London quality standards – acute medicine and emergency general surgery

In-hours and out-of-hours workingThe recommendation is for consultant physician presence at hospitals for 12 hours per day, every day of the week. Variation existedbetween London’s hospitals in the number of hours an admitting consultant physician was expected to be on-site and the situationworsened on the weekends. This variation was also seen across emergency general surgery services.

Audit of acute medicine and emergencygeneral surgery standards All acute hospitals in London were audited against the agreed andcommissioned acute medicine and emergency surgery standardsbetween May 2012 and January 2013. Audit teams comprised ofclinicians – from within and out of London – clinical commissioners andpatient representatives. The audits aimed to assure commissioners thathospitals were compliant with the standards and patients werereceiving high quality and safe care, or help them to find solutions forproviders that were unable to meet them. A full report of compliancewas produced for each provider of these services in London.

Audit results

All hospitals recognised the value of meeting the standards and clinicalleaders at the hospital visits highlighted that the audit was useful in:

■ reinforcing the importance of meeting the London qualitystandards;

■ focusing teams on prioritising efforts to address gaps identified; and

■ developing approaches to monitoring delivery and ongoingachievement of the standards.

London quality standardsLondon quality standards, based on clinical evidence, nationalrecommendations and best practice were developed to ensurethat all acute medicine and emergency general surgery servicesprovide care that is safe, and of consistently high quality forpatients across London, seven days a week. These would beservices that improve patient outcomes.

Meeting these standards will ensure that there is no difference inthe quality and safety of these services provided on weekdaysand weekends, or between and within hospitals; could save aminimum of 500 lives; and improve emergency care and outcomes for patients treated in the capital.

The London quality standards were included in 2012/13 acutecommissioning intentions – hospitals providing acute medicineand emergency general surgery services must comply with thestandards in order to continue to be commissioned.

London quality standards and audit of acute hospitals

Many hospitals have recognised that compliance with all of thestandards may mean a significant change to the way services areprovided at a local and at a cluster/network level.

Key findings of the audit include:

■ No one hospital has met all of the standards.

■ No one standard will remain unmet by April 2013 by allhospitals, demonstrating significant scope for shared learningand service redesign.

■ Many hospitals have made significant efforts to change practiceto achieve the standards and some have robust plans in progress.

■ The audit findings show a positive journey of improvement but the majority of hospitals still have significant progress tomake to ensure standards are in place consistently across sevendays of the week.

Initial results show that improvements had been made in workingpractices including early consultant involvement for patientsadmitted acutely, consultants freed from elective commitmentswhilst responsible for emergency admissions, extended dayworking and multi-disciplinary input, as well as improvements topatient experience through provision of information and capturingand acting upon patient experience data.

A compelling case for change was essential as a lever for implementing the standards and strong clinical leadership was vital. Compliance with the London quality standards will aim to ensure that all acute medicine and emergencygeneral surgery services provide care that is safe, and of consistently high quality for patients across London, seven days a week. These would be services that improve patient outcomes. Strong clinical leadership and widestakeholder buy-in and engagement allowed this programme to be delivered.

Contact england.serviceredesign@nhs.net for further information

Percentage of standards met across London’s acute hospitals

A lack of senior involvementDelays to both consultant review and a lack of senior involvementin patient care have been linked to poor patient outcomes.Working patterns should be set up to support early involvementin the care of emergency admissions and consultants should befreed from other clinical commitments and elective duties whilston-take. There was stark variation across London betweenweekdays and the weekend in the number of emergencyadmissions that were reviewed by a consultant within 12 hours.Additionally, less than half of consultant physicians andconsultant surgeons were always freed from other duties.

Consultant review of emergency medicaladmissions within 12 hours

Consultant review of emergency surgicaladmissions within 12 hours

Always

Very often

No response

Sometimes

No

Sometimes

Yes

Always

Very often

Sometimes

Weekday Weekend Weekday Weekend Consultant surgeonsConsultant physicians

23%

77%

28%

52%

10%

38%24%

48%

48%

26%

26%

46%

25%

29%

29%16% 3%

52%

Do consultants undertake any other duties whilst on-take?

Met

Plans in place

Not met50%

47%

3%

50% 47%

3%

52%

44%

4%

Acutemedicine

Emergencysurgery

0

2

4

6

8

10

12

14

London hospitals

0

2

4

6

8

10

12

London hospitals

Consultant physician hours on-site Consultant surgeon hours on-site

There was also variation in outcomes between weekday and weekend admissions. London data showed that the probability of dying as a result of many emergency conditions was significantly higher ifthe admission was at the weekend, compared to a weekday. If the weekend mortality rate in London was the same as the weekday rate there would be a minimum of 500 fewer deaths a year.Reduced service provision at weekends is associated with this higher mortality rate.

Who was involved?

The work was clinically-led. Through an applicationprocess, over 30 clinicians were appointed to form multi-disciplinary clinical expert panels covering thefull geographical spread of London and a range ofclinical disciplines. A patient panel was also formed to inform all developments.

Each clinical expert panel worked in conjunction with the relevant Royal Colleges, professionalrepresentative bodies and the London Deanery toreview current service provision and develop the casefor change. There was also close co-operation with the London-wide GP Clinical Commissioning Council.Current and future commissioners were representedon the programme board.

London’s emergency admissions

The NHS London 2011 Survey of Acute Trusts found that many hospitals were not meeting bestpractice recommendations for the provision ofacute services and highlighted marked variation across London’s hospitals in working patterns for acute medical and emergency general surgical care. This variation increased overnight and at the weekend.

Acute medicine and emergency general surgery services need to deliver a safe and consistently highquality service for patients seven days a week. However, progress towards this had been piecemealand out-of-hours cover remained particularly fragile.

This meant that services in London were notconsistently delivering the safe and high qualityemergency care that patients expected.

Variation in outcomes

Outcomes for patients in London varied considerably across different hospitals. A variety of outcomemeasures provided an indication of the quality of aservice and enable comparisons between services across London:

■ Depending on the hospital, length of stay forpatients admitted as an emergency with respiratorydisease was two to three times as long.

■ Four in every ten patients were re-admitted within 30 days of their original admission,compared with just 1 in 10 patients re-admitted tothe best performing trusts.

The case for changeLondon Health Programmes, on behalf of all commissioners in London, developed quality standards to improve the quality and safety and reduce the variation found across acute medicine and emergencygeneral surgery services in the capital.

Reviews by the National Confidential Enquiry into PatientOutcome and Death and reports from Royal Collegesidentified that the provision of acute medicine andemergency general surgery services can vary significantly. Patients do not always get the same high standards of care they need, particularly over the weekend.

These reviews have common themes: there is ofteninadequate involvement of consultants in the assessment and subsequent management of many acutely ill patients, junior doctors are often practising withoutadequate supervision, and variations in outcomes andmortality rates exist between routine working hours and out-of-hours care.

Monday - Friday Saturday - Sunday Weekday London average Weekend London average

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