Making Seven Day Services a

Reality

Hayley Mounsey

Locality Delivery Facilitator

NHSIQ Seven Day Services Improvement Programme

NHS | Presentation to [XXXX Company] | [Type Date] 2

“ 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

Five day service model not meeting

patient needs or expectations.

NHS | Presentation to [XXXX Company] | [Type Date]

3

Fewer people are admitted to hospital as an emergency at

the weekend but… chances of dying are noticeably higher

100

200

300

400

500

600

700

800

900

MON TUE WED THU FRI SAT SUN

Dis

char

ges

(000

's)

3.4%

3.5%

3.6%

3.7%

3.8%

3.9%

4.0%

4.1%

Emerency admissions

Percentage who are discharged dead

DH analysis of HES data 2010/11

National figures, England 2010/11

Variation in diagnostic services National self-assessment tool Standard 5 and 6

By 2020 the government commitment is to:

• ‘…ensure you can see a GP and receive the hospital care you need,

7 days a week by 2020’.

• ‘…with hospitals properly staffed, so that the quality of care is the

same every day of the week.’

Conservative Party Manifesto, 2015.

Seven Day Services

The 10 Clinical Standards

Patient Experience

Time to first consultant

review

MDT Review

Shift Handovers

Transfer to community and Primary

and social care

Mental Health

Quality Improvement Diagnostics

On-going review

Intervention /Key services

Context: • Following discussions with the Academy of Medical Royal Colleges the following four standards

have been identified as having the most impact on reducing weekend mortality Standard 2: Time to Consultant Review Standard 5: Access to Diagnostics Standard 6: Access to Consultant-directed Interventions Standard 8: On-going Review • Each Trust has been asked to support the establishment of a robust baseline showing the extent to

which these standards are being met, utilising the NHS Improving Quality Seven days Service Self-Assessment Tool (7DSAT) www.7daysat.nhs.uk

• Submission to the 7DSAT needs to be completed by Friday 4th September 2015

• Results of the baseline survey will be published nationally and will provide a baseline against which the progress of implementation can be measured on a quarterly basis

• This baseline will be used to track the progress against the roll-out of the standards nationally.

Early Adopter sites and role of NHSIQ team

1. Diagnostics: Spreading evidence-based models

2. Drive for spread: Engaging all healthcare communities in moving towards services that meet the clinical standards and identifying the top interventions

3. Designing new models of seven day services

Key lessons learned from early adopters

in first year • Workforce

– Weekend consultant reviews

– Staff group shortages

– Development of new and extended roles

• Shared whole health economy vision and governance

• Increasing use of networks and partnership arrangements

• The use of a hub approach for care outside hospitals.

• Information governance and data sharing

• Measurement of the clinical standards and improvements in seven day services

• Leadership for change and staff engagement

• Patient involvement and experience of care

• The importance of enlightened commissioning

Role of commissioner in delivering seven day services

• Approve the Service Delivery and Improvement Plans agreeing prioritised 5 Clinical Standards in year 1 and remaining in year 2.

• Monitor progress in partnership with TDA and Monitor

• Develop strong relationships across the pathway to support delivery of Clinical Standard 9 i.e. BCF, co-commissioning, commissioning of community services

• Ensure seven day services initiatives link with other transformational change programmes e.g. Prime Minister’s Challenge, Vanguards, Urgent and Emergency care

• Capture voice of patients and the public

Central Lancashire Health and Social Care – Whole

System Transformation Programme

Step Up Step Down

Jane Kitchen

Clinical Commissioning Group

• Outlier for delayed transfers of care

• Outlier for long term residential and nursing care admissions

• Under utilisation of intermediate care services

• Patient experience of discharge was poor

• Complex multi agency discharge arrangements –

and only Monday - Friday

Step Up Step Down - Why?

Step Up Step Down - How did we get buy in?

• KPMG commissioned to complete analysis of what wasn’t working within urgent care across the health and social care economy (Clinical Senate) – the why

• Establishment of a programme board reporting into Clinical Senate – each project had a senior responsible officers reporting to board.

• 7 day services was core in every project, not a

separate one!

A ‘Single Point of Access’ will

coordinate access to the range of

available intermediate care services

with delegated authority to directly

access an agreed range of Social Care

services

3

Maximising local service provision to

enable patients to remain/regain

independence, preventing unnecessary

hospital admission and supporting safe

and timely discharge

1

Integrated Transitional Care and

Integrated Discharge /Admission

avoidance teams will provide a more

flexible and responsive service,

promoting continuity of care and fewer

hand-offs between professionals

2

Everyone has a bed – it’s in their own

home

“Discharge to Assess, not Assess to Discharge”

No long-term care decisions should be

made from a hospital bed

Promoting independence

for patients:

Better health and social care

outcomes

Improved experience for

services users and carers

Care closer to home

Reduced health and

social care costs

1

2

3

Step Up Step Down - Principles

Everyone has a bed – it’s in their own home

Discharge to Assess, not Assess to Discharge

No long-term care decisions should be made from a hospital bed

1

2

3

The first thing to consider is how we can safely

enable this person to go home

Agreed a working definition “what needs to happen

to enable this person can leave hospital”

We wanted to ensure that everybody had the

opportunity for a period of

rehabilitation/ recuperation prior to

making life changing decisions

Step Up Step Down - Principles

• Developed an economy wide project group

• Reported into programme board

• Step Up or Step Down – Concept, not a place

• Trusted assessor pathways into the following services

■ Low level VCFS support

■ Domiciliary Reablement (with or without therapy)

■ Community beds for recuperation, rehabilitation and assessment

• Medical cover embedded

• Pathways included exit routes

• Links with other projects .

Step Up Step Down - What we did

• Project leads from LCC and

CCG

• Weekly meeting

• Membership from all partners

• Devolved decision making

responsibilities

• No blame culture

• Working closely with social

care providers

• Project leads regularly

worked at the hospital to

affect culture change

• Critical friend

Step Up Step Down - How did we do it?

• Engaged with patient advisory groups

• Learning from what patients tell

us • Communications campaign

• Dashboard to show impact

• Hold our nerve

• Learning circles when it went wrong

• Celebrated the successes

• The support of Senate • Bribery – in the form of biscuits

and cake to the operational group

Step Up Step Down - How did we do it?

Monthly report and dashboard to

measure:

• Number of referrals received

• From where/who

• Which pathway utilised

• Delays and reasons

• Occupancy levels

• LOS in both acute & community beds

• Outcome for individuals

• Re-admission rates

• Patient experience

Step Up Step Down - How will we know it is working?

• Whole system integration: Patients see one service –

seamless care; part of their planned journey; offering flexibility. • Delayed access to Intermediate care has reduced from 8.6% • to 5% in first 9 months • Delays in discharge, attributed to social care, reduced from

13% to 7.8% in first 9 months. • There has been increased utilisation of community beds from

75% utilisation in 2012/13 to 91% in 2014/15. • Number of patients returning directly to home has increased • by approximately 20 extra patients a week. • Length of stay in community beds has reduced, on average

from 38.5 to 28.3 days. • Multiple assessments are no longer required leading to

improvements in patient experience. • Increased admission avoidance – right care, right place,

right time …. not always a hospital bed, care closer to home. • Better patient experience, with improved outcomes, for them

and their carers

Step Up Step Down - Key Outcomes

• CHC needs to be included

• Integrated discharge team under the day to day

management of one organisation

• Home of choice policy

• Wider than Preston, Chorley and South Ribble

• A shared vision

• Can't be done in isolation

• It is achievable

Step Up Step Down - Lessons

learned

Sustaining, Expanding and Enhancing

Healthcare Services for Older People,

Seven Days a Week

Stuart Ellis

Associate Director of Finance - Transformation

Claire Lambie–Fryer

Senior Clinical Transformation Manager

Common themes across Clinical Pathways prior

to becoming an early adopter site for 7 Day

Services

• Variation

• Availability of senior decision makers

• Access to clinical services and assessments

• Increased length of stay

• Pressures on bed base within the Trust

Or simply

Overall Approach

• Collaboration between 10 East Midlands Acute Providers

• Partnership working with CCG

• Supported by EM Clinical Senate

• Identifying key challenges

• Sharing good practice

• Supporting plans for future Improvement

• 21st Century joined up care

Capturing the Learning

• Worked closely with NHSIQ

• Pilots ongoing in Surgery, Medicine and Pediatric Areas

• Case Studies available on NHSIQ website

• One pilot that has since been funded and is providing

consistent patient care over 7 days across Chesterfield

Royal Hospital is the Acute Frailty Unit.

Acute Re-enablement Unit (ARU)

Frailty Unit Project Timeline

• January 2014 CRHFT redesigned its care pathway for frail

older people to improve access to high quality patient

centred acute care, increase flow through the hospital and

reduce avoidable harm to patients by reducing length of stay

• Initially as a pilot project partially funded by commissioners.

• Patients are admitted directly from ED or the Emergency

Admissions Unit to the Frailty Unit. There is as yet no direct

GP access although this is planned for the future.

Key Challenges

• At the beginning, there was some anxiety from staff about working in

this new way.

• Providing access from and advice to primary and community services.

• Making sure the Frailty Unit is optimised and used appropriately so

flow is maintained.

• Implementing the model using a phased approach with limited staffing

resources.

• Providing access from and advice to primary and community services.

• Maintaining a safe, calm, dementia friendly environment for patients

Key performance indicators

Number of admissions (KPI: Minimum 80 per month during first year of operation)

KPI - Re-admission rates less than the average

for non-elective medicine

KPI-ALOS 4 nights during first year of operation

KPI - >50% of patients to return to their

pre-admission place of residence

Potential savings on reduction of bed days

• With this model, Chesterfield Royal Hospital is now one of ten pilot sites participating in the National Acute Frailty Network programme, part of NHS

Elect, which aims to support the widespread adoption and improvement of

Frailty Services in England

• In addition to the Frailty Service, a ‘Discharge to assess-and-manage’ (D2AM)

model has been commissioned and is now in use since June 2015 for Frailty Unit patients, seven days a week.

• Falls Partnership Service (joint enterprise) - FPS is a seven day service

working from 6am to 6pm consisting of a paramedic and therapist who are called out acutely in an ambulance to patients who have fallen

and do real time assessments in the patient’s own environment

Rules of Engagement

• Get started! Identify enthusiastic staff

members, agree a date and start with your first

patient. Don’t worry about having all of your internal

processes perfect first.

• Attend the PDSA meetings, bring your patient’s

information and be prepared to honestly discuss

how it has gone.

• Speak to staff that have started this work to hear

and learn from their experiences.

Managing the process

• Remember the risk of keeping someone in hospital

can be far greater than the risk of them being at

home even when they are not 100% back to how

they were pre-admission.

• Think discharge when a patient is admitted.

• Get others involved at the earliest possible stage.

• Make sure any difficulties or successes are taken

to the PDSA meetings.

Moving Forward for ARU

• Providing an enhanced “front door” frailty service outreaching to

ED, EMU and CDU.

• Use of new technologies to provide timely access to the specialist

team and ultimately to enable people to remain safely supported

in their own homes where appropriate.

• Integrating the existing outpatient falls clinic into the Frailty Unit,

as well as rapid access MDT clinics in order to avoid

unnecessary hospital admission

• Greater integration with Falls, Dementia and Palliative care

services under the umbrella of the 21st Century Acute

Frailty Services Workstream.

Next Steps in our 7 Day Services Journey

• Development of a 7 Day Services Matrix across all

specialities

• Building on existing partnerships and building new ones

• Development and agreement on metrics for 7DS

• Making 7DS part of the Annual Trust Audit Programme

• Translating enthusiasm into care.

• Sustaining the momentum