Adopting seven-day working in practice: a report by the Royal College of Physicians and Surgeons of Glasgow

Abstract

Following the UK Academy of Medical Royal Colleges Report on seven day consultant present care, the Royal College of Physicians and Surgeons of Glasgow held a symposium to explore clinicians’ views on the ways in which clinical care should best be enhanced outside ‘normal’ working hours. In addition, a survey of members and fellows was undertaken to identify the tests which would make the greatest impact on care out of hours. Key messages were: (a) that seven-day consultant delivered care would not achieve the desired benefit to patient care if introduced in isolation from other inter-relating factors. These include alternatives to hospital admission, enhanced nursing support, increased junior medical, pharmacy, social care and ambulance availability and greater access to selected diagnostic services; (b) that the care of hospital inpatients is a service which is one part of the totality of secondary care provision. Any significant change in the deployment of staff for inpatient care must be carefully managed so as not to result in a reduced quality of care provided by the rest of the system.

Keywords

Acute patient care diagnostic services emergency care primary secondary care interface seven-day services

Introduction

This report summarises a symposium held at the Royal College of Physicians and Surgeons of Glasgow in November 2013 and the results of a survey undertaken among Fellows and Members of the college prior to that meeting. The meeting was attended by clinicians, allied health staff and representatives from health boards and the Scottish Government.

The stimulus from this symposium arose from a number of studies in different countries^1–4 and within different specialties^5,6 which demonstrated poorer outcomes for patients admitted on weekends and public holidays⁷ than during the working week. We had also reviewed the UK Academy of Medical Royal Colleges Report ‘Seven Day Consultant-Present care⁸ particularly in regard to the standards suggested by that body.

Background

The UK Academy of Medical Royal Colleges Report ‘Seven Day Consultant-Present Care’ identified the following standards:

Standard 1: Hospital inpatients should be reviewed by an onsite consultant 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.

Standard 2: Consultant-supervised interventions and investigations along with reports should be provided seven days a week if the results will change the outcome or status of the patient’s care pathway before the next ‘normal’ working day. This should include interventions which will enable immediate discharge or a shortened length of hospital stay.

Standard 3: Support services both in hospitals and in the primary care setting in the community should 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.

The Academy called on colleges to ‘describe the implications for staffing, along with the resources, support services and timescales required to deliver the standards’. In response to this, a Royal College of Physicians and Surgeons of Glasgow symposium discussed the practical considerations involved in implementing such standards. Several of the clinicians who attended the College Symposium held management as well as clinical roles. The following themes were discussed:

Differences in the cohort of patients admitted at weekends, as compared with during the week.

Reflecting on their clinical experience, attendees stated the view that patients admitted just before and during the weekend were more likely to:

be admitted via the emergency department;

present out of 9–5 hours;

be of an older age;

have illness of greater severity and

be admitted from a nursing home.

How such differences influence the needs for care delivery.

Attendees made representation that:

such differences in levels of disease severity and co-morbidity require greater cross-specialty input to decision making, rather than being limited by the lack of availability of such opinions;

this population was more likely to need early multi-disciplinary input;

care of this group needed weekend access to care planning and social service support and

the pattern of admission arose from reduced discussions ahead of admission between primary and secondary care providers. In turn, this limited secondary care awareness of the multifactorial background to admission and secondary care opportunity to plan alternatives to admission.

The potential for enhancing non-admission routes to care provision

Attendees concluded that these would involve the need for a new approach to service planning at the weekend with greater access to:

outpatient clinics and clinic nurse and admin staffing;

specialist nurse advice;

managing the gap between emergency and elective service provision: consideration of community-based assessment centres;

rapid access to social and home service response;

partnership working between A + E and hospital-based GP or nurse-led assessment centres and

undertaking formal lessons learned exercises for re-admission.

Barriers to effective patient throughput at weekends

Attendees concluded that these involved several areas. There was strong agreement that weekend issues were not simply a feature of the acute admissions ward, but rather a factor of patient management throughout all wards, with resultant impact on the front door:

delayed decision making due to limited access to tests, procedures and results, especially in down-stream wards;

delays in timing of decision due to number of patients to be reviewed by insufficient numbers of staff undertaking patient review;

difficulties in accessing pharmacy discharge support later in the day;

lack of staff to run radiology scanning equipment fully during daytime hours;

delayed portering to tests;

competition between current inpatients and waiting list cases for diagnostic test capacity and procedure list availability;

unnecessary length of stay on account of lack of consultant and specialist input to decision making on ward patient reviews with lack of junior doctor confidence to discharge or instruction of tests not required as an inpatient;

delayed social service assessment, lack of available home support services and ambulance transport;

reduced nurse staff levels on wards;

public expectation and pressure from families to avoid discharge and

reduced communication with primary care teams: barriers between IT systems at both ends of the admission cause difficulty and limited access to primary care teams reduces patient assessment and discussion with hospital teams pre- and post-admission.

Potential mechanisms for improving number and timing of discharges

Attendees considered that there were multiple areas that could be improved:

Greater focus of the admission on the management of the new acute issues. Greater provision of policy-based community assessment to manage recovery or monitoring following a change in treatment. Telehealth monitoring was also considered potentially useful.

enhanced recovery through the provision of community rehabilitation teams/hubs;

seven-day specialist input to advice and assessment;

seven-day administrator service at ward level;

optimising clinical time for assessment by reducing time spent locating patients, records and dealing with multiple groups of nursing staff, through locating patients managed by a given clinical team in the one area and reducing non-therapeutic moves of patients around hospital;

greater provision of access to reports and results;

full-day pharmacy service;

reducing time spent logging into multiple systems: unified hospital IT systems with single sign-on;

rapid access to electronic whiteboards and similar systems for enhanced real-time overview of patients and actions;

enhancing information sharing and rapid identification of patients likely to require medical review at weekends, either pre-discharge or because of known clinical concerns;

enhanced systems to reduce time and improve quality of handover for all patients throughout 24-h cycle and

increased numbers of advanced nurse practitioners providing support for result management, discharge writing, liaison with community teams. The low-turnover of staff in comparison with junior medical staff was felt to be an advantage for patient care.

Considerations in regard to increased numbers of senior medical staff at weekends

Attendees were concerned about several issues:

The future attractiveness of acute disciplines may be adversely affected, especially in the context of existing recruitment to front door specialties.

Time worked at the weekend will impact on time available for work during weekday hours for elective work and clinics. It is important to avoid creating new problems when fixing that at weekends.

Increased senior medical input on its own has limited value if decisions cannot be taken or actions implemented without associated increases in junior medical staff, specialist and advanced nurse practitioners, administrative staff, diagnostic service staff, social service staff, portering staff and ambulance staff.

Greater rest and catering facilities would be needed.

Potential impact of changing the working week on teaching and training

Individual trainee to trainer contact during the week may be further fragmented in contrast to the recommendations of the Shape of Medical Training Report.

Trainer compensatory rest may disproportionally reduce time for formal teaching and other formal education activities.

Survey results

Some investigations and in particular CT examinations of Chest, Abdomen and Brain were felt to be available already at weekends. However, clinicians commented that these were often available only under set conditions that were not applicable to weekday tests, or that tests were available on Saturdays, but not on Sundays. Other views expressed are presented in the tables. Tables 1 and 2 show that the majority of clinicians feel that there are a significant number of tests which if available at weekends and public holidays would enhance patient care or reduce patient stay and for which routine access on a five-day basis is insufficient.

Table 1.

Tests by percentage of clinicians who stated that routine access to these tests would enhance patient care or reduce stay at weekends and public holidays.

0–25%	26–50%	51–75%	76–100%
ERCP Virology Cytology Bone marrow	Technician ECG 24-h ECG Angiography Exercise testing Pleural ultrasound TFT & hormonal tests Pathology Bronchoscopy Dialysis	Echocardiography Abdominal ultrasound CT chest CT abdomen CT brain Venous ultrasound CTPA Endoscopy MRI brain MRI other Microbiology

Note: Additional services suggested as needed at W/E & PH: joint US, HIV test, Carotid and arterial US, interventional radiology, pacemaker check or on call AICD technical check. Exercise testing useful only if reporting service is also available.

Table 2.

Tests according to percentage of clinicians who stated that access to these tests over only five days would be sufficient.

0–25%	26–50%	51–75%	76–100%
Angiography Echocardiography Abdominal ultrasound Pleural ultrasound Venous ultrasound CT chest CT abdomen CT brain CTPA MRI brain MRI other Microbiology Endoscopy Dialysis	Technician ECG 24-h ECG Exercise testing ERCP Bronchoscopy	TFT & hormonal tests Pathology Virology Cytology	Bone marrow

However, the tests selected by the majority as necessary for weekend and public holiday access were not the same as those tests whose provision on a 24-h basis was regarded as necessary for safe patient care (Table 3). Rather, clinicians recognised that there was need for a service similar to what is available during the week for certain tests (Table 1). They appeared to acknowledge the difference between emergency 24/7 patient needs and the investigation-dependent decision making needed on a daily basis to avoid delays in patient care and optimise patient throughput.

Table 3.

Tests according to percentage of clinicians who stated that access to these tests are needed 24/7 to deliver safe patient care.

0–25%	26–50%	51–75%	76–100%
24-hr ECG Exercise testing TFT & hormonal Pathology ERCP Virology Cytology Bone marrow Bronchoscopy	Technician ECG Pleural ultrasound Venous ultrasound MRI brain MRI other	Angiography Echocardiography Dialysis	Abdominal ultrasound CT chest CT abdomen CT brain CTPA Endoscopy Microbiology

Other services suggested as needed 24/7: US musculoskeletal, MRI spine, CT neck, CT sinuses, interventional radiology, arterial doppler.

A variety of free text comments were also made. These have been themed and representative comments for each theme are listed as follows:

must match seven-day specialty availability for patient review and decision making to seven-day diagnostic services;

if radiology and pathology/microbiology provided weekday service at weekends and PH, then patients would be sorted quicker;

emergency inpatient stay frequently extended by 48 h waiting on imaging requests placed on Fridays;

we need all services available for at least part of the day seven days a week to improve safety and efficiency;

every day should be the same. Second class healthcare at weekends and PH is not acceptable;

much that is only available as an emergency service currently at W/E and PH needs to be provided as seven-day service;

increase in length of five day hours of service provision is also needed;

full access to social/support services needed seven days a week and

inpatient physiotherapy and occupational therapy are needed as per weekdays to support satisfactory throughput and patient improvement.

Discussion

Both the survey respondents and symposium attendees voiced the strong opinion that current clinical service provision is neither safe nor acceptable. Nevertheless, there were concerns that increased senior medical input to patient management over evenings, weekends and public holidays would be a wasteful exercise unless closely aligned to changes in service provision across the patient journey. This especially includes the primary care interface, patient transport, social care, junior medical and nursing staff levels, and access to pharmacy and diagnostic services. Furthermore, unless handled with care and engagement with the profession, our clinicians are concerned that such new patterns of working could pose additional risks to patient care and training during ‘standard’ working hours.

In addition the survey responses present evidence that a blanket provision of all diagnostic services on a seven-day or 24-hour basis is not felt by practicing clinicians to be necessary for safe patient care. Rather, such clinicians can readily identify certain tests and procedures which are felt to impact on clinical decision making at weekends and public holidays more than others.

There are significant ways in which services could be re-designed to provide alternatives to patient admission or to optimise patient management outside of 9–5 Monday–Friday, that rely on measures other than increased senior medical input. However, there is also a need to consider whether the 9–5 approach to service provision during the week best matches current service needs.

In the short term, the priority should be to introduce more alternative pathways to hospital admission, provide extended hour access to a defined set of diagnostic tests and pharmacy support, increase the number of advanced nurse practitioners available to release medical time for decision making and deliver an extended hour provision of social care and ambulance transport. Increases in senior medical presence at weekends and public holidays, with the resultant reduction in continuity of care, elective services and training during the week, should only be considered as part of such a whole system service change. Without this the potential overall benefit to patient care will be lost.

Conclusion

The Royal College of Physicians and Surgeons of Glasgow urges the Scottish and UK Governments to remove the inequity of care at weekends and public holidays, as compared with during the week. The college strongly recommends that this development takes account of the multi-factorial elements involved in such care provision as the issues cannot be addressed by increasing consultant numbers at weekends in isolation. Clinicians are best placed to advise on those aspects of service delivery that impact most on clinical decision making and safe patient care at weekends and during public holidays, and plans to implement service change require full engagement with the profession.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of conflicting interests

None declared.

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