Changes in weekend and weekday care quality of emergency medical admissions during implementation of the 7-day services national health policy

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy
BMJ Quality & Safety 2021;30:536-546.
(Full text available through NHS OpenAthens: Register here https://openathens.nice.org.uk/ )

• The aim of this study was to determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services introduced in 2013 to improve care quality and outcomes for weekend emergency admissions. Reviews of patients (n=4000 ) admitted to 20 acute hospitals Trusts as emergencies at weekends and on weekdays between financial years 2012–2013 and 2016–2017.
• Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation).

Mortality rate 'weekend effect' not a reliable measure of care quality in hospitals

Mortality rate 'weekend effect' not a reliable measure of care quality in hospitals
NIHR News 6 June 2019

• Analysis of data from 68 studies covering data from over 640 million hospital admissions across the world and concluded that, contrary to commonly held assumptions, the higher death rates amongst patients admitted to hospital at weekends are unlikely to reflect in-hospital quality of care, and may be attributed to differential criteria for admitting patients and other factors in the community preceding hospital admission. 
• Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis. BMJ Open 2019;9:e025764

Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust.

Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust.
BMJ Qual Saf 2019;28:223-230, 19 February 2019

• Retrospective analysis of 4 years weekend and weekday adult emergency admissions to a university teaching hospital [Queen Elizabeth Hospital Birmingham] concluded that patients admitted to hospital on weekends are sicker than those admitted on weekdays. The cause of the weekend effect may lie in community services.

Variations in mortality across the week following emergency admission to hospital

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14
Health Services and Delivery Research November 2017, 5(30)

• Retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. 
• Nationally excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes after severity of patient illness was accounted for. Mortality rates are also elevated for patients admitted during night-time periods. 
• The estimated cost of implementing 7-day services exceeds the maximum amount that the NICE would recommend the NHS should spend on eradicating excess mortality at weekends.

Flow of patients between the NHS and social care - local performance metrics

Local area performance metrics
Department of Health, 29 November 2017

• A new dashboard which allows local areas of assess the flow of patients across the boundary between the NHS and social care. 
• It provides a set of six measures indicating how health and social care partners in every Local Authority area in England are performing at the interface between health and social care. Included in the dashboard is a breakdown of delayed days attributable to social care per 100,000 of the population and the equivalent for NHS-attributable delays. 
• The metrics are:
• Emergency Admissions (65+) per 100,000 65+ population 
• 90th percentile of length of stay for emergency admissions (65+) 
• TOTAL Delayed Days per day per 100,000 18+ population 
• Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/ rehabilitation services 
• Proportion of older people (65 and over) who are discharged from hospital who receive reablement/ rehabilitation services 
• Proportion of discharges (following emergency admissions) which occur at the weekend 

Seven-day Services - England, April 2016 - March 2017, Experimental statistics

Seven-day Services - England, April 2016 - March 2017, Experimental statistics
NHS Digital 31 October 2017

• The experimental statistics presented in this report are being published to provide information on how we can effectively measure both improvement and variation in care provision across the week. It includes indicators on the following topics:
• Mortality within 30 days of admission by week-part of admission to hospital 
• Emergency readmissions within seven days of discharge from hospital by day of discharge 
• Length of stay following an emergency admission to hospital by day of admission

Level of sickness on mortality at weekends

Impact of the level of sickness on higher mortality in emergency medical admissions to hospital at weekends
Journal of Health Services Research & Policy 29 September 2017

• Analysis of emergency medical admissions at the weekend linked with electronic National Early Warning Score (over 45,000 admissions during 2014) found that patients are sicker, have earlier clinical assessments, and after adjusting for the severity of their sickness, do not appear to have a higher mortality compared to weekday admissions.

Seven Day Services Clinical Standards

Seven Day Services Clinical Standards
NHS England updated 11 September 2017

• Supporting information for trusts implementing the ten seven day hospital services clinical standards, along with the evidence base for each standard.

Mortality risks and A&E admissions at weekends

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records
Lancet 9 May 2017 DOI: http://dx.doi.org/10.1016/S0140-6736(17)30782-1

• This analysis of mortality rate (within 30 days) of emergency admission to four NHS hospitals used a range of common haematology and biochemistry test results or other proxies for workload did not find an association between hospital workload and mortality. It is suggested that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.

Abstract:

NHS Improvement 7 day services webbpage

Seven day services in the NHS
NHS Improvement

• A webpage dedicates to supporting 7 day services across the NHS including
• What does it mean to provide seven day services?
• The 10 clinical standards
• The four priority standards
• What do seven day services mean for patients?
• Related content
• Resources

The London Quality Standards programme evaluation

The London Quality Standards: A case study in changing clinical care.
Nuffield Trust 14 February 2017

• From 2011, the NHS in London embarked on a major programme to improve care for patients in emergency and acute services by introducing a set of professional standards. The London Quality Standards (LQS) set out a range of minimum requirements, including regular consultant review during out-of-hours and at the weekends.
• This evaluation draws on surveys and interviews with those responsible for developing the standards and the frontline staff responsible for making them a reality. It found that the introduction of the LQS worked well in making people aware of shortcomings in care, and drove real change in how people worked, but initial statistical analysis did not show any evidence that they achieved consistent improvement in patient outcomes.
• The most important factor in making the standards a reality was a bottom-up effort from clinicians. There were some deficiencies in hospitals’ ability to manage complex changes, and evidence of a deep disconnect between frontline staff and top managers. The use of reconfiguration as a “stick” to drive the standards demotivated staff, and eventually came to be seen as an empty threat.

Commissioning and delivering enhanced seven-day NHS services

Commissioning and delivering enhanced seven-day NHS services
NHS Confederation 17 November 2016

• An analyses what is already known about seven-day provision from the work of NHS national bodies, NHS organisations and others, and explores what the evidence tells about the case for an enhanced seven-day NHS.

Seven day services - NHS England blogs

Read NHS England blogposts on seven day services here.

Seven day hospital services - 10 clinical standards

Seven day hospital services
NHS England

• Resources developed by the Seven Days a Week Forum including 
• 10 clinical standards to end variations in outcomes at the weekend (updated Feb 2016)
• Summary of Initial Findings from the NHS Services
• evidence base document
• survey of acute trusts
• shared learning on how seven day services benefit patients
• 7 Day Services Self Assessment Tool
• Link to My NHS hospital performance dashboard
• A set of Case studies based on the clinical standards is also available.
• See also NHS Improvement : How seven day services can benefit patients

The 'weekend effect' is about both admissions and mortality rates

Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission
J Health Serv Res Policy 1355819616649630, May 6, 2016 as doi:10.1177/1355819616649630

• This retrospective analysis of data from 2013-14 of hospital A&E and community admissions and mortality within 30 days of admission considers whether it is the number of deaths or the number of admissions that is driving the elevation of mortality rates at weekends.
• HSJ commentary by authors (Subscription required)

Abstract

• Objective Patients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends leads to selection of patients with greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends.
• Method Retrospective observational study of all 140 non-specialist acute hospital Trusts in England analyzing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends.
• Results Similar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010).
• Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054).
• The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths.
• Conclusions There are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.

Health Select Committee report on Primary Care

Primary Care 

House of Commons Health Select Committee 21 April 2016

• This report analyses the challenges facing primary care and examines the long-term solutions which can improve access to services and patient care. 
• Conclusions and recommendations
• Utilising information technology
• Variable quality
• Improving the patient experience
• Multi-disciplinary teams
• The role of federations
• Guarding against conflicts of interest
• Workforce planning
• Selection of undergraduates
• Tackling local shortages
• Nursing
• Training and education
• Workforce and federations
• Regulation
• GP leadership
• Changing incentives in the system
• Investing in primary care
• Future funding

Recommendations directly affecting CCGs:

Emergency readmission rates by day of discharge

Seven-day Services, England, Provisional, July 2014 – June 2015 (Experimental statistics)
HSCIC, 29 January 2016

• This analysis uses Hospital Episode Statistics (HES) data to look at emergency readmission rates split by day of their previous discharge. 
• The report concludes that "it is not possible to determine whether this variation is due to differences in quality of care and/or service provision, or due to differences in the case-mix of patients."
• Key findings 
• Emergency readmissions within seven days of discharge from hospital 
• The rate of emergency readmissions within seven days of discharge increased over the week from a low of 3.2 per cent for discharges on Mondays, Tuesdays and Wednesdays to a high of 4.9 per cent for discharges on Sundays. 
• The overall rate of emergency readmissions within seven days of discharge from hospital on a weekend was 4.4 per cent, 1.1 percentage points higher than the corresponding rate for discharges during the rest of the week (3.3 per cent). 
• Due to changes in the methodology used for the calculation of the emergency readmissions indicator, these results are not comparable to those included in the previous edition of this publication. 
• Length of stay following an emergency admission to hospital 
• Nationally, there is a small amount of variation in the distribution of length of stay by day of admission, ranging from 47 per cent of discharges following an emergency admission on a Saturday having a length of stay of 0 or 1 days to 52 per cent of discharges following an emergency admission on a Thursday having a length of stay of 0 or 1 days, a range of 4 percentage points.
• See commentary in BMJ 2016;352:i621 (Available with NHS OpenAthens ID)

Commentary on the research around 7 day working

How much healthcare policy is based on evidence?
SA Mathieson, Guardian 1 December 2015

• Analysis of the discussion around the research evidence relating to 7 day working week in the NHS.
• "The NHS relies on scientific evidence to assess new medicines: drugs are only authorised if they pass clinical trials, and offered only if they pass a cost-benefit test. But similar research into healthcare policy is often used to fuel arguments rather than guide decisions."

High Impact Change Model

High Impact Change Model
ADDAS, NHS England, LGA, DH 1 December 2015

• This model provides practical options to support local health and care systems particularly around patient flow and discharge and to assess how effectively current systems are working. It also encourages areas to consider new interventions to be introduced throughout the year.
• The tool identifies eight high impact changes:
• early discharge planning
• systems to monitor patient flow
• multi-disciplinary/multi-agency discharge teams, including the voluntary and community sector
• home first/discharge to assess
• seven-day services
• trusted assessors
• focus on choice
• enhancing health in care homes

Analysis of GP patient survey to understand weekend opening preferences

Weekend opening in primary care: analysis of the General Practice Patient Survey
Br J General Practice 2015

• Analysis of data from the General Practice Patient Survey 2014 to understand the associations between perceived benefit from seeing or speaking to someone at the weekend and age, sex, deprivation, health conditions, functioning, work status, rurality, and quality of life.
• Of the participants (n=881 183) 80.9% did not report any problems with opening times. Of those who reported inconvenient opening times, 73.9% stated that Saturday opening, and 35.8% Sunday opening, would make it easier for them to see or speak to someone.