Presentation made by Celia Ingham Clark National Director for Reducing Premature Mortality, at Improving access to seven day services. Southampton 25 March 2015

1. www.england.nhs.uk
Clinical Standards for
Seven Day Services in
Acute Care
Celia Ingham Clark
National Director for
Reducing Premature
Mortality
March 2015

2. www.england.nhs.uk
• "the provision of acute medical care in such a way
that there is no difference in quality (experience,
safety and clinical effectiveness) for patients whether
it is a weekday or a weekend."
What do we mean by
‘seven day services’?

3. Seven day services: Why?
• Illness happens seven days a week
• Currently outcomes differ at weekends
• Trainee feedback suggests variable consultant involvement in
acute care out of hours
• Hypothesis that patients admitted at weekends are sicker due to
limited access to primary care
• Importance of “failure to rescue” in defining the difference
between hospitals with high and low mortality rates
• Acute illness can occur at any time and patient expectations are
rising as other sectors (e.g. banking and retail) have moved to
offer seven day services
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4. Key themes
• There is often inadequate involvement of senior medical
personnel in the assessment and subsequent management of
many acutely ill patients, particularly at the weekend
• Limited access to diagnostic services and allied health
professionals at weekends to establish multi-disciplinary
management plans and facilitate transfer out of hospital
• Poor weekend emergency service provision is associated with an
increased variation in outcomes such as:
• Mortality rates
• Patient experience
• Length of stay
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5. Cause of the weekend effect - multifactorial
• Variable staffing levels in hospitals at the weekend
• Fewer senior decision makers of consultant level skill and
experience on site at the weekend
• A lack of consistent support services, such as diagnostic and
scientific services at weekends
• A lack of community, primary and social care services which
could prevent some unnecessary admissions and support
timely discharge
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6. Seven day services: What?
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True emergencies –
where minutes delay
can affect risk of death
• Cardiac arrest
• Ruptured aortic aneurysm
• Acute MI
• Extra-dural haematoma
Services provided
promptly
• Emergency laparotomy
• Fractured NOF (DH 2011 BPT to improve care)
• “hot” cholecystectomy
Routine services
• Endoscopy
• MRI scans
Services not
commonly provided
at weekends now
• Routine elective surgery
• Routine GP consultations
• Contact with specialist nurses
• Routine outpatient appointments
Similar spectrum applies to diagnostics and their reports: FBC, U&E, ECG,
CXR, CT, USS and cardiac echo, spirometry, histopathology
Spectrumofcare

7. Seven day services:
Not ‘should we’ but ‘how far should we go’?
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• Care and services need to shift towards seven day services to
abolish differentials in:
• Patient safety
• Patient experience
• Clinical effectiveness

8. Seven Day Services Forum: clinical standards
The CRG developed 10 clinical standards based on the evidence
and recommendations from Royal Colleges and expert bodies.
These follow the patient pathway, apply seven days a week and aim
to ensure:
• Prompt access to consultant review and multi-disciplinary
assessment
• Availability of diagnostics to support decision-making
• Timely treatment and interventions
• Planned, safe and appropriate timing of transfers from hospitals
All standards are based on existing recommendations from Royal
Colleges and expert bodies and will cover the seven days of the
week
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9. Alignment with Academy of Medical Royal
Colleges
The clinical standards are deliberately aligned with the Academy of
Medical Royal Colleges work on consultant-delivered care:
• Consultant involvement: All 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
• Consultant supervision: Consultant-supervised interventions and
investigations, and their reports should be provided, seven days per
week, if the results will change the outcome or status of the patient’s
care pathway before the next ‘normal’ working day – this should include
interventions and investigations which will enable immediate discharge
or a shortened length of hospital stay
• Support services, seven days a week: Support services both in
hospital and in the community and primary care setting should be
available seven days per week to ensure that the next steps in the
patient’s care pathway, as determined by the daily consultant review, can
be taken9

10. Clinical standard 1:
Patient experience
• Patients, and where appropriate families and
carers, must be actively involved in shared
decision making and supported by clear
information from health and social care
professionals to make fully informed choices
about investigations, treatment and on-going care
that reflect what is important to them. This should
happen consistently, seven days a week.
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11. 2: Time to first consultant review
• All emergency admissions must be seen and
have a thorough clinical assessment by a
suitable consultant as soon as possible but at
the latest within 14 hours of arrival at hospital
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12. 3: Multi-disciplinary team review
• All emergency inpatients must have prompt
assessment by a multi-professional team to
identify complex or on-going needs, unless
deemed unnecessary by the responsible
consultant. The multi-disciplinary assessment
should be overseen by a competent decision-
maker, be undertaken within 14 hours and an
integrated management plan with estimated
discharge date to be in place along with
completed medicines reconciliation within 24
hours
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13. 4: Shift handovers
• Handovers must be led by a competent senior
decision maker and take place at a designated
time and place, with multi-professional
participation from the relevant in-coming and out-
going shifts. Handover processes, including
communication and documentation, must be
reflected in hospital policy and standardised
across seven days of the week
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14. 5: Diagnostics
Hospital inpatients must have scheduled seven-day
access to diagnostic services such as x-ray,
ultrasound, computerised tomography (CT),
magnetic resonance imaging (MRI),
echocardiography, endoscopy, bronchoscopy and
pathology. Consultant-directed diagnostic tests
and their reporting will be available seven days a
week:
• within 1 hour for critical patients
• within 12 hours for urgent patients
• within 24 hours for non-urgent patients
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15. 6: Interventions
Hospital inpatients must have timely 24 hour
access, seven days a week, to consultant-
directed interventions that meet the relevant
specialty guidelines, either on-site or through
formally agreed networked arrangements with
clear protocols, such as:
• critical care
• interventional radiology
• interventional endoscopy
• emergency general surgery
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16. 7: Mental health
Where a mental health need is identified following
an acute admission the patient must be assessed
by psychiatric liaison within the appropriate
timescales 24 hours a day, seven days a week:
• Within 1 hour for emergency care needs
• Within 14 hours for urgent care needs
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17. 8: Ongoing review
• All patients on the AMU, SAU, ICU and other high
dependency areas must be seen and reviewed by
a consultant twice daily, including all acutely ill
patients directly transferred, or others who
deteriorate. To maximise continuity of care
consultants should be working multiple day blocks
• Once transferred from the acute area of the
hospital to a general ward patients should be
reviewed during a consultant-delivered ward
round 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
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18. 9: Transfer to community, primary
and social care
• Support services, both in the hospital and in
primary, community and mental health settings
must be available seven days a week to ensure
that the next steps in the patient’s care pathway,
as determined by the daily consultant-led review,
can be taken
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19. 10: Quality Improvement
• All those involved in the delivery of acute care
must participate in the review of patient outcomes
to drive care quality improvement. The duties,
working hours and supervision of trainees in all
healthcare professions must be consistent with
the delivery of high-quality, safe patient care,
seven days a week
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20. Seven Day Services: Implementation
• Year 1 (2014/15) – local contracts should include an Action
Plan to deliver the clinical standards within the Service
Development and Improvement Plan Section
• Year 2 (2015/16) – those clinical standards which will have
the greatest impact should move into the national
requirements section of the NHS Standard Contract
• Year 3 (2016/17) – all clinical standards should be
incorporated into the national requirements section of the
NHS Standard Contract with appropriate contractual
sanctions for non-compliance.
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21. Enablers for implementation
• NHS England Implementation Board and delivery sub-group
• Development of metrics to support the standards
• Clinical Senates support
• NHS IQ to introduce a large-scale transformational change
programme to support the spread of seven day services
• CRG continues to provide expert advice
• In London – ongoing audit of implementation of Quality
Standards, and lessons shared
• Inspection and assurance – CQC hospital inspections to
include assessment of seven day services implementation
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22. Implications for patients
• Improved experience
• More consistently receive prompt diagnosis and
timely treatment
• Less time spent waiting for something to happen
• Reduced risk of poor outcomes
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23. Implications for tax-payers
• Better care for loved ones experiencing acute
illness
• Likely higher staff costs in the NHS
• To achieve best value in seven day services likely
to need to change the models of care
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24. Implications for staff
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• Some staff groups will need to change working
patterns
• More likely to feel part of a multiprofessional team
when working at weekends
• More likely to find Monday workload manageable
• Less likely to receive patient complaints

25. Implications for managers and
commissioners
• More consistent patient benefits if move all related
services to seven day provision together, rather
than piecemeal
• Some services will need to be provided across a
collaborative network where not cost-effective to
run a low volume service on every site
• Likely higher staff costs
• Potential savings through reduced complications,
reduced complaints, evening out work across the
week
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26. The wider context
Recognising relationships with other work including:
• Primary Care Transformation
• Urgent and Emergency Care Review
• Integrated care programme
• Reconfiguration proposals and service change plans
• Productive elective care
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27. Patient perspective
• “I was lucky. Shouldn’t every one of us
have the best chance possible no
matter what time of day or day of the
week it is?”
• Rodney Partington, Patient representative
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