical ST7
‘I learn most when I am left on
my own to get on with it –
wouldn’t want the consultant
looking over my shoulder all
the time’

26. ‘The method by which a consultant-led
review takes place need not be constrained
to formal, physical bed-side ward
rounds by a consultant’

27. Other appropriate methods of consultant-led review could include:
• Ward round undertaken by a doctor in training
or SAS doctor, followed by a discussion of all,
and review of selected patients by the consultant
• A multi-disciplinary team ‘board-based’ round.’

28. Teaching vs service at weekends
Medical CT2 Trainee
‘Consultants don’t tend to
teach on weekend ward
rounds so they are much
quicker’

29. Structured education..
AMU Consultant
‘Consider impact on
attendance at grand rounds,
xray meetings journal clubs,
etc’

30. Continuity of training....
Medical Consultant
‘Consultant rota needs to
be in synch with trainee to
ensure maximal contact
time’

31. Current consultant contract:
3hrs weekend time = 4hrs weekday time
More weekend hours
= fewer total training hrs

32. A Phased Evaluation of the
Impact of High-Intensity Specialist-Led Acute
Care (HiSLAC)
of Emergency Medical Admissions
to NHS Hospitals (Commissioned call 12/128)
3 year study in 2 phases
Prof Julian Bion, University of Birmingham
J.F.BION@bham.ac.uk

33. Thank You