Summary and Next Steps
The Taskforce was convened to consider the implications of delivering a sustainable seven-day clinical service across NHSScotland and to offer proposals as to how that could be achieved.
Delivering sustainable services
NHSScotland already delivers a seven-day service across a range of clinical areas. Emergency patients are admitted to hospitals across the country seven days per week and 24 hours a day. Similarly elective patients within hospitals receive care out-with the normal working day. Some NHS Boards also undertake elective operations at weekends and we note that the first allocation from the Scottish Government's Performance Fund includes an allocation to NHS Highland to support them in providing elective procedures at weekends.
While we have been considering how access to appropriate decision makers, tests and treatments can be provided when required in out of hour periods, we recognise that this cannot be considered in isolation of the service provided during the rest of the week. Improvements to care provided at weekends must be built on a sustainable workforce supported by appropriate infrastructure across the week. So while we recognise the importance of making best use of the resources we have, we need to look at new models of care rather than just stretching our existing resources across seven days.
A strong theme that has emerged is that services should be configured to ensure that people receive the care they need in the most appropriate location to deliver that care. This does not always happen at the moment. Too often, older people are admitted to hospital when a package of assessment, treatment and support in the community might have better served their needs, and maintained their independence. Surveys conducted in Scotland and elsewhere, indicate that approximately a quarter of patients in acute beds in a morning no longer require healthcare in an acute setting. Approximately half of these patients are there due to healthcare related issues and many of them are waiting for a clinical decision to allow them to go home. It is also important to recognise that towards the end of their lives people often move in and out of hospital, so a significant proportion of acute care patients require palliative and end of life care. A study of inpatients in Scottish hospitals suggested that almost 1 in 10 patients in teaching or general hospitals at any given time will die during that admission. Almost 1 in 3 patients will have died a year later, rising to nearly 1 in 2 for the oldest groups. Models such as Anticipatory Care Planning can support conversations with patients, their families and carers and help people to think ahead and have greater control and choice over their care and support. A Palliative and End of Life Framework for Action will be published later this year and we will want to ensure that we reflect that in our work. The scale of this challenge will only increase as the service deals with the growing number of people with longer term and often complex needs, many of whom are older. The work that is being progressed to deliver the 2020 vision, including health and social care integration and the range of initiatives to avoid unnecessary hospital admissions and enable appropriate discharge from acute care are supporting the necessary change in the balance from acute care to community and primary care.
As the new integrated partnerships begin their work from April 2015, it will be important for us to engage with them on how their integrated strategic commissioning role of preventing admission and supporting appropriate discharge can support improvements in the continuity of care for patients across seven days.
The principle of delivering care the patient needs in the most appropriate place also applies within the acute hospital sector. Clinical care in acute hospitals is increasingly dependent on multi-disciplinary teams supported by the availability of complex technology. All of these components require to be sustainable in order to deliver a high quality service across seven days. Acute general surgery exemplifies the challenges to be faced. It is currently delivered on 29 sites but the complexity of the surgery varies. Increasingly it is recommended that surgical teams have access to an intensive care unit and interventional radiology services.
In the lead up to the implementation of the 48 hour working week for junior doctors, various work streams were undertaken looking at how to run safe and sustainable rotas. WTD - The Implications and Practical Suggestions To Achieve Compliance, a report done jointly by the Royal College of Anaesthetics and the Royal College of Surgeons England published in 2009, identified the minimum staff required to run a safe and sustainable rota, while providing a good work life balance was eight. The work done also shows that the number of staff needed in any workforce is dependent on the amount of cover required, how many staff are needed at certain times of the day, and the skills that are required at any particular time. Therefore minimum staffing numbers covering rotas can vary significantly between different specialties and sites. Importantly they require a sufficient population base/case load to ensure that the health professional can maintain their skills.
This dilemma has been addressed for vascular surgery services by focusing the intervention components of the treatment in fewer centres while ensuring that some non-invasive components of the vascular service are delivered in local hospitals. Such a model provides optimal clinical care for patients as they are able to access the majority of services through their local hospital and if they require more complex acute care this is delivered by sustainable teams on a seven day basis.
In moving forward we will look to develop models that bring sustainable teams together in secondary care while maintaining access for patients to appropriate care in their local hospital.
The recently announced review into out of hours primary care services will be important in supporting our progress towards sustainable seven day services. Also of relevance to our work is the UK Shape of Medical Training Review which considered how doctors' training could enable them to better meet the changing needs of patients, society and health services. One of the review findings was that patients need a different kind of doctor in the future whose training equips them to work across the interface between primary and secondary care. This means enhancing the skills of general practitioners and preparing hospital doctors to undertake duties in community settings. UK Health Ministers have welcomed the report and approved development activity to explore how medical training can be adapted to meet future patient and service needs. This will be taken forward in a planned way, and overseen by a Scottish Implementation group.
Drawing on these pieces of work where appropriate we will wish to consider new and emerging models of community based care that could enhance the local services for patients, while enabling acute hospitals to focus on their core activity; namely the treatment of seriously ill patients or those that require specific interventions. There are a range of options that could be considered from hubs to extended hubs and greater use of community hospitals.
Delivering a sustainable workforce
Sustainable services cannot be delivered without a sustainable workforce and we will consider carefully the workforce implications of this work as we move forward.
The solutions to sustainable seven day services require us to maximise the contribution from all healthcare professions in acute and primary care, working to the top of their professional capability.
In addition to the contribution from the medical profession, there are also numerous examples in the past of how nursing has taken on new or expanded roles across acute and community services, which has improved patient care. This can be seen in the introduction of nurse prescribers, hospital at night teams and minor illness advanced practice. As part of this programme we are keen to explore whether more can be done to empower and enable advance nurse practitioners to operate as senior-decision makers including in out of hours periods. Advance nurse practitioners already work in a wide variety of roles. In community settings they may be part of an enhanced primary care team or connected to GP services. Increasing numbers also work in secondary and tertiary care settings, such as Accident and Emergency, minor injury units, medical assessment units and hospital at night teams. They also work within specialities, such as paediatrics, neonatal care, cancer care, ophthalmology and orthopaedics.
The particular expertise of such nurses lies in their ability to operate both in specialist areas but also as a 'generalist', with a wide range of skills, a broad knowledge base and the ability to deliver specific aspects of care which complements the role of medical colleagues and other members of the health and social care team.
We would also propose as part of this programme to undertake a review of district nursing which looks at the current and future role of district nurses, ensuring that the available education and training supports this.
Allied health professionals (AHPs) also make a significant contribution to the care of patients in out of hours periods. While historically the majority of AHP services have operated on a five day basis, over the last two years the established AHP delivery pattern has been shifting and is now increasingly different across Scotland. This is primarily in response to service need, but also patient preference. Most recently the targeted use of AHP staff over weekends and out of hours periods in areas of service pressure has been making a significant contribution to patient flow, weekend (and earlier) discharge as well as the prevention of unnecessary admissions to hospitals through AHPs working in Accident and Emergency Departments, Admission Units, Frailty Teams, hospital at home, including community paramedics and other out of hours services. AHPs have also expanded their roles as prescribers, Advance Practitioners and AHP consultants across a range of specialties, working across hospital and community settings. We will build on this work, focussing on allied health professions that will make the most significant contribution to sustainable services across seven days.
It is crucial that we recruit the staff we need but also that we retain the staff we have and support them through providing them with good quality work, a good work life balance with working patterns designed to facilitate this, attractive working conditions and recognised career pathways.
From our work to date we have identified a number of actions which we would propose to take forward in the next phase of the programme.
- We will review the services provided in the 29 sites that undertake acute surgery to ensure that the models of care are sustainable while maintaining appropriate care in local hospitals.
- We will consider how the effectiveness of ward rounds at weekends can be improved to provide better patient care.
- We will consider further opportunities for nurses, AHPs and healthcare scientists to contribute to developing sustainable services, including how they can operate as senior decision makers in acute and primary care and by undertaking a review of district nursing.
- We will consider new models for reviewing and reporting diagnostic imaging and the provision of interventional radiology.
- We will co-ordinate further work to support the sustainability of Scotland's six Rural General Hospitals.
- We will continue to link to the range of national activity that is supporting the development of sustainable seven day services, including contributing to the review of out of hours primary care and the refresh of maternity and neonatal care.
- To enhance local services, while protecting acute care resources, we will explore new models of care such as community hubs and the greater use of community hospitals with a view to developing pilots.
- We will use a strong evidence base to support us in progressing these next steps.