Seven Day WorkingThe economic case to increase clinicaldecision making at the weekendDavid HalsallAnalytical ServicesNovem...
Let us start by asking the simple question– what are the main value added activities that an acute trust offers?Treatmenta...
In elective activity hospitals clearly show a stop – go weekendeffect. In unscheduled activity there is also a weekend dro...
At the weekend the acute hospital will shrink its capacity, but some keyareas shrink more than others – what are the conse...
Fewer people are admitted to hospital as an emergency at theweekend but the chances of dying are noticeably higherDay of a...
What we know about the differences between weekday and weekendacute hospital death rate• What we have distilled from publi...
Fewer emergency patients are admitted at the weekend but the chance ofdying is higher – There are possibly two effects dri...
Making the economic case for the reduction in the difference betweenthe weekday and weekend level of service requires an e...
Would we expect incremental changes to resources to have a directlinear link to patient care or would we guess that there ...
So let’s look at an example were extra resources are added to generalmedicine at the weekend and see if the economic case ...
The case can be made that the cost of the extra consultants could beoffset by increasing the weekend discharge rate• A con...
In addition to the direct costs and benefits there are a range of additionalbenefits which also could be used to evaluate ...
Although it is impossible to attribute the improvement in performanceto the change in the weekend working pattern it is co...
So is there scope to improve weekend discharge rates? Looking atcancer patients as an example it seems very few are discha...
This approach re-balances the weekend hospital by increasing senior-led decision making capacity which in turn reduces the...
Summary• From the inception of the NHS, hospitals have been intended to be medicalconsultative centres rather than hostels...
Upcoming SlideShare
Loading in …5
×

Seven day working in the NHS - outline economic case

370 views

Published on

This presentation, first given to the North West Medical Leaders Congress in April 2012, gives an initial analysis of the benefits that could be achieved by increasing clinical decision making capacity in NHS hospitals over the weekend. NHS England have now embarked on a detailed investigation of the costs and opportunities that enhanced weekend working might achieve. This is due to published in autumn 2013

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
370
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Seven day working in the NHS - outline economic case

  1. 1. Seven Day WorkingThe economic case to increase clinicaldecision making at the weekendDavid HalsallAnalytical ServicesNovember 2012
  2. 2. Let us start by asking the simple question– what are the main value added activities that an acute trust offers?TreatmentandproceduresNursingledcareEvidencebaseddecisions
  3. 3. In elective activity hospitals clearly show a stop – go weekendeffect. In unscheduled activity there is also a weekend drop-offeffect in activity.Admissions by Day of the Week(relative to total of admission route)0%5%10%15%20%25%MON TUE WED THU FRI SAT SUNPercentageoftotalBirth Emergency elective - ordinary daycaseDH analysis of HES
  4. 4. At the weekend the acute hospital will shrink its capacity, but some keyareas shrink more than others – what are the consequence of that?TreatmentandproceduresNursingledcareEvidencebaseddecisionsPatients admittedat the weekendhave treatmentdeferred untilMondayPatients are not reviewed fullyand maysuffer from afailure to rescue
  5. 5. Fewer people are admitted to hospital as an emergency at theweekend but the chances of dying are noticeably higherDay of admission DH analysis of HES data 2010/11National figures, England 2010/11Evidence 1 – Higher deaths if admitted at the weekend0%2%4%6%8%10%12%14%16%18%MON TUE WED THU FRI SAT SUNPercentageofpatients3.2%3.4%3.6%3.8%4.0%4.2%PercentageofpatientwhodiePercentage emergency admissions by day of the weekPercentage of patients who are discharged dead
  6. 6. What we know about the differences between weekday and weekendacute hospital death rate• What we have distilled from published evidence is:-1. You are no more likely to die if you are in hospital over the weekendcompared to a weekday if you were admitted on a weekday2. Emergency patients admitted over the weekend have a higher riskof dying in hospital and within 30 days of discharge – even after casemix adjustment is applied. We have no estimates of difference thismake to life expectancy but researchers have advised us the effect ismore likely to be small – days not weeks or months.3. Elective patients admitted at the weekend do have a higherprobability of dying compared to those admitted on a weekday – butthis is possibly due to higher risk elective patients being treatedearlier in the week over the normal cycle of hospital scheduling
  7. 7. Fewer emergency patients are admitted at the weekend but the chance ofdying is higher – There are possibly two effects driving this (i) a morecomplex case mix at the weekend and (ii) failure to rescue some patientsChange from weekday to weekend admission-25%-20%-15%-10%-5%0%5%10%15%admissions deaths chance of deathDH analysis of HES data 2010/11Emergencyadmission byweekend andweekdayadmissionEvidence 2 At the weekend we have a more complex patient mixIn either case it looks like we need to improve the decision making capacity at theweekend as the supply and demand for senior staff is not in balance
  8. 8. Making the economic case for the reduction in the difference betweenthe weekday and weekend level of service requires an evaluation of thecosts and benefits of any re-configuration• Economic evaluation in principle is straight forwardShowing that economic benefit outweighs the costs is only part of the story• Are savings nominal or cash releasing?• What is the timing of the savings v any investment?Extra CostSavingsQALYHealthBenefitsCost/benefitQIPP savings ifcash releasingWhat sort of economic analysis shall we do?
  9. 9. Would we expect incremental changes to resources to have a directlinear link to patient care or would we guess that there is a non-linearrelationship?A measure of access to careFor example time between admission and senior reviewLooking at benefits – a conceptual model to help our thinking01020304050607080901000 10 20 30 40 50 60 70 80 90AmeasureofthebenefitcarebringsForexamplelevelofdisabilityfollowingastrokeNormal weekdayworking ?WeekendWorking?BestPractice ?A conceptual model of the link between access to care and benefits care brings1/3 cost 1/3 cost 1/3 costHigh benefit tocost ratioDiminishingbenefit to cost ratio
  10. 10. So let’s look at an example were extra resources are added to generalmedicine at the weekend and see if the economic case stacks up• In 2007 Heartland Hospital instigated early consultant review to reducethe risk to patients when AMU patients are transferred to specialistmedical wards at weekends.• The appointment of 2 additional acute physicians released consultanttime from the AMU to allow several consultants to conduct short roundson their base wards of newly transferred in patients - replacing theweekend “safari” ward round of new admissions by a single consultant.• This reduced delays in having a clear clinical management plan andreduced LoS for patients admitted towards the end of the week.• In particular it was identified that opportunities were being missed todischarge some patients in the subsequent 24-72 hours after admission.• In common with many acute trusts discharges at weekends were lessthan on weekdays.• Seven day working of key clinical and social service staff is required toachieve a levelling out of discharge pathways.Example
  11. 11. The case can be made that the cost of the extra consultants could beoffset by increasing the weekend discharge rate• A consultant (including overheads) could cost £150,000/year• A patient awaiting discharge will cost around £250/day• So £300,000 is equal to around 1200 patient days• Or in other words if 23 patients are discharged 1 day earlier each weekend thatwould cover the cost of the 2 extra consultants.• In effect one ward would have to close for a day a week to recover the cost.• The other changes to weekend working patterns are achieved by negotiated HRprocessesExample£300,000/year23 patients aweek have their LoSreduced by 1 day
  12. 12. In addition to the direct costs and benefits there are a range of additionalbenefits which also could be used to evaluate the change in practice• Improve patient satisfaction• Better training of junior doctors• Enhance patient care quality and safety• Ward staff feel more supported
  13. 13. Although it is impossible to attribute the improvement in performanceto the change in the weekend working pattern it is consistent with whatyou would expectPercentage of Deaths in Hospital Following Emergency Admission(Birmingham trust and England)3.0%3.2%3.4%3.6%3.8%4.0%4.2%4.4%4.6%4.8%5.0%2005/06 2006/07 2007/08 2008/09 2009/10 2010/11DeathsasapercentageofemergencyadmissionsRR1EnglandSource DH analsys - of HES dataEnglandBirmingham Heartlands & Solihull NHS Trust (RR1)RR1 20010/11Weekday = 3.5%Weekend = 3.9%RR1 2006/07Weekday = 4.5%Weekend = 5.4%+20%+14%England 2006/07Weekday = 4.5%Weekend = 4.8%+6%England 2006/07Weekday = 3.7%Weekend = 4.0%+10%Example2010/11
  14. 14. So is there scope to improve weekend discharge rates? Looking atcancer patients as an example it seems very few are discharged at theweekend at presentLength of stay for cancer patients - Emergency admission0500100015002000250030003500MONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSFRISATSUNMONTUEWEDTHURSDays from admissionNumberofdischargesMondayWednesdaySaturdayMonday - deadWednesday - DeadSaturday - DeadSaturdayMondayWednesdayAdmitted Monday, Wednesday & Saturday offset to show day of the week patternDH analysis of HES data 2010/11 cancer emergency admissionsBut to release the cash toreinvesthospital capacity wouldhaveto reduce at the weekendtypically by 20 – 30 bedsIrrespective of when the patient isadmitted feware discharged at the weekend
  15. 15. This approach re-balances the weekend hospital by increasing senior-led decision making capacity which in turn reduces the demand forpatients staying in hospital unnecessarily, reducing LoS andimproving outcomesTreatmentandproceduresNursingledcareEvidencebaseddecisionsReducing the demandCash released
  16. 16. Summary• From the inception of the NHS, hospitals have been intended to be medicalconsultative centres rather than hostels providing treatment[1].Current hospital weekend working patterns tend to reflect the latter rather thanthe former.• The year-on-year improvements seen in outcomes seem to lag for weekendadmissions by 1 to 2 years.• With targeted interventions and good HR practices the difference betweenweekend and weekday service can be reduced showing overall cost benefit.• It is also possible that by keeping the discharge rate close to the weekday rateat the weekend levelling up the weekend service could be cost saving, howeverthis will require a more rigorous use of weekday only and seven day bedcapacity.•[1] Chief Medical Officer, Ministry of Health, 31st March 1948

×