Out of Hours Care and Seven Day services Extended Session

Out of Hours Care and Seven Day services Extended Session Juliane Kause Clinical Director Emergency Care Seven Day Services Clinical Lead University Hospital Southampton

Session objective National update: 7 Day Services Hospital at night or out of hours services? Local examples Southampton and the South Staff solutions: new roles, role change, staff development Challenges along the way Improvements as a result of this work

7 day services - what it means for patients If I need to make an appointment to see or speak to a GP, I can get an evening or weekend appointment if I need to. My GP surgery offers a mix of face-toface, telephone, email and video consultations. NHS 111 If I have an urgent need, I can phone or electronically contact NHS 111 and the NHS will arrange for me to see or speak to a GP or other health professional any hour of the day and any day of the week. If I need emergency care whilst in hospital, I will receive the same high quality of care any day of the week and any hour of the day. An experienced clinician will make timely decisions about my care and I will be able to access the services I need. I can always get health advice from the NHS on my laptop, phone or through the internet. If I need community support when I leave hospital, I can get this any day of the week I can get health advice 7 days a week from a range of services, like pharmacy. 3 24/7 access to health advice 7-day community support 7-day community pharmacy

Improving Out of Hours and weekend care will have a positive impact in 4 key areas Better Patient Experience Improved Patient Flow Patient Safety Better clinical supervision across the week 4

A set of clinical standards were identified to support 7 day services in hospitals Priority clinical standards Standard 2: Time to consultant review Standard 5: Diagnostics Standard 6: Consultant directed interventions Standard 8: On-going review in high dependency areas Clinical standards which enable sustainable delivery 5 Standard 1: Patient Experience Standard 3: MDT Review Standard 4: Shift Handover Standard 7: Mental Health Standard 9: Transfer to primary, community & social care Standard 10: Quality Improvement The 10 clinical standards were developed by the NHS Services, Seven Days a Week Forum led by Professor Sir Bruce Keogh. Priority standards are identified as the minimum set of clinical standards needed to tackle variation in mortality, patient flow and experience. Selection is supported by the Academy of Medical Royal Colleges.

Seven Day Services Clinical Standards With NHS England we incorporated feedback into latest information on the priority clinical standards https://www.england.nhs.uk/wp-content/uploads/2017/02/clinical-standardsfeb17.pdf 6

7 day services in hospitals - milestones By 2020/21, the four priority standards available to 100% of the population By April 2018, the four priority standards available to 50% of the population By April 2017, the four priority standards available to 25% of the population April 2017 25% April 2018 50% 2018/19 April 2020 100% 7

Early implementers of 7 day services clinical standards North Northumbria Healthcare NHS FT Mids & East Sherwood Forest Hospitals NHS FT Royal Wolverhampton NHS Trust 8 South Salisbury NHS FT Buckingham Healthcare NHS FT London London North West Healthcare NHS Trust

How does NHS Improvement / NHS England support the delivery of 7 day services with partners? CCG Improvement and Assessment Framework NHS Planning Guidance Sustainability and Transformation Partnerships Improvement Support NHS Improvement Standard Contract Support CQC Inspection Framework Support for CCGs 9

Support for 7 day services in each region Delivery planning Enabling system wide conversations Communicating between the trusts and the ALBs Helping with the how to Supporting measurement North Pete Barnaby Jo James Mids & East - Ian Hall Marie Tarplee London - Fran Davies Rhuari Pike 10 South - Daniel Derozarieux Sue Cottle

Regional 7 day services leads Region Lead Contact email London Midlands & East North South Fran Davies NHSI fran.davies1@nhs.net Rhuari Pike NHSE r.pike1@nhs.net Ian Hall NHSI Ian.hall9@nhs.net Marie Tarplee NHSE m.tarplee@nhs.net Pete Barnaby NHSI pete.barnaby@nhs.net Jo James NHSE jo.james5@nhs.net Daniel Derozarieux NHSI dderozarieux@nhs.net Sue Cottle NHSE sue.cottle@nhs.net 11

Spreading the word.. Video and written case studies of staff already implementing seven day hospital services Animated film clarifying the four clinical standards and benefits to staff and patients https://improvement.nhs.uk/resources/seven-day-services/ 12 In reality, when [staff] started doing it they said, this is brilliant, we don t get managers bothering us, we don t get emails, we can get hands on patients all day. Annette Purkis, Head of Therapies, University Hospital Southampton NHS FT

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Context Provides services to some 1.9 million people living in Southampton and South Hampshire. Provides specialist services to more than 3.7 million people in central southern England and Channel Islands. Major centre for teaching and research in association with University of Southampton and partners including the Medical Research Council and Wellcome Trust. Every year our 10,550 staff treat around 140,000 inpatients and day patients, including about 50,000 emergency admissions; see over 500,000 people at outpatient appointments; and deal with around 110,000 cases in our emergency department.

OOH/7Day Services plan...always open, always ready... 3 year project plan Local (departmental/directorate) solutions and overarching plan In house gap analysis by Directorate/specialty Workforce Budget setting Discharges: NEL weekday vs weekend Community links

Workforce solutions Nurses in Medicine Transformation from nurse coordinator/bed manager (Band6) to Advanced nurse practitioner (Band7) Separation of bed management from clinical work Key to success Clear definition of roles Advanced nursing practice pathway (MSc) Hospital at night practitioner to Out of Hours Advanced Nurse practitioner Development of MDT delivering OOH care

Baseline 2012 in Medicine 13 medical wards, including Respiratory HDU 378 beds Medical outliers up to 100 in the winter Shift patterns between health care professions not coordinated Medical assistant cover sporadic No weekend pharmacy service 8 SpR vacancies (out of 27) 2012 OOH staffing 1 SpR 1 SHO 1 night nurse practitioner

Nursing role transformation 2012 WTE: 2 Band 6, one Band 7 Shift: 20:30 to 09:00 Role: Staffing Bed management Clinical coordination Challenges: Rota gaps Overwhelmed by workload Reputational issues for trainee doctors 2015 8 WTE Shifts: 16:00 to 04:30 weekday 20:00 to 08:30 every day 08:00 to 20:30 Weekend/ PH Role Clinical Benefits Stability Education Support for ward nurses and junior doctors Control of work flow

Workforce solutions therapy services 5 day services stretched to seven days Physiotherapy and occupational therapy combined New Band 3 and Band 4 roles Service design based on clinical need Early successes: timely end of life care discharges equitable service for all patients Challenges: Culture change Some staff were new to weekend working

Therapy Services Staffing and rota models 1 Clinical Area Hours Rota Weekend Hours Sat and Sun Cardiothoracics Weekend Service Respiratory 1.5 wte Surgery 8am-4pm 1wte OT Cancer Care Rehabilitation 1wte B2-4 Medicine AMU CF MOP Pulmonary Rehab Paediatrics Weekend Service 8am-4pm 8am-4pm sat and Sunday. Sat 8.30-1pm Sun 9-12pm Sat 9-1pm Sun 9-12.30 pm CMH Hospice Respiratory Rehabilitation AMU/Med MOP Respiratory Ortho OT 1wte 9-12.45 2wte PT 8-4 (1 Senior) 1wte OT 1wte PT 2wte B2-4 1wte OT 1wte PT 1wte B2-4 1wte PT 8am-4pm 1wte band 4 7 PT (hours as first column) 1wte band 5-7 OT (hours as first column) 1wte band 2 8a Sat 8.30-12.30pm (hours as first column) Sun 9-12.30 Rehabilitation Twilight/Out of hours Respiratory Twilight 12pm-8pm On-call via Switchboard 8pm- 8am Respiratory Twilight 12pm-8pm On-call via Switchboard 8pm- 8am Respiratory Twilight 12pm-8pm Respiratory On-call via Switchboard 8pm- 8am PRESENTATION TITLE/DATE CAN GO HERE

Therapy Services Staffing and rota models 2 Clinical Area Hours Rota Weekend Hours Sat and Sun Twilight/Out of hours Musculoskeletal Weekend Service 8am-4pm Physio OT Rehabilitation 2/3wte PT 1/2wte OT 3wte B2-4 (B4 Sat only) Respiratory Twilight 12pm-8pm On-call via Switchboard 8pm- 8am Neurosciences NICU Stroke Weekend Service 8am-4pm Weekend Service 8am-4pm Respiratory Rehabilitation OT/PT Rehabilitation 1wte PT 1wte B2-4 1wte Sat = OT/ Sun = PT 1wte OT 1wte PT 1wte B2-4 Neuro Twilight On-call via Switchboard 8pm- 8am Neuro Twilight On-call via Switchboard 8pm- 8am

Workforce solutions Doctors Administrators on AMU 2015 now national Background 56 bedded AMU 70-100 daily attendances/admissions 41% direct discharge rate 30-40 electronic discharge summaries (EDS) per day 15 minutes to complete EDS excluding to take out medications (TTOs) 10 hours per day = time required by junior doctors to complete EDS 3 SHO grade doctors on ward based duties each day, one SHO for admissions, 1-2 SpRs, 1 consultant 08:00-22:00, seven days a week Median length of stay 20 hours Junior doctors carry the administrative burden at the expense of direct patient care and education European Working Time Rule considerations

Context - Support staff on AMU Medical Assistants, Band 3 Iv access, ECGs, Urine tests, NGTs, catheters 24/7 x1 Doctors Administrators, Band 3 Administration, medical house keeping Band 3 08:00 to 18:00 seven days X2, Mon to Fri X1 Sat/ Sun Ward clerks, Band 2 Transfers, discharges, medical record management 07:00 to 15:00 seven days x3 16:00 21:00 x1 Mon to Fri Clinical Coordinators, Band 4 Bed management 07:30 to 23:00 Seven days a week x1

Recruitment Advertised on open market Internal and external recruitment Competitive selection process Skills required Dynamic Attention to detail Able to work well in acute environment initiative 30/10/2017 Juliane Kause UHS

Training Six week training programme Trust induction Coding education session Trust IT clinical applications course Medical terminology course Dummy discharge summaries Competency framework Medical model Clinical supervisor AMU consultant = mentor

Placement/Utilisation 2 doctors administrators on duty each day (Mon to Fri) and one on Sat, Sun and public holidays DAs join the morning ward round checklist approach encouraged to include CQuIN items DAs give patient information leaflets after the ward round DAs liaise with junior doctors when results become available DAs restock treatment room (checklist approach) DAs conduct departmental audits DAs write eds, checked and signed by junior doctor

Accountability Overall clinical accountability = AMU consultant of the week Accountability for each electronic document = signing clinician Line management = administration manager for each department Education = mentor consultant and clinical director emergency care

Professional networks of DAs within each department/organisation Integrated valued members of the MDT within three month of introducing Doctors Administrators Coders Quality for income (cost improvement and transformation) Ward clerks Nurses Doctors

Impact on clinical service Improved documentation of initial consultant review Improved patient information Improved quality, detail and narrative on EDS More direct discharges from AMU Reduced length of stay (median LOS 20 hours to 16 hours) Improved patient flow to wards Consistency throughout the week

Impact on staff Doctors have more time to treat patients Time between AMU admission and AMU initial AMU doctor assessment has halved (2 to 1 hour) Improved job satisfaction for doctors, nurses, pharmacists, social workers, H@H as we are better able to deal with acutely unwell patients and patients ready for discharge Improved educational experience for staff in training Fewer vacancies (other local initiatives have also contributed to this)

Post evaluation Value added financial Value to patients and clinical staff Service improvement initiatives Patient information CQUIN data completion Trusted colleagues Integral part of MDT EDS audit shows DAs provide better documentation than junior doctors (N = 40) Consistent quality

Workforce Solutions Acute Care Fellows 13 Acute medical wards including respiratory high care 378 beds 1 SPR (21:00-09:30) 1 SHO (21:00-09:30) 1 FY1 (21:00-02:30) + referrals from non medical specialties

SpR and SHO shift pattern pre 2014

Acute Care Fellows 6 Acute Care Fellows Senior Registers (ST5 and above) Breadth of specialty experience Gastroenterology/Cardiology/ Respiratory /Endocrinology Time out of specialty training for clinical /scientific research leading to higher degree (PhD/MD) Introduced January 2014

The role OOH team leadership Collaborative working to ensure right person/ right place/ right time Clinical reviews Priority to the acutely unwell and deteriorating patient Assisting with routine work one team ethos Supervision of juniors Review of the acutely unwell patient Clinical procedures Teaching - Adhoc / Scheduled

OOH service 2015 Footprint unchanged Improved job satisfaction and perceived patient safety by medical SpRs and senior nurses No SpR vacancies for over a year Outliers continue to be a challenge, but the number have dropped by 1/3 from 120 + (in 2012/3) to maximum of 80 (2014/5) Fewer PEA cardiac arrests 43 in 2013 13 in 2014

Rota 10 shifts over 2 weeks 4 weeks research Continuous service 7 days a week 365 days a year.

Working Pattern for all trainee doctors in medicine Mon-Thurs 1 ACF 16:00-00:00 2 SHO 8:00 20:30 1 F1 8:00-20:30 1 F1 16:00-00:00 SPR 20:00-08:30 SHO 20:00-08:30 Fri -Sun 2 SPR 08:00-20:30 / 16:30 2 SHO 08:00-20:30 1 F1 08:00-20:30 2 ACF 16:00-00:00 / 04:00 1F1 16:00-00:00 SPR 20:00-08:30 SHO 20:00-08:30

SpR rota in Medicine since 2015

The benefits of new workforce models Shared workload Timely review of patients Broad range of specialty knowledge collectively OOH Reduces the overflow of routine work to the night shift

Benefits to Acute Care Fellows Up to date Retain clinical skill set Develop management /leadership/ GIM competencies Experienced clinicians are not lost to the NHS Supports out of programme research

Improvements Delivered UHSFT Internal Operational Standards (2012) Extended service provision Educational packages for nursing staff and junior doctors Creation of new job roles (Acute Care Fellows, Medical Assistants and Doctors Administrators) New online task management and handover system (Doctors Work List one stop shop ) designed by us for us

PDSA CYCLES Development and improvement of junior doctors rota Rota alignment for all professions Change of handover practice from paper to IT tools Improvement of Trust communication Identifying staff training needs Development of transfer kit and protocols Improvement of working practices with others e.g. CCOT Doctors administrators Acute Care Fellows Increase ANP numbers and formal training scheme Medical assistants (team based) Electronic data management system Increase weekend consultant ward rounds

MEASURABLE RESULTS STAFF no vacancies and excellent staff retention PATIENTS FLOW AND SAFETY Reduced LOS (2 days in 2 years); Falling readmission rates (2013-21%, 2014-16% 2015-13%). Reduced cardiac arrests. FINANCIAL- Significant reduction in spending on bank nurses and locum doctors NATIONAL RECOGNITION AND COLLABORATIONnational leader in OOH care, patient and staff codesign of services, clinical academic profile, innovation

Out of Hours Models of Care Pre OOH Work Structure OOH / 7 Day Services Pharmacist SpR Patients Medical Assistants Nurses Physio Med. Asst. Nurses and Patients SHO OOH Team (ANPs/ACFs) FY1 Doctors Admin FY1 SpR Consultants SHO

Support Services Radiology Pharmacy Therapy

Radiology Consultant Cover Pre 2011 All on call from home General (incl MSK and most spinal) Neuro (incl diagnostic angiography and, when suitably skilled, interventional) Cardothoracic IR Paediatric

Diagnostic Radiology Consultant presence at weekends from 2013 Neuroradiology 2 sessions each day (incl spinal on Sundays) General / abdominal - 1 session each day MSK / spinal 1 session Saturday Cardiothoracic on call from home Paediatric on call from home

Workforce Increase over 5 years * FTE Radiology Workforce by Staff Group 2012 / 01 2013 / 01 2014 / 01 2015 / 01 2016 / 01 2017 / 01 * Consultant 35.5 38.7 42.3 44.2 42.2 45.7 10.2 Other Doctors 30.0 26.6 31.7 34.2 32.0 30.5 0.5 Nurse 12.8 14.8 16.0 12.2 17.5 15.1 2.3 Radiographer 126.3 135.8 140.4 146.2 145.4 147.3 20.9 Admin Staff 45.1 45.2 48.3 51.2 50.8 51.9 6.8 Healthcare Scientist 3.4 3.2 4.0 4.0 4.0 4.0 0.6 Clinical Support Workers 45.1 41.6 45.3 46.7 49.3 60.2 15.0 Technicians 3.0 3.0 3.7 5.3 4.3 4.3 1.3 Total 301.3 308.9 331.7 344.0 345.5 358.9 57.6

Radiology OOH in 2015 Radiographers ED, CT and MRI, sonographers, interventional Radiology SpRs shifts evening / night / weekend Radiology Consultants on call and shifts

Support services: Pharmacy to support discharges and therapeutic drug monitoring 2014 Weekdays: 09:00 to 17:00, Sat and Sun 09:00 to 12:00 AMU and Medical Wards No PH service no dispensary 2016 Weekdays:09:00 to 19:00 acute admission areas, weekends PH: 09:00 to 17:00 Dispensary open from 09:00 to 17:00 seven days a week

Support Services therapy services 5 day services stretched to seven days Physiotherapy and occupational therapy combined New Band 3 and Band 4 roles Service design based on clinical need Early successes: timely end of life care discharges equitable service for all patients Challenges: Culture change Some staff were new to weekend working

New ways of working MDT works seven days a week and nights where required On call replaced by shift work where required Shift harmonisation of all professions working and MDT handover Trust huddle at 11pm to discuss acuity and workflow Do all outstanding emergency work outstanding before midnight

Thank you

Would I do it again? Absolutely! Juliane Kause UHS 30/10/2017