This presentation, first given to the North West Medical Leaders Congress in April 2012, gives an initial analysis of the benefits that could be achieved by increasing clinical decision making capacity in NHS hospitals over the weekend. NHS England have now embarked on a detailed investigation of the costs and opportunities that enhanced weekend working might achieve. This is due to published in autumn 2013

1. Seven Day Working
The economic case to increase clinical
decision making at the weekend
David Halsall
Analytical Services
November 2012

2. Let us start by asking the simple question
– what are the main value added activities that an acute trust offers?
Treatment
and
procedures
Nursing
led
care
Evidence
based
decisions

3. In elective activity hospitals clearly show a stop – go weekend
effect. In unscheduled activity there is also a weekend drop-off
effect in activity.
Admissions by Day of the Week
(relative to total of admission route)
0%
5%
10%
15%
20%
25%
MON TUE WED THU FRI SAT SUN
Percentageoftotal
Birth Emergency elective - ordinary daycase
DH analysis of HES

4. At the weekend the acute hospital will shrink its capacity, but some key
areas shrink more than others – what are the consequence of that?
Treatment
and
procedures
Nursing
led
care
Evidence
based
decisions
Patients admitted
at the weekend
have treatment
deferred until
Monday
Patients are not reviewed fully
and may
suffer from a
failure to rescue

5. Fewer people are admitted to hospital as an emergency at the
weekend but the chances of dying are noticeably higher
Day of admission DH analysis of HES data 2010/11
National figures, England 2010/11
Evidence 1 – Higher deaths if admitted at the weekend
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
MON TUE WED THU FRI SAT SUN
Percentageofpatients
3.2%
3.4%
3.6%
3.8%
4.0%
4.2%
Percentageofpatientwhodie
Percentage emergency admissions by day of the week
Percentage of patients who are discharged dead

6. What we know about the differences between weekday and weekend
acute hospital death rate
• What we have distilled from published evidence is:-
1. You are no more likely to die if you are in hospital over the weekend
compared to a weekday if you were admitted on a weekday
2. Emergency patients admitted over the weekend have a higher risk
of dying in hospital and within 30 days of discharge – even after case
mix adjustment is applied. We have no estimates of difference this
make to life expectancy but researchers have advised us the effect is
more likely to be small – days not weeks or months.
3. Elective patients admitted at the weekend do have a higher
probability of dying compared to those admitted on a weekday – but
this is possibly due to higher risk elective patients being treated
earlier in the week over the normal cycle of hospital scheduling

7. Fewer emergency patients are admitted at the weekend but the chance of
dying is higher – There are possibly two effects driving this (i) a more
complex case mix at the weekend and (ii) failure to rescue some patients
Change from weekday to weekend admission
-25%
-20%
-15%
-10%
-5%
0%
5%
10%
15%
admissions deaths chance of death
DH analysis of HES data 2010/11
Emergency
admission by
weekend and
weekday
admission
Evidence 2 At the weekend we have a more complex patient mix
In either case it looks like we need to improve the decision making capacity at the
weekend as the supply and demand for senior staff is not in balance

8. Making the economic case for the reduction in the difference between
the weekday and weekend level of service requires an evaluation of the
costs and benefits of any re-configuration
• Economic evaluation in principle is straight forward
Showing that economic benefit outweighs the costs is only part of the story
• Are savings nominal or cash releasing?
• What is the timing of the savings v any investment?
Extra Cost
Savings
QALY
Health
Benefits
Cost/benefit
QIPP savings if
cash releasing
What sort of economic analysis shall we do?

9. Would we expect incremental changes to resources to have a direct
linear link to patient care or would we guess that there is a non-linear
relationship?
A measure of access to care
For example time between admission and senior review
Looking at benefits – a conceptual model to help our thinking
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80 90
Ameasureofthebenefitcarebrings
Forexamplelevelofdisabilityfollowingastroke
Normal weekday
working ?
Weekend
Working?
Best
Practice ?
A conceptual model of the link between access to care and benefits care brings
1/3 cost 1/3 cost 1/3 cost
High benefit to
cost ratio
Diminishing
benefit to cost ratio

10. So let’s look at an example were extra resources are added to general
medicine at the weekend and see if the economic case stacks up
• In 2007 Heartland Hospital instigated early consultant review to reduce
the risk to patients when AMU patients are transferred to specialist
medical wards at weekends.
• The appointment of 2 additional acute physicians released consultant
time from the AMU to allow several consultants to conduct short rounds
on their base wards of newly transferred in patients - replacing the
weekend “safari” ward round of new admissions by a single consultant.
• This reduced delays in having a clear clinical management plan and
reduced LoS for patients admitted towards the end of the week.
• In particular it was identified that opportunities were being missed to
discharge some patients in the subsequent 24-72 hours after admission.
• In common with many acute trusts discharges at weekends were less
than on weekdays.
• Seven day working of key clinical and social service staff is required to
achieve a levelling out of discharge pathways.
Example

11. The case can be made that the cost of the extra consultants could be
offset by increasing the weekend discharge rate
• A consultant (including overheads) could cost £150,000/year
• A patient awaiting discharge will cost around £250/day
• So £300,000 is equal to around 1200 patient days
• Or in other words if 23 patients are discharged 1 day earlier each weekend that
would cover the cost of the 2 extra consultants.
• In effect one ward would have to close for a day a week to recover the cost.
• The other changes to weekend working patterns are achieved by negotiated HR
processes
Example
£300,000/year
23 patients a
week have their LoS
reduced by 1 day

12. In addition to the direct costs and benefits there are a range of additional
benefits which also could be used to evaluate the change in practice
• Improve patient satisfaction
• Better training of junior doctors
• Enhance patient care quality and safety
• Ward staff feel more supported

13. Although it is impossible to attribute the improvement in performance
to the change in the weekend working pattern it is consistent with what
you would expect
Percentage of Deaths in Hospital Following Emergency Admission
(Birmingham trust and England)
3.0%
3.2%
3.4%
3.6%
3.8%
4.0%
4.2%
4.4%
4.6%
4.8%
5.0%
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11
Deathsasapercentageofemergencyadmissions
RR1
England
Source DH analsys - of HES data
England
Birmingham Heartlands & Solihull NHS Trust (RR1)
RR1 20010/11
Weekday = 3.5%
Weekend = 3.9%
RR1 2006/07
Weekday = 4.5%
Weekend = 5.4%
+20%
+14%
England 2006/07
Weekday = 4.5%
Weekend = 4.8%
+6%
England 2006/07
Weekday = 3.7%
Weekend = 4.0%
+10%
Example
2010/11

14. So is there scope to improve weekend discharge rates? Looking at
cancer patients as an example it seems very few are discharged at the
weekend at present
Length of stay for cancer patients - Emergency admission
0
500
1000
1500
2000
2500
3000
3500
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
FRI
SAT
SUN
MON
TUE
WED
THURS
Days from admission
Numberofdischarges
Monday
Wednesday
Saturday
Monday - dead
Wednesday - Dead
Saturday - Dead
Saturday
Monday
Wednesday
Admitted Monday, Wednesday & Saturday offset to show day of the week pattern
DH analysis of HES data 2010/11 cancer emergency admissions
But to release the cash to
reinvest
hospital capacity would
have
to reduce at the weekend
typically by 20 – 30 beds
Irrespective of when the patient is
admitted few
are discharged at the weekend

15. This approach re-balances the weekend hospital by increasing senior-
led decision making capacity which in turn reduces the demand for
patients staying in hospital unnecessarily, reducing LoS and
improving outcomes
Treatment
and
procedures
Nursing
led
care
Evidence
based
decisions
Reducing the demand
Cash released

16. Summary
• From the inception of the NHS, hospitals have been intended to be medical
consultative centres rather than hostels providing treatment[1].
Current hospital weekend working patterns tend to reflect the latter rather than
the former.
• The year-on-year improvements seen in outcomes seem to lag for weekend
admissions by 1 to 2 years.
• With targeted interventions and good HR practices the difference between
weekend and weekday service can be reduced showing overall cost benefit.
• It is also possible that by keeping the discharge rate close to the weekday rate
at the weekend levelling up the weekend service could be cost saving, however
this will require a more rigorous use of weekday only and seven day bed
capacity.
•[1] Chief Medical Officer, Ministry of Health, 31st March 1948