New clinical standards backed by rewards and sanctions
NHS England’s National Medical Director Sir Bruce Keogh today sets out a plan to drive seven day services across the NHS over the next three years, starting with urgent care services and supporting diagnostics.
He is publishing the findings of his Forum on NHS Services, Seven Days a Week, set up in February this year, together with a series of recommendations that will be considered by the NHS England board at its public meeting on Tuesday (17 Dec).
The Forum points to significant variation in outcomes for patients admitted to hospitals at the weekend across the NHS in England – a problem affecting most healthcare systems around the world.
This is seen in mortality rates, patient experience, the length of hospital stays and readmission rates. For example, the increased risk of mortality at the weekend could be as high as 11per cent on a Saturday and 16 per cent on a Sunday, according to an analysis of over 14 million hospital admissions in 2009/10.
Causes include: variable staffing levels in hospitals at the weekend; fewer decisions makers of consultant level and experience; a lack of consistent support services such as diagnostics and a lacks of community and primary care services that could prevent some unnecessary admissions and support timely discharge.
Until now Sir Bruce has been setting out “the moral case” for change in a bid to convince all parts of the NHS to embrace a move to seven day services.
But today he sets out ten new clinical standards (see board paper) that describe the standard of urgent and emergency care all patients should expect seven days a week, each supported by clinical evidence and developed in partnership with the Academy of Medical Royal Colleges.
They describe, for example, how quickly people admitted to hospital should be assessed by a consultant, the diagnostic and scientific services that should always be available, and the process for handovers between clinical teams.
Sir Bruce says these standards “undo more than 50 years of accumulated custom and practice that have failed to put the interests of patients first”. He recommends they be adopted by the end of the 2016/17 financial year.
To do this in a way that is financially and clinically sustainable, NHS providers and commissioners should explore new ways of working – in networks, collaboratives, and federations – that consider distribution of services between organisations.
Sir Bruce says delivering the standards should be part of the five year strategic plans being developed by clinical commissioning groups all over the country. He says a similar set of standards is already being developed for primary care.
Sir Bruce recommends that NHS England backs the standards with incentives, rewards and sanctions. It should:
- Incorporate progressively the ten clinical standards in hospital contracts with sanctions for non-compliance. Contracts in 2014/15 should require an action plan for implementation. Financial incentives, through a system called Commissioning for Quality and Innovation (CQUIN), should be encouraged, based on the standard for time from arrival to consultant assessment.
- Publish information on how the clinical standards are being met over seven days in a format that is accessible and comparable. This will enable the public to see what their local healthcare providers are doing and to hold them to account.
- Use the £3.8 billion Better Care Fund, pooled with local government, to drive change. Applying to the fund, clinical commissioning groups and local authorities should show they are addressing the need for services at weekends that support patients being discharged from hospital and prevent unnecessary admissions.
He also suggests that NHS England should:
- Ask the Care Quality Commission to consider how to assess implementation of the standards. Sir Bruce says the CQC is likely to assess availability of weekend services as part of its assessment of hospital safety. He says “for acute services to be judged safe, they have to be safe 24/7” and he recommends that no hospital could be rated “outstanding” if the clinical standards are not being applied.
- Agree with Health Education England that education contracts should include consultant availability to provide adequate supervision of doctors in training, seven days a week in line with the clinical standards. This means that junior doctors in training must be properly supported by consultants. He argues this is important not just to improve quality of care but also to improve the training of the next generation of NHS doctors.
- Ask NHS Improving Quality to help all local commissioners and providers of services by introducing a transformational change programme. This includes selecting 13 “early adopter” (see Forum’s report below) health economies in England that will help develop new models of delivering care over seven days, as well as the creation of tools for assessing provision and monitoring progress.
- Commission pilots across England during 2014/15 to set up improved access to General Practice for at least 500,000 people. It will evaluate these pilots and identify ways to improve access to routine primary care in 2015/16.
Sir Bruce says that the increasing number of doctors being trained gives the NHS huge opportunities to work differently. Currently some 6500 doctors take up entry level posts each year and projections suggest a 60 per cent rise in the number of consultants by 2020 if training and recruitment continues at the same rate.
He recommends extending the Forum’s remit and asking it to set out proposals by Autumn 2014 for a fully integrated seven day services covering primary and community services and social care, as well as hospitals.
Sir Bruce says his own research shows that the issues are not unique to the NHS. He argues that as the biggest integrated healthcare system in the world, the NHS is better placed than others to resolve the issues.
He says: “As the custodians of £97 billion of public money, we must buy the health services patients deserve. We know that patients and the public want us to act now to make seven-day services a reality in all parts of the NHS.
“There are encouraging examples for NHS organisations that have moved to making healthcare services more accessible seven days a week to avoid compromising safety and patient experience.
“We need to accelerate the pace and spread of these changes. In doing so, we can ensure the NHS leads the world in providing equality of access to consistent, high quality healthcare, seven days a week.
“There is increasing evidence that mortality rates for patients admitted to hospitals on both sides of the Atlantic are higher at weekend; our junior doctors feel clinically exposed and unsupported at weekends; and hospital chief executives are worried about clinical cover.
“It seems inefficient that in many hospitals expensive diagnostic machines and laboratory equipment are underused at weekends, operating theatres lie fallow and clinics remain empty. This while access to specialist care is dogged by waiting lists and GPs and patients wait for diagnostic results.
“We should also consider whether, in the 21st century, it is still acceptable for the NHS to expect people to always take time off work to access healthcare or to support a relative or friend to do the same? This has an economic impact as well as an impact on patient and family experience.
“This is not just about hospitals but the whole NHS system. One part cannot function efficiently at the weekend if other parts don’t.
“If people are to experience genuine seven-day treatment and care, we must look beyond emergency services and beyond the services offered to hospital inpatients. We need to make similar improvements across primary, community health and social services, removing barriers between organisations.”
Further information: NHS England Press Office on 07768901293
- NHSIQ’s report: NHS Services open seven days a week: Every day counts
- Forum Summary report
- Board Paper