Seven day hospital services learning and sharing event: summary of discussion

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In December 2016, trusts met together to share learning and experience of working towards seven day hospital services. This summarises some of the successes, solutions, challenges, suggestions and comments regarding the seven day hospital services programme.

The seven day services programme

The seven day services programme aims to ensure that patients admitted as an emergency receive high quality consistent care whatever day they enter hospital. 

27 ‘early adopter’ trusts are focusing on incorporating the seven day priority clinical standards into the urgent and emergency care they provide by April 2017. They shared successes, challenges and solutions at a recent event and these following examples of learning were captured at that event.

Standard 2 – time to first consultant review

Challenges mentioned by trusts / areas to consider

  • some trusts have problems capturing the data accurately, especially if they don’t use electronic medical notes
  • many trusts that collected data retrospectively had difficulties getting notes for analysis following their 'coding' process
  • some trusts found challenges with data capture because of missing details such as accurate time documentation - these omissions and inaccuracies may have negatively affected the seven day services assessment tool (7DSAT) results in some trusts
  • senior clinical and management engagement with the seven day services programme promotes frontline engagement with the clinical standards
  • staff who are unfamiliar of their trust’s acute consultants will have difficulty accurately assessing notes, especially if the roles and grades of doctor are not recorded

Potential solutions discussed by trusts

  • using electronic records facilitates accurate recording and identifies patients needing consultant review - when trusts are considering procuring such software, this should ensure such a capability is possible
  • where trusts aren't using electronic records, a focus on enhanced training about recording detail in the notes, and support from the 7DSAT audit team, may be useful
  • consultants involved in the acute review of new patients could see patients in the Emergency Department (ED) before transfer to a ward, which may help with the flow of patients especially when trusts have high bed occupancy
  • the use of recently retired consultants to increase the capacity for the review of newly admitted patients can help with meeting this standard

Find out more

Consult the NHS England Sustainable Improvement Team’s website to access resources and advice on the 7DSAT survey. 

Job planning

Challenges mentioned by trusts / areas to consider

  • for small specialties, job planning cannot produce cover without a networked or cross-site solution - this needs to be acknowledged from the start and potential networked solutions sought early on in the planning process
  • a workforce with lots of sub-specialists but few generalists can be a challenge to providing a seven day service due to capacity - consideration should be given to the skill mix of the consultant workforce
  • trusts with significant consultant vacancies may find job planning challenging
  • more thorough job planning may reveal fragile or unsustainable services

Potential solutions discussed by trusts

  • new job plans for multi-site trusts should include cross-site working
  • for a more efficient service, ensure consultants focus on activities that require their skills and ask them to identify other tasks that can be delegated
  • think about incentives while job planning and ensure job plans are flexible - for example some clinicians will work more weekends for more time off during the week
  • providing annual consultant contracts may be another tool to ensure a service continues to fit the needs of the trust
  • utilise opportunities from changes to elective care to support seven day service provision - this can have efficiency benefits as well as waiting list reduction and financial benefits; for example weekend endoscopy lists for elective patients that can also be used for urgent cases
  • approach sub-specialists to see if they would like to re-develop and strengthen their generalist specialty skills to add capacity to their specialty’s generalist service

Winning hearts and minds

Challenges mentioned by trusts / areas to consider

  • acknowledge the difficult nature of implementing seven day services and support those leading it
  • seven day services may raise staff retention issues, especially if staff can work elsewhere without moving. However, flexible working can have benefits for family life and should be explore
  • resistance to seven day services may be due to other interests - for example extra payments for weekend sessions may make staff reluctant to provide a service routinely
  • resistance may be because weekend services are perceived to affect weekday and elective work, as well as finances targets
  • acute specialties already working a seven day rota are less resistant to seven day services; specialist doctors not providing acute care can be more resistant as it may involve a change from their routine and familiar practices
  • resistance may also come from allied health professionals (AHPs) such as radiographers, pharmacists, and therapists who may work at the weekend less often
  • gaps among junior doctors and allied health professionals that support consultants may make the workforce feel that a seven day services is too great a challenge

Potential solutions discussed by trusts

  • identify leaders working towards seven day services and divert the less engaged senior staff elsewhere - work with your strengths
  • a specialist doesn’t have to lead their own service into seven day services:  another clinician can do it if they have the vision, understanding and support
  • patient feedback is a strong motivator to change working behaviour - using narratives and incidents resulting from not providing seven day services can also drive change in practice and counter resistance
  • highlighting others who have already changed to deliver seven day services can act as an example to colleagues
  • consider campaigns to raise awareness, rather than forcing change - a sense of inevitability about the introduction of seven day services may also convince staff they ‘may as well start now’
  • resistance may come from local authorities or local politicians - counter this with senior clinical leaders making the argument
  • career development or more exciting work may retain some staff: for example, offering development opportunities for radiographers during the week if, in return, they do some clinical work at weekends
  • extended roles for nurses, physician associates and other clinicians can help support consultants and seven day services delivery

Innovative workforce solutions

Challenges mentioned by trusts / areas to consider

  • the lack of AHPs to cover seven day services was raised as a potential challenge that needed mitigating
  • there were similar concerns with the capacity of the radiology reporting services
  • some trusts mentioned challenges in both consultant capacity and junior medical staff numbers that affected the delivery of seven day services

Potential Solutions discussed by trusts

  • a single staff bank system for AHPs across a locality may help
  • radiology reporting hubs may provide a networked reporting solution
  • reporting radiographers and extended role reporting radiographers who can report certain CT scans may help with reporting capacity
  • some trusts suggested employing staff focused on patient flow – usually registrars from the in-house bank – at weekends, or a consultant discharge round, and increasing nurse protocol discharges
  • some trusts renegotiated contracts so that AHPs work a 35-hour, five-day week with a day a month at the weekend to make up their hours to 37.5 - some AHPs prefer this as it reduces the backlog that builds up on Monday
  • training physician’s assistants and advanced nurse practitioners and integrating them into the service could help redeploy doctors
  • allowing physician’s associates and clinical pharmacists to prescribe may help reduce pressure on medical staff

Reconfiguring services

Challenges mentioned by trusts / areas to consider

  • care homes and nursing homes may not be set up to deal with discharges from hospital at the weekend 
  • trusts with many consultants may find reconfiguring services straightforward - smaller specialties with few consultants are a bigger challenge
  • seven day services can affect outpatient activity, targets, other quality measures and finances
  • responding to pressure for change in other areas – for example, reducing agency use – may accelerate the reconfiguration needed for seven day services

Potential solutions discussed by trusts

  • trusts need to compare whether their working practices are typical, and challenge them if necessary
  • reconfigurations and service redesigns need significant internal and external stakeholder engagement - this may be challenging but it increases efficiency and productivity
  • splitting emergency and elective care across the estate can be a solution for some trusts, through economies of scale: two-site solutions depend on how close the sites are
  • technology is important in ensuring networks and cross-site trusts function effectively - networked solutions allow the quick and robust transfer of clinical information, especially for imaging, but depend on intra-operability

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