Simon Bennett

Deputy Director – Quality Framework Team

NHS England

DEVELOPING A 7 DAY HEALTH SERVICE

18 November 2013, Melbourne

WORKSHOP AGENDA

Session 1: NHS Context and Overview of NHS Services, Seven Days

A Week Programme (9.15-10.30)

Morning tea (10.30-11.00)

Session 2: ‘One Size Doesn’t Fit All’ - Setting Clinical Standards

(11.00 -12.30)

Lunch (12.30-1.30)

Session 3: Incentives, Rewards and Sanctions (1.30-3.00)

Afternoon tea (3.00-3.30)

Session 4: Finance, Costing and Salford Royal NHS Foundation

Trust Case Study - Tony Whitfield (3.30-4.30)

Round Up and ‘Top Tips’ (4.30-4.45)

WORKSHOP AGENDA

Session 1: NHS Context and Overview of NHS Services,

Seven Days A Week Programme (9.15-10.30)

The NHS is 65 years old

NHS facts and figures

• 1.4 million staff

• £109 billion annual budget

• Over one million patients treated every 36 hours

• 15 million hospital admissions per year

• 88 million outpatient attendances

• c. £12 billion spent on medicines

Context

• Since 2000 the NHS enjoyed a decade of growth and expansion.

• Expenditure has doubled in real terms.

• We have seen real improvements:

More patients treated than ever before;

Reduced waiting times; and

Better outcomes for cancer and heart patients.

The NHS faces increasing pressures … Ageing population

Diseases of modern lifestyles Rising consumer expectations

The cost of new drugs is increasing

… and a big financial challenge

• Funding has grown historically by around 4% per year.

• No significant real growth during this Parliament.

• Prices will increase by 2.5% per year and demand by 2.7%.

• By 2014/15 we will face a funding gap of around £20 billion.

• We must respond by becoming much more efficient - doing

things differently to get more value from the resources we have.

The Coalition Government’s NHS Reforms In 2010 the new Government set out its vision for the

future of the NHS.

It described how the NHS will:

• put patients at the heart of everything it does;

• focus on continuously improving those things that really

matter to patients - the outcome of their healthcare; and

• empower and liberate clinicians to innovate, with the

freedom to focus on improving healthcare services.

What does NHS England do?

The NHS belongs to the people

It is there to improve our health and well-being,

supporting us to keep mentally and physically well, to

get better when we are ill and, when we cannot fully

recover, to stay as well as we can to the end of our

lives. It works at the limits of science – bringing the

highest levels of human knowledge and skill to save

lives and improve health. It touches our lives at times

of basic human need, when care and compassion are

what matter most.

“ At the end of last year, the research company Dr Foster found mortality rates rose by 10%

at weekends. Other studies have shown similar correlations.

” BBC News, Health

NHS top doctor: Hospitals should operate seven days a week

NHS Services, Seven Days a Week - evidence

London Health Programme – Case for Change in Audit Emergency Services

Dr Foster 2011 Good Hospital Guide

Royal College of Surgeons’ report on High Risk General Surgical Patients

Academy of Medical Royal Colleges report- Seven Day Consultant Present

Care

Analysis of 14.2m NHS admissions in 2009/10

In their 2011 report, Dr Forster Intelligence suggested :

Staff • Fewer staff at work at weekends

• Less experienced and lacking supervision

• More exhausted, and used inefficiently

Services • Diagnostics and scientific services are reduced

• Specialist interventions not available

Patients • Fewer discharges to a person’s preferred place of death

• People wait longer before seeking help

• Admission thresholds are not consistent

Why is there a higher mortality risk at the weekend?

National clinical leaders said:

“Local solutions have to be found - there’s no such thing as a single

model”

“Let’s address the key specialities and their supporting functions

first”

“As clinical leaders, we know what needs to be done so why don’t

we go out there and do it?”

“We have to get it right at first point of contact. How do we get away

from having the reserve team running the hospital past 11am on

Saturday?”

“Good quality costs less in the long run”

“Monday mornings can be chaotic as we play catch up”

“We need to improve the system around the hospital, so that the

whole patient pathway functions over seven days”

“We need a hard-edged issue to get this change going, so mortality

is the best place to start”

“Junior doctors feel clinically exposed at weekends”

National clinical leaders said:

Benefits for patients from a seven day service

Case studies collected by NHS Improving Quality identify

benefits for patients arising from the presence of a senior

decision maker, of consultant level skill and experience,

including:

• the speed of assessment, diagnosis and treatment;

• intervention to spot and prevent deterioration;

• safer and more timely supported discharge; and

• reduced risk of emergency readmission.

Organisational benefits from a seven day service

Case studies collected by NHS Improving Quality point to the

potential for improved quality and organisational efficiency

through:

• fewer complications;

• admission to the right place, first time;

• better supervision of the work of doctors in training;

• better use of expensive plant and equipment; and

• avoidance of waste and repetition and reduced bed pressure

Monday - Friday.

“The NHS will move towards

routine services being

available seven days a

week. This is essential to

offer a much more patient-

focused service and also

offers the opportunity to

improve clinical outcomes

and reduce costs”

NHS England - the Offer

NHS Services, Seven Days a Week Forum

As a first stage, the review will focus on improving diagnostics and

urgent and emergency care. This very important!

It will identify the consequences of the non-availability of clinical

service across the seven day week.

It will provide insight and evidence to NHS commissioners and

proposals for improvements.

It will publish a report of its findings by the end of 2013.

NHS Services, Seven Days a Week Forum

Chair

National

Medical Director

Forum

Clinical

Standards Workforce Finance Commissioning Provider/

Service models

Celia Ingham-

Clark Raj Bhamber Tony Whitfield Mark Spencer Mark Hackett

Key messages

We are proposing ten standards for commissioners describing minimum

standards of care patients should expect to receive seven days a week.

To drive change, levers beyond pure commissioning are required. A mix of

formal contractual levers and informal levers are required, and work at different

levels – national, local, organisational, team and individual.

Reform of consultants’ contract pay and terms and conditions is a key enabler of

seven day services, and the British Medical Association’s commitment to

support the same high quality care across the seven day week is welcomed.

It is reasonable to conclude that a move to seven day services does appear

financially achievable but it may be unsustainable for all existing hospitals to

move all of their current range of services to a seven day basis. In the longer

term, seven day services are likely to support the case for consolidation of

hospital services on fewer sites.

Integration is essential to optimise value from local resources.

Next steps – the bigger picture

• NHS Improving Quality - Seven Day Services Improvement

Programme.

• How will we know what is changing?

• A whole system approach - remove barriers and make

improvements across primary, community and social care.

• Financial enablers - Integrated Transformation Fund;

General Practice Challenge Fund.

NHS England AGM 12-09-13

Seven days a week service: is it feasible?

Professor Sir Bruce Keogh: “It’s going to be

radical. It’s going to be difficult. But we have

to be up for it.”

Seven day services - why does it matter?

“ I think it is intolerable in a society like ours that we see mortality rates so affected by when you enter hospital. What really amazes me is that so many people who know, are so accepting of the situation”

Patient : Learning Exchange August 2013

“If I’d had my stroke at a weekend, no doubt I would be using a wheelchair today with the unplanned burden to my family and the state! Shouldn’t every one of us have the best chance possible, no matter what time of day or day of week it is?”

Mr Rodney Partington speaking to NHS IQ : 2011

WORKSHOP AGENDA

Session 1: Video – ‘So The Question Is…’

WORKSHOP AGENDA

Session 2: ‘One Size Doesn’t Fit All’ - Setting Clinical

Standards (11.00 -12.30)

Clinical Reference Group

A Clinical Reference Group (CRG) was convened with representation

from patients, primary care, acute care and social care to develop clinical

standards and provide expert clinical advice and input to the NHS

Services, Seven Days a Week Forum. Specifically with regard to:

• Establishing the clinical evidence base for providing NHS Services,

Seven days a week; and

• Defining standards of care that will help commissioners and

providers to deliver a consistently high quality service at all times

of the week.

Methodology and outputs

Using a combination of experience and expertise, desk-based research, a

national survey and existing case studies, the CRG:

• Defined 10 clinical standards along the acute emergency inpatient

pathway with a supporting evidence base for seven day working.

• Aligned to the Academy of Medical Royal Colleges seven day

working standards.

Key findings • There is often inadequate involvement of senior medical personnel in

the assessment and subsequent management of many acutely ill

patients, particularly at the weekend.

• There is limited access to diagnostic services and allied health

professionals at weekends to establish management plans and

facilitate discharge.

• Poor weekend emergency service provision is associated with an

increased variation in outcomes such as:

• Mortality rates;

• Patient experience; and

• Length of stay.

Proposed clinical standards The Group have 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; and

• Planned, safe and appropriate timing of discharges.

All standards have supporting information and definitions to ensure clarity.

Patient experience Evidence base

• Patient survey results consistently highlight areas of concern including poor

communication, unproductive waits, lack of timely information and not being included in

decision making.

• The 2012 Health and Social Care Act and Francis Inquiry both align with the above

findings and establish a mandate for focussing on improving patients’ involvement in and

experience of their care.

• Studies have associated hospitals with higher patient experience ratings with better patient

outcomes.

Proposed standard

• 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.

Time to first consultant review Evidence base

• Delays to both consultant reviews and a lack of on-going senior involvement in patient care

have been linked to poor outcomes in patients, including mortality.

• Evidence shows that being admitted to hospital at the weekend is associated with a

significantly increased risk of dying within 30 days of admission compared to being

admitted on a weekday

• Examples of seven day consultant delivered care have an absence of the negative impacts

associated with traditional five day working patterns. For example London’s heart attack

centres operate a consultant-delivered service seven days a week and no observed

difference is found between weekday and weekend mortality rates.

Proposed standard

• All emergency admissions to be seen and assessed by a relevant consultant as soon as

possible but at the latest within 14 hours from the time of arrival at hospital.

Multidisciplinary working

Proposed standard

• 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.

Evidence base

• Multidisciplinary team (MDT) working enables the effective care of patients with complex

clinical presentations.

• Reduced weekend services impact the timeliness of input from allied health professionals,

whether to assess and implement a management plan or to facilitate patients’ discharge.

• This impacts negatively on a patient’s experience by unnecessarily prolonging their

hospital stay and risks poorer clinical outcomes from further loss of mobility and risk of

healthcare acquired infections.

• One example of seven day physiotherapy saw an average length of stay reduction of 1.5

days.

• There is potential for improving efficiency and patient flows through effective MDT working.

Handovers Evidence base

• Misinformation, missing information or untimely information contributes to a significant

number of patient safety incidents and workflow problems.

• A 2010 survey of physicians found only 33% of respondents felt handover was being done

well.

• Continuity of safe and effective patient care relies heavily on robust handover processes,

however, many hospitals have none or poorly designed processes, particularly at the

weekend.

• Reduced weekend consultant presence reduces consultant input to handovers.

• Negative impacts include inefficiencies, repetitions, delayed decisions, repeated

investigations, incorrect diagnoses, incorrect treatment, and poor communication with the

patient.

Proposed standard

• 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.

Diagnostics Evidence base

• The vast majority of emergency inpatients require some form of diagnostic service to

support timely clinical decision-making and ensure patients are quickly on the right care

pathway or discharge expedited.

• Services have progressed in recent years but variation in the availability of diagnostic

imaging and senior reporting services particularly at the weekend still remains variable.

• There is also significant underutilisation of equipment at weekends.

Proposed standard

• 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; and

• within 24 hours for non-urgent patients.

Intervention / key services Evidence base

• Emergency admitting hospitals require the timely availability of a range of interventional

services including emergency surgery, critical care, endoscopy and interventional

radiology.

• Radiological and endoscopic treatment has become increasingly prevalent with clear

benefits of minimal invasion and enhanced recovery improving outcomes, experience and

efficiency of care.

• However, service arrangements overnight and at weekends vary significantly across the

country with many having either ad-hoc or no networked arrangements in place.

Proposed standard

• All hospital inpatients must have 24 hour access, seven days a week to consultant-

directed interventions either on-site or through formally agreed networked arrangements

with clear protocols:

• emergency general surgery;

• critical care;

• interventional radiology; and

• interventional endoscopy.

Mental health Evidence base

• An estimated 80% of all hospital bed-days are occupied by adult patients with co-morbid

physical and mental health conditions including depression, dementia and delirium.

• Liaison psychiatry is still perceived as an optional rather than essential part of acute

hospital services with significant variation of provision and models across the country.

• Adverse consequences include a two to three fold increase in hospital mortality rates,

increased length of stay typically of around 5-10 days, increased re-admission rates and

increased rates of discharge to institutional care rather than the patient’s home.

Proposed standard

• People with mental health needs are assessed within the appropriate timescales 24 hours

a day, seven days a week:

• within 1 hour for emergency care needs; and

• within the same day for urgent care needs.

On-going review Evidence base

• Consultant medical ward rounds or clinical reviews should be on-going clinical activities, critical to

providing high-quality and safe care to patients in a timely manner.

• Acute units with two medical ward rounds reviewing all patients had a lower mortality rates for patients

with a hospital length of stay of more than seven days.

• Medical and Surgical Royal Colleges recommend twice daily consultant review of all patients on acute

wards, with the Academy of Royal Colleges recommending daily consultant review on downstream

wards following a patient’s acute phase.

• However, varying consultant and MDT working patterns negatively impact hospitals ability to deliver

consistently high quality care.

Proposed standard

• 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.

Onward transfer / discharge Evidence base

• Effective discharge or transfer of care requires forward planning and the availability of

services both in the hospital and in the community, seven days a week.

• A lack of planning and reduced service provision at the weekend can delay discharge from

the unavailability of a competent decision-maker, equipment, medicine and appropriate

documentation.

• Similarly, unavailability of social services assessments and primary and community care at

weekends creates further barriers to timely discharge.

• This can result in unnecessarily longer lengths of stay and patients being re-admitted to

hospital as a result of sub-optimal discharge planning.

Proposed standard

• Support services, both in the hospital and primary and community setting 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.

Quality improvement Evidence base

• The review of patient outcomes should focus on the three pillars of quality care: patient

experience, patient safety and clinical effectiveness.

• Attention should be paid to ensure the delivery of seven day services supports training that

is consistent with General Medical Council and Health Education England

recommendations and that trainees learn how to assess, treat and care for patients in

emergency as well as elective settings.

• All clinicians should be involved in the review of outcomes to facilitate learning and drive

quality improvements.

Proposed standard

• 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.

WORKSHOP AGENDA

Session 2: ‘One Size Doesn’t Fit All’ - Setting Clinical

Standards

Questions for consideration:

• Is there a strong clinical evidence base in Australia

for 7 day services?

• Does it make sense to prioritise services as the NHS

in England is doing?

• How applicable are the Forum’s clinical standards to

the Australian health service?

WORKSHOP AGENDA

Session 3: Incentives, Rewards and Sanctions (1.30-3.00)

Approach • Extensive discussions with key stakeholders on available

and appropriate levers for change.

• Discussion on evidence of their effectiveness.

• Working group established to determine priority and likely impact of the proposed levers.

• Ensuring alignment with the national review of incentives and other workstreams.

• Discussions are on-going with key stakeholders regarding proposed recommendations and full feasibility testing.

• Recommendations will also be informed by forum discussions on timescales for implementation.

Findings • Levers beyond pure commissioning are needed.

• A mix of formal and informal levers need to work at different levels: national, local, organisational, team and individual.

• Moving from five to seven day service provision requires a significant cultural shift alongside the necessary practical and logistical changes.

• Widespread support for the clinical standards and their evidence base and the introduction of seven day services is vital.

Incentives, rewards and sanctions

The main levers fall into the following categories:

Contractual mechanisms

Payment system mechanisms

Inspection and assurance

Measurement and transparency

Education commissioning and revalidation

Engagement

Contractual mechanisms (1) • The NHS standard contract lends itself to precisely described,

comprehensible standards.

• There are several sections where the clinical standards, against which

services will be commissioned, could fit.

• This would also have the benefit of consistent application and avoid

the risk of them being implemented piecemeal.

Proposed recommendation

From 2014/15 local contracts should include an action plan to deliver the clinical standards

within the Service Development and Improvement Section.

Contractual mechanisms(2): CQUINs • CQUINs allow commissioners to reward providers for achieving specific

improvement goals. The national review of incentives suggests the

CQUIN framework may change from 2015/16.

• In the short-term CQUINs provide an opportunity to encourage progress

in meeting the standards in 2014/15.

Proposed recommendation

To incentivise progress in meeting the clinical standards a local CQUIN should be

considered, based on the standard for time from arrival to initial consultant assessment.

Payment system mechanisms • A review of the payment system is underway by Monitor and NHS

England. The new National Tariff will set out new prices, new rules on

price-setting and on varying national prices. It aims to align payment with

quality outcomes rather than treatments or inputs.

• The Forum has formally responded to the review to encourage linking

payment to delivery of evidence-based standards. For emergency care,

reimbursement should be based on the clinical standards.

Proposed recommendations

NHS England and Monitor should ensure that the new payment system reflects the extent

to which clinical standards are being delivered on every day of the week.

Inspection and assurance • The Care Quality Commission regularly assesses hospitals and other

sites delivering NHS care against a set of national standards.

• A new Chief Inspector of Hospitals will carry out targeted inspections and

develop a ratings system to allow comparison of organisations.

• Inspection has the potential to ensure delivery of the clinical standards,

seven days a week.

Proposed recommendation

No hospital rating equivalent to ‘outstanding’ should be awarded by the Care Quality

Commission and Chief Inspector of Hospitals, unless emergency services in line with the

clinical standards are provided on every day of the week.

Measurement and transparency • Achievement of the standards depends on data gathering and reporting,

but no system is currently in place. At the same time, the national

incentives review aims to reduce the burden of information collection.

• There is evidence that publishing data improves the achievement of

standards or guidelines. Such a system would encourage healthy

competition between both providers and commissioners.

Proposed recommendations

Future revisions to the Clinical Commissioning Group (CCG) indicator set by NHS

England, supported by NICE, should include indicators relating to delivery of the clinical

standards.

NICE should consider accrediting the clinical standards as an evidence-based resource. If

accredited, the standards should then be used to inform any future quality standard

produced by NICE on seven day services.

Data and information relating to the achievement of the clinical standards and the provision

of seven day services should be published in an accessible and benchmarked format.

Education commissioning and revalidation • Medical education and training budgets far exceed financial incentives.

Junior doctors are fundamental to the functioning of most hospital

departments, but have limited supervision at weekends.

• Allocation of training posts to providers that meet standards, particularly

levels of consultant supervision, is therefore a powerful lever for change.

• Ensuring that clinicians’ appraisals and revalidation refer to the clinical

standards will also support delivery.

Proposed recommendations

Education contracts with Health Education England should include consultant availability to

provide adequate supervision of doctors in training seven days a week in line with the

clinical standards.

Consultant revalidation and appraisals should reflect delivery of the clinical standards,

seven days a week, as appropriate to the specialty and setting.

Engagement • Clinical standards must be seen as credible and evidence based.

• Patient and public engagement should include the message that

services and outcomes are not currently consistent seven days a week.

• Professional engagement should include the benefits of the standards in

terms of both patient outcomes and experience and also improvements

to working lives.

Proposed recommendation

The evidence base for the clinical standards, quality and outcome benefits, and the

working life implications of the delivery of the clinical standards should be widely shared

through comprehensive engagement with a wide range of stakeholders – patients and

carers, clinicians, commissioners and providers.

WORKSHOP AGENDA

Session 3: Incentives, Rewards and Sanctions

Questions for consideration on each table:

• What are the levers available to the Australian health

service to encourage a 7day service?

• How do you change culture?

• How do you make change clinically and financially

sustainable?

WORKSHOP AGENDA

Session 4: Finance, Costing and Salford Royal NHS

Foundation Trust Case Study - Tony Whitfield (3.30-4.30)

Seven Day Services in the English NHS

Tony Whitfield, HFMA President

Melbourne

What the Trust Provides:

• Community based Health care

• General acute services (Salford)

• Tertiary services (Gtr Manchester & beyond)

• Research and Development

• Teaching and Learning

• Corporate Services

Facts and figures for SRFT

• Income £420m

• 6,014 staff

• 51,000 inpatients

• 588,000 community contacts

• 28,000 day cases

• 77,500 new outpatients

• 220,000 follow-up outpatients

• 78,000 A&E attendees

What we stand for

“ At the end of last year, the research company Dr Foster found mortality rates rose by 10%

at weekends. Other studies have shown similar correlations.

” BBC News, Health

NHS top doctor: Hospitals should operate seven days a week

Introduction • The planning for Seven Day Services (SDS) in

England began in autumn 2012. The work is led by the Medical Director for NHS England, Sir Bruce Keogh. Initially it is looking only at hospital emergency admissions and supporting diagnostics

• There are 4 main drivers: to reduce hospital mortality at weekends; to improve efficiency; to move with the times (like non-health services); and to improve patient experience

• SDS to be formally launched by the end of 2013

The financial work on SDS

• Finance and costing was one of 5 SDS work streams. The others were clinical standards, workforce, commissioning levers and provider models

• There is much published evidence on the benefits of seven day working, but almost none on the costs. The main task of the finance work stream was to identify potential costs and savings

• HFMA worked closely with 7 volunteer hospitals over 6 months. The costs are their costs and might not be typical of the whole NHS

Summary of SDS costs

• Costs are incremental costs of moving from current services to the SDS standards – some hospitals (especially in London) are already closer to SDS

• Costs are pay costs (no real impact on non-pay). The biggest element of cost is additional consultants

• Costs are net of known savings, mainly reduced length of stay

• At most of these 7 hospitals, SDS could add 5%-6% to the cost of emergency admissions, or 1.5%-2% to the total cost base of the hospital

Current Seven Day Provision

Emergency Village – 8am til 8pm x 7 days per week

Intensive Care / High Dependency Units

Service Specific Developments – Major Trauma (Neurosurgery and Orthopaedic trauma)

Stroke

Emergency Medical Admissions – 1 Acute Physician of the Day (Sat and Sun)

Accident and Emergency

Current Seven Day Provision Emergency Village – establishment of dedicated 55 bedded assessment unit incorporating medical and surgical admissions along with ambulatory care area (chairs and beds)

Emergency Village – acute physician led unit 8 – 8 x 7 days per week

Emergency Medical Admissions – 1 Acute Physician of the Day (Sat and Sun)

Accident and Emergency – consultant led seven days a week

Investment in front end of £1.9m delivered through savings in acute ward beds and non recurrent re-ablement PCT money

Emergency Village admissions tariff re-negotiated through risk share arrangements with PCT/ CCG

Current Seven Day Provision

Diagnostics CT Supporting Emergency Village 24 / 7 Plain Film

MR supporting Greater Manchester 24/7 through on call arrangements arrangements dedicated weekend sessions 9am – 5pm

Endoscopy supporting Emergency Admissions through GI Bleed on call rota and slots within elective WLI provision at weekends

Pathology supporting all emergency Department and Emergency admissions 24/7

Current Seven Day Provision Therapies / Pharmacy

Physiotherapy Provided 8am – 5pm weekend (limited cover) Respiratory Physio provided 24.7 through on call Occupational Therapy provided 8am – 5pm weekend (limited cover) Pharmacy support TTO and Emergency Village 9am to 5pm at weekends

Assumptions of costing work 1. Specialist 7 day Consultant ward rounds for Emergency

Admissions in the following specialties:

Secondary Care Services

Cardiology Gastroenterology Geriatric Medicine Respiratory Diabetes / Endocrinology General Surgery, including sub-

specialisation to upper and lower GI

Specialist / Tertiary Services Acute Neurology (excluding Stroke) Neurosurgery (excluding Trauma) Spines Renal Medicine

9.72 WTE Consultants

£1.1m (Net) + 9.3 WTE Consultants 3 Middle Grade Doctors

£1.4m

2. Seven Day Diagnostics:

Assumptions of costing work

Radiology Weekend sessions for the following modalities: - Ultrasound - Interventional

Radiology

Cardio-Respiratory Weekend sessions for all modalities

Endoscopy Weekend sessions to support GI bleeds, emergency admissions and offer elective / daycase slots

3.3 WTE Radiographers £130k +

2.48 WTE Technicians £60k

5 WTE Nurses £229k 0.6 WTE Consultant £70k

Assumptions of costing work

3. Seven Day Therapies / Pharmacy:

AHPs Additional resourcing within - Physio - Occupational Therapy

Pharmacy Re-alignment of week / week day rotas to provide seven day pharmacy

2.88 WTE £147k +

No increase to WTE £97k (additional cost for weekend enhancements

Assumptions of costing work

4. Emergency Department Consultant presence - In order to maximise benefits of seven day inpatient services, 24 hours a day presence of consultants in ED is required Supports specialist trauma, stroke service specific pathways Enables SRFT to reduce threshold of admission resulting in cost reductions of inpatient beds

6.1 WTE Consultants

£900k

Issues with service delivery

Interventional Radiology Sub Specialisation requires additional cost e.g. General Surgery (how far do you go??) Junior Doctor Rotas Emergency Department – is this part of the project?

Benefits Realisation

Additional Endoscopy Income generated through utilisation of additional weekend capacity = £357k Consultant costs – savings against on call Gastro bleed rota = £150k Consultant Endoscopy Waiting List weekend payments = £127k Removal of weekend Acute physician of the day rota = £111k LOS savings associated with admission avoidance AND reduced LOS through weekend consultant –led intervention £900k

Benefits Realisation

Reduction in LOS – HRG level data provided through consultant review at patient and HRG level Admission avoidance – clinical review of short stay admissions, patients admitted overnight

Main financial implications of SDS

• SDS at the ‘front end’ of the hospital can pay for itself, by reducing unnecessary admissions and length of stay e.g. Salford’s ‘emergency village’

• SDS after the front end appears to increase costs if nothing else changes. Affordability may delay a quick implementation

• Efficiencies other than length of stay are hard to value, but Mondays would become much easier

• Changes to pay terms could reduce SDS costs

Wider implications of SDS

• To provide SDS for all residents of a large city could be much less costly than providing it at every existing hospital site in the city. SDS may lead to service reconfiguration and collaboration

• SDS requires more doctors than the NHS currently has, and a permanent change in how doctors work

• The full benefits of SDS in acute hospitals can only be achieved with SDS in primary, community and social care as well. England is still a long way from this

WORKSHOP AGENDA

Session 4: Finance, Costing and Salford Royal NHS

Foundation Trust Case Study - Tony Whitfield (3.30-4.30)

Questions for Tony?

WORKSHOP AGENDA

Round Up and ‘Top Tips’ (4.30-4.45)

‘TOP TIPS’

• Partnership, partnership, partnership.

• Engage patients and the public early in the process and

understand local needs.

• Wherever you start know what the bigger picture looks like

and share it.

• Change should be clinically led - who are your champions?

• Identify and use a range of levers and enablers.

• Continually capture and measure benefits – mortality rates,

patient experience, workforce satisfaction etc etc etc.

• One size doesn’t fit all, but be clear how you are going to

spread good practice.

• Have courage!

THANK YOU!

simonbennett1@nhs.net

www.england.nhs.uk

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