Seven Day WorkingThe economic case to increase clinicaldecision making at the weekend

David Halsall

Analytical Services

November 2012

Let us start by asking the simple question – what are the main value added activities that an acute trust offers?

Treatmentand

procedures

Nursingled

care

Evidencebased

decisions

In elective activity hospitals clearly show a stop – go weekend effect. In unscheduled activity there is also a weekend drop-off effect in activity.

Admissions by Day of the Week(relative to total of admission route)

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DH analysis of HES

At the weekend the acute hospital will shrink its capacity, but some key areas shrink more than others – what are the consequence of that?

Treatmentand

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Nursingled

care

Evidencebased

decisions

Patients admittedat the weekendhave treatmentdeferred until

Monday

Patients are not reviewed fullyand may

suffer from a failure to rescue

Fewer people are admitted to hospital as an emergency at the weekend but the chances of dying are noticeably higher

Day of admission DH analysis of HES data 2010/11

National figures, England 2010/11

Evidence 1 – Higher deaths if admitted at the weekend

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Percentage emergency admissions by day of the week

Percentage of patients who are discharged dead

What we know about the differences between weekday and weekend acute 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 weekend compared to a weekday if you were admitted on a weekday

2. Emergency patients admitted over the weekend have a higher risk of dying in hospital and within 30 days of discharge – even after case mix adjustment is applied. We have no estimates of difference this make to life expectancy but researchers have advised us the effect is more likely to be small – days not weeks or months.

3. Elective patients admitted at the weekend do have a higher probability of dying compared to those admitted on a weekday – but this is possibly due to higher risk elective patients being treated earlier in the week over the normal cycle of hospital scheduling

Fewer emergency patients are admitted at the weekend but the chance of dying is higher – There are possibly two effects driving this (i) a more complex case mix at the weekend and (ii) failure to rescue some patients

Change from weekday to weekend admission

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DH analysis of HES data 2010/11

Emergency admission by weekend and

weekday admission

Evidence 2 At the weekend we have a more complex patient mix

In either case it looks like we need to improve the decision making capacity at the weekend as the supply and demand for senior staff is not in balance

Making the economic case for the reduction in the difference between the weekday and weekend level of service requires an evaluation of the costs and benefits of any re-configuration

• Economic evaluation in principle is straight forward

Showing 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 Cost Savings

QALYHealth

Benefits

Cost/benefit

QIPP savings ifcash releasing

What sort of economic analysis shall we do?

Would we expect incremental changes to resources to have a direct linear link to patient care or would we guess that there is a non-linear relationship?

A measure of access to care For example time between admission and senior review

Looking at benefits – a conceptual model to help our thinking

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Normal weekday working ?

Weekend Working?

Best Practice ?

A conceptual model of the link between access to care and benefits care brings

1/3 cost 1/3 cost 1/3 cost

High benefit to cost ratio

Diminishingbenefit to cost ratio

So let’s look at an example were extra resources are added to general medicine at the weekend and see if the economic case stacks up

• In 2007 Heartland Hospital instigated early consultant review to reduce the risk to patients when AMU patients are transferred to specialist medical wards at weekends.

• The appointment of 2 additional acute physicians released consultant time from the AMU to allow several consultants to conduct short rounds on their base wards of newly transferred in patients - replacing the weekend “safari” ward round of new admissions by a single consultant.

• This reduced delays in having a clear clinical management plan and reduced LoS for patients admitted towards the end of the week.

• In particular it was identified that opportunities were being missed to discharge some patients in the subsequent 24-72 hours after admission.

• In common with many acute trusts discharges at weekends were less than on weekdays.

• Seven day working of key clinical and social service staff is required to achieve a levelling out of discharge pathways.

Example

The case can be made that the cost of the extra consultants could be offset 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 that would 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 HR processes

Example

£300,000/year

23 patients a week have their LoS

reduced by 1 day

In addition to the direct costs and benefits there are a range of additional benefits 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

Although it is impossible to attribute the improvement in performance to the change in the weekend working pattern it is consistent with what you would expect

Percentage of Deaths in Hospital Following Emergency Admission(Birmingham trust and England)

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RR1

England

Source DH analsys - of HES data

England

Birmingham 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%

Example

2010/11

So is there scope to improve weekend discharge rates? Looking at cancer patients as an example it seems very few are discharged at the weekend at present

Length of stay for cancer patients - Emergency admission

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Admitted Monday, Wednesday & Saturday offset to show day of the week pattern

DH analysis of HES data 2010/11 cancer emergency admissions

But to release the cash to reinvest

hospital capacity would have

to reduce at the weekendtypically by 20 – 30 beds

Irrespective of when the patient is admitted few

are discharged at the weekend

This approach re-balances the weekend hospital by increasing senior-led decision making capacity which in turn reduces the demand for patients staying in hospital unnecessarily, reducing LoS and improving outcomes

Treatmentand

procedures

Nursingled

care

Evidencebased

decisions Reducing the demand

Cash released

Summary• From the inception of the NHS, hospitals have been intended to be medical

consultative centres rather than hostels providing treatment[1]. Current hospital weekend working patterns tend to reflect the latter rather than the former.

• The year-on-year improvements seen in outcomes seem to lag for weekend admissions by 1 to 2 years.

• With targeted interventions and good HR practices the difference between weekend and weekday service can be reduced showing overall cost benefit.

• It is also possible that by keeping the discharge rate close to the weekday rate at

the weekend levelling up the weekend service could be cost saving, however this will require a more rigorous use of weekday only and seven day bed capacity.

•[1] Chief Medical Officer, Ministry of Health, 31st March 1948