Improving Access to Seven Day Services: one size does not fit all

NHS South East Workshop. 17th March 2015

Dr Rob Haigh

Deputy Medical Director and Chief of Medicine

Western Sussex Hospital NHS Foundation Trust

To outline why the trust proposes to

improve safety, clinical outcomes and

patient experience, regardless of the

time of day or day of the week

To demonstrate that “one size does not

fit all” when selling the dream of

consistent care across the whole week

2

…. has widespread national support, including all

main professional bodies

consistent care across seven days will bridge

current major service gaps

… evidence shows that targeted changes, including

increased consultant-present care, improves safety,

clinical outcomes and the experience of patients

3

5

Dr Foster HSMR by Day of Admission

80

85

90

95

100

105

110

115

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

WSHFT

Acuity weekend admissions is higher

Mean NEWS 2.26 vs. 2.0 for weekday admissions

• Most wards managed by Band 5 nurse at weekend.

• Typically 20% of the weekday numbers of junior

doctors on duty at weekend.

• Weekend AMU consultant cover restricted

• Majority of existing in-patients fail to see a

consultant from Friday to Monday.

6

7

L i v e d i s c h a r g e s p e r d a y ( n o n - e l e c t i v e )

-

2 , 0 0 0

4 , 0 0 0

6 , 0 0 0

8 , 0 0 0

1 0 , 0 0 0

1 2 , 0 0 0

W S H F T S R H W o r t h i n g

All staff will contribute to 7 day working; in return, the Trust will

make clear commitments to staff, with respect to working

patterns, rest and work-life balance. Many staff already

routinely work to a 7 day model.

There will be new investment to support 7 day working, BUT

we will identify opportunities for role extension, the avoidance

of waste and duplication, service redesign and innovation.

We will implement a pragmatic and gradual solution, beginning

in Medicine, which is identified as the area of highest risk.

8

Executive (COO)

Deputy MD and Deputy DoN

Consultants : Acute Medicine, Gen. Surgery, CD for Imaging, Chiefs of Service.

Medical Matrons x2

Head of Medicines Management

Head of Therapies

Senior HR business partner

FT Governor and Staff side

PMO

(W+C, junior doctors)

9

Keogh standard Lead(s)

1. Patient experience Medical Matrons – Katrina and Lisa 2. Time to first consultant review Joe Wileman and Pauline Whitehouse

3. MDT review Saffron Mawby and Nicky Sullivan 4. Shift handovers Joe Wileman and Pauline Whitehouse 5. Diagnostics Hatef Mansoubi and Saffron Mawby

6. Intervention/key services Rob Haigh

8. On-going review Rob Haigh and Saffron Mawby

10

7 day intranet page–information about programme, a

short questionnaire/feedback mechanism, a video

montage and details about getting involved. Content

builds, as we progress.

Engage with different staff groups through existing

mechanisms. e.g. Employee Partnership Forum,

Medical Staff Committee, board of governors etc

11

Initial gap analysis prepared against each standard.

Definition of what consultant model could look like

i.e. delivering consultant present care - by division

Priority focus on Medicine – ensuring greater

consultant presence in AMU, & ramping up

supporting services (radiology & pathology)

12

Learning from other Trusts that are succeeding, prepared

OBC, on-going work on consultant model.

Additional investment is significant (£2m+ based on the

experience of other Trusts),

Identify opportunities for more effective and efficient working,

linked to learning from Virginia Mason.

Pragmatic view on Keogh’s aspiration for consultant-led ward

rounds on every ward, every day - unlikely to be feasible in the

medium term.

13

Ultimately, the Keogh standards require 7 day collaboration between all of the health, social and community services. We are keen to host a joint role on behalf of the LHE –supported by the Coastal Cabinet.

14

15

Aspect of service

All coverage is per site on both Saturday and Sunday, unless otherwise stated

Consultant model

• AMU: 8am-8pm consultant cover • AMU ‘hub’ consultant outreach to specialty wards on a selected patient basis

Nursing model

• Band 6 day shifts on every ward • Diabetes, Alcohol liaison and Resp Specialist Nurses – morning cover • Palliative and EOLC specialist nursing

Diagnostics • Radiology: 9am-6pm consultant and radiographer cover for investigations and reporting; sonographer cover 3 hours

• Endoscopy: 1 PA Sat planned list, to include emergency scoping requirements (plus 24/7 GI bleed rota)

• Phlebotomy extension • Echo for planned and urgent activity and on-call technician

Pharmacy • Senior pharmacist and medicines reconciliation technician on each AMU – whole daytime • Targeted senior pharmacist support to wards • Additional dispensary support

Therapies • OT and Physiotherapy (in line with consultant model) • Dietetics – on-call weekend & bank holiday coverage • SALT – Dysphagia on-call service

Other support

• Additional roles to supplement junior doctors • Administration, portering, transport, revised management rotas • Additional hospital social workers, community equipment and continuing care provision

Is focusing on weekend emergency care really the best way forward ?

17

Mon Tues Wed Thur Fri Sat Sun

OPD Y Y Y Y No No

PTWR & rolling new patient review

Y Y Y Y PTWR’s only

PTWR’s only

Unselected Take

Y Y Y Y Yes Yes

Endoscopy Y Y Y Y No No

CEPOD Theatre

Y Y Y Y Yes Yes

Elective Theatre

Y Y Y Y No No

SpA Y Y Y Y No No

18

Mon Tues Wed Thur Fri Sat Sun

OPD Y Less ? Y Less ? Yes Yes

PTWR & rolling new patient review

Y Y Y Y Yes Yes

Unselected Take

Y Y Y Y Y Y

Endos’y Y Y Less Y Yes ? Elective Theatre

Y Less Y Y Yes Yes

SpA No Y No Y ? ?

Makes every weekend day like every other day

Activity outline to mirror profile of weekend

emergency admissions

Optimises use of expensive resources

Financially beneficial

Supports RTT and planned care

It’s what many patients want

19

We electronically surveyed 1000 patients & directly

interviewed 60 of these.

Feedback linked to the day of the week and time of the patient’s

admission.

Our emergency patients tell us that we communicate

less well in the evening and at weekends (and

especially weekend evenings)

20

21

Changing how we work, to deliver consistent care across 7 days will improve safety, quality & clinical outcomes. We all share this responsibility.

Although some changes will require additional investment and recruitment, innovation/working differently, and standardisation provide the basis of our developments

There are great opportunities for role extension & service redesign – PA’s, Resident On Call Consultants, SSP’s,

Engage at every opportunity … staff, esp. consultants, may be

increasingly concerned about what 7 day working means for them.

There is no hidden plan & staff will not be expected to do more hours or be put under undue pressure

22

THANK YOU

23