Every day counts

NHS
Improving Quality

NHS Improving Quality in collaboration with NHS England

NHS services - open seven
days a week: every day counts

NHS services - open seven days a week: every day counts

Contents
Patient foreword

4

Foreword by Sir Bruce Keogh

5

Introduction

6

Patients and the public want the NHS to change

7

NHS services, open seven days a week

9

What to do before moving to seven day services

10

Patients and the public - get them involved

28

Apply a systematic improvement approach

30

Capture and measure the benefits

33

The importance of leadership and teamwork at all levels

35

Summary

45

References

46

Acknowledgements

47

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“This jewel, this precious,
marvellous NHS”
It would be useful if our traumas and crises limited themselves to office
hours. Life would be simpler and safer if we only suffered strokes or
multiple traumas, if we only found lumps or pee’d bloody urine, or if we
only had heart attacks, mental health crises and babies from Monday
9am to Friday 5pm. But our illnesses and conditions don’t limit
themselves to office hours. So why does the NHS?
And the thing that keeps coming up is that if we were starting this thing
from scratch – this jewel, this precious, marvellous NHS – we wouldn’t
design a part-time system.
Clearly, the four and a half day system creates inconvenience we have
become used to - taking time off work to see a GP or consultant, or to
accompany a relative or neighbour; hospitals spending half of Monday
‘warming up’ systems and machines, and dealing with the backlogs and
crises that built over the weekend.
But it creates distress too. What are we to do out of hours? With a lump, a failed insulin pump, a
teenager self-harming?
And everyone ‘knows’ that if you’re in hospital over the weekend everything goes quiet - tests can’t
be authorised because there aren’t any consultants, they can’t be carried out because the machines
are turned off, or the labs aren’t staffed; nothing is signed off, and you can’t be discharged because
no-one can contact GPs, District Nurses or social care agencies. And that’s before we get into the
‘poor experience’ of feeling neglected or unsafe because of low staffing and the absence of
experienced staff.
But much worse, much more frightening, is the increasingly compelling evidence that five-day
working costs lives. That your chances of dying are increased significantly because of the simple fact
that you arrived there on a Saturday (an 11% increased risk of dying) or, even worse, on a Sunday (a
16% increased risk).
And measuring the dead is only one aspect. What of the many who’ve survived but who’ve had
worse outcomes than if they had been admitted on a weekday - delayed diagnoses and treatment,
more complications, longer stays and more re-admissions?
So, what to do?
We need to find a way of doing something sensible and obvious, but fantastically difficult. This begs
two questions:
Question 1: How can we take on the extraordinary challenge of integrating services into a
seamless, consistent, high-quality seven-day service?
Question 2: Actually, how can we not?

Fiona Carey, Cancer patient and patient representative

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Foreword by Sir Bruce Keogh
It is nearly two years since NHS Improvement published a collection of
case studies in Equality for All: delivering safe care seven days a week,
to illustrate how seven day services were being designed and delivered
in the NHS.
We now know that across the country, more hospitals, primary and
community care organisations and social care services are working
together to face this challenge and address the link between poorer
outcomes for patients and the reduced level of service provision at the
weekend. We also know that patients and the public want us to act
now to make seven day services a reality in all part of our NHS.
Earlier this year, I established the NHS Services, Seven Days a Week
Forum to give all NHS commissioners the insight and evidence they
need to move the NHS towards routine services being available seven
days a week. The findings from the first stage of the Forum’s review, which has focused on urgent
and emergency care services, will be published by the end of the year.
That is just the start, and the scope of the Forum’s review will quickly widen to include consideration
of a fully integrated service delivering high quality treatment and care seven days a week. This
important publication from NHS Improving Quality includes case studies providing practical examples
of where organisations and teams have already started to implement this type of change to the
delivery of their services.
Working across the whole of the health and care system to find solutions that are both clinically and
financially sustainable will require innovation, commitment and collaboration. I hope that the
experiences of the organisations and teams featured in this publication will be useful to all
organisations as they seek to change services to give patients the treatment and care they need
seven days a week.

Professor Sir Bruce Keogh
NHS Medical Director

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Introduction
The delivery of seven day services across England
is a priority for NHS England and the NHS
Improving Quality (NHS IQ) partnership.
NHS IQ is supporting this priority through the
development of a three to five year, Seven Day
Services Improvement Programme aimed at
ensuring equity in care for patients regardless of
the day of the week, through supporting the
spread of new models of seven day services
across the NHS at scale and pace.

Building on the case studies which were
presented in Equality for All: Delivering safe care
- seven days a week1, this publication provides
further evidence of what can be achieved by
sharing the learning that is emerging from
across the NHS.

This will be a key improvement for the 21st
century, and the NHS could potentially lead
the world in its ambition to provide equality of
access to high quality and safe healthcare seven
days a week.

1

NHS Improvement (2012) Equality for All: Delivering safe care - seven days a
week available at: www.nhsiq.nhs.uk/resourcesearch/publications/nhs-imp-seven-days.aspx

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Patients and the public want
the NHS to change
There is a compelling case for healthcare services
to be accessible seven days a week, to avoid
compromising patient care, safety and patient
experience.
Growing media coverage2 and evidence has
highlighted how the lack of continuity of care over
the weekend period can have significant
consequences for patients, carers and their
families3.

‘‘

I was lucky, but
shouldn’t every one of
us have the best
chance possible, no
matter what time of
day or day of the
week it is?
Patient representative

• Reduced service provision throughout
hospitals, including fewer consultants
working at weekends, is associated with
higher weekend mortality rates5
• Patients do not always experience equity in
access to the optimum treatment or
diagnostic test. This can result in delays to
their treatment that can contribute to less
favourable clinical outcomes4
• Emergency admissions activity at weekends is
around a quarter lower than the rest of
the week.3
• Significant variations exist in patient outcomes
and service arrangements, both between
hospitals and also within hospitals depending
on whether the patient is admitted on a
weekday or weekend.3

’’

View full story at
www.nhsiq.nhs.uk/improvement-programmes/
acute-care/seven-day-services.aspx

2

www.guardian.co.uk/society/2013/may/28/death-risk-higher-nhs-fridays
Sunday Times Article, Sunday, 14 July 2013
3
Dr Foster Intelligence. Inside your hospital. Dr Foster hospital guide 2011–2011.
4
Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shanian D, Roche WR, Stephens I, Keogh B, Pegano D (2012):
Weekend hospitalization and additional risk of death: An analysis of inpatient data J R Soc Med 2012 Feb;105(2):74-84
5
NHS England (2013) The evidence base from the urgent and emergency care review Available at:
www.england.nhs.uk/wp-content/uploads/2013/06/urg-emerg-care-ev-bse.pdf

www.nhsiq.nhs.uk

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‘‘

Seven day care is about
having a service that
gives me care, any day
of the week, that meets
my needs to maximise
my recovery and wellbeing whilst keeping me
safe.
Patient

’’

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Across England, services across hospitals,
community and social care have started to
implement changes and have demonstrated the
benefits for patients and carers. Many
organisations are empowering staff to make
improvements and drive forward seven day
services.
Case studies demonstrating these improvements
are available at:
www.nhsiq.nhs.uk/everydaycounts7ds


NHS services, open
seven days a week
Seven day service provision is about equitable
access, care and treatment, regardless of the day
of the week. The level of service provided should
ensure that the patient has a seamless pathway of
care when accessing services no matter what day
of the week.
Assessing the access to the different range of levels
of provision seven days a week is a key starting
point (Figure 1).
Figure 1. Levels of service provision*
Level 0 – Five days a week e.g. Monday to Friday, 9am - 5pm, 8am – 4.pm (routine eight
hours service)
Level 1 – Monday to Friday at departmental level, extended hours e.g. 8am – 8pm
Services limited to one department or a service that is beginning to deliver some services beyond
8am - 6pm Monday to Friday services. This could be extended working days and some weekend
services however, does not deliver equitable services irrespective of the day of the week.
Level 2 – Services are delivered seven days a week, but limited range of services on a
Saturday and Sunday
Services that are delivered seven days per week, but not always offering the full range of services
that are delivered on week days. This limited range of services goes beyond “on call” and
emergencies only and facilitates some clinical decision making and discharge, though is likely to be
one service and not integrated with other service delivery, (e.g. pharmacy services offering a limited
range of services with several staff available, radiology offering weekend lists for inpatients).
Level 3 – Services offered seven days a week with several departments working together to
provide services across the organisation
A whole service approach to seven day service delivery that requires several elements to work
together in order to facilitate clinical decision making or treatment, often covering more than one
workforce group (e.g. stroke services integrating acute stroke clinicians, imaging, specialist nurses,
TIA clinics, thrombolysis).
Level 4 – An integrated seven day service across the organisation
A whole system approach to seven day service delivery by integrating the requirements for elements
of seven day services across more than one speciality area (e.g. across several departments and
services within an acute trust, integration of several services across health and social care to reduce
admission to the acute sector).

*The levels of service are levels of provision and should not be interpreted as levels of progression.
Some services may only need to be provided at agreed levels e.g. Level 1.

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What to do before moving to
seven day services
Top tips
Assess where you are, using the seven
day service self-assessment toolkit.
www.nhsiq.nhs.uk/7ds-toolkit
Plan what service(s) you need to deliver
over seven days
Focus on the bigger picture and
understand what seven day services
involve
Involve other departments,
organisations; get to know the key
people and improve your
communication, engagement and
integration – work as a team
Engage patients and the public early in
the process – find out what they want
and expect
Understand your local needs, test
assumptions, identify drivers and
enablers for change and test
new ideas
Apply a systematic improvement
approach and capture the benefits and
learning to help engage others
Listen, learn and share
Focus on what you can do and have
courage, remember this is about a
better clinical service and access for
patients

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Every organisation and community will have a
different starting point for developing seven day
services, dependent on an understanding of local
needs across their health and care economy.
As shown by the case studies in this publication, a
number of NHS organisations have developed
seven day services in response to a range of service
requirements.


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Model of provision

Improving the patient
experience

Organisations

Single point of access for mental
health patients in crisis, 24/7,
365 days

Reducing delays in
access to services

Northumberland Tyne and Wear NHS
Foundation Trust

Integrated approach across
health and social care, providing
care closer to home for frail and
older patients

Improving the patient
experience

Aneurin Bevan Health Board, Blaenau
Gwent County Borough Council,
Caerphilly County Borough Council,
Monmouthshire County Council,
Newport City Council and Torfaen
County Borough Council

Access to imaging and
reporting seven days a week

Reducing delays in
treatment and
improving bed usage
at weekends

Salisbury NHS Foundation Trust
Royal Liverpool & Broadgreen
University Hospitals NHS Trust
University Hospitals Leicester NHS Trust
Royal Free London NHS Foundation Trust
Papworth NHS Foundation Trust

Access to consultant outpatient
clinic and diagnostic services
seven days a week

Preventing admissions
to hospital

University Hospitals of Leicester NHS
Trust

Telemedicine provides 24/7
thrombolysis for stroke patients
in remote and rural areas

Improving access to
treatment

Lancashire and Cumbria Heart and
Stroke Network

Clinical decision making and
treatment of acute stroke

Reducing delays in
diagnostics, treatment
and rehabilitation

University Hospital of North
Staffordshire NHS Trust

Nurse led triage, assessment and
treatment of GP referrals to
avoid unnecessary acute
admissions

Reducing
inappropriate
admissions to hospital

Pennine Acute Hospitals NHS Trust Royal Oldham Hospital

Seven day physiotherapy service
to enhance recovery

Reducing variation in
mortality and
improving recovery
rates

South Tees Hospitals NHS Foundation
Trust - James Cook Hospital

Social care presence on acute
medical unit, seven days a week,
improves discharges from
hospital

Reducing delays in
discharge of patients
from hospital

Epsom and St Helier University
Hospitals NHS Trust, and Surrey County
Council Adult Social Care

Patients being able to die in the
place of their planned choice
when services are not available
seven days a week

Improving patient
choice

Rowcroft Hospice Devon/South Devon
Healthcare NHS Foundation Trust

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LEVEL 3
Seven day
service provision
within an
organisation

24/7 telephone service reduces delays in access to
the right service to meet service user mental health
needs and support... time to listen time to care
Northumberland Tyne and Wear NHS Foundation Trust operate a single point of access initial
assessment response team for service users with any mental health issues. This telephone service
was developed in response to an audit that demonstrated that only 35% of mental health crisis calls
required intervention, while 45% were for advice and signposting.

” The availability of a telephone referral line means that in some cases
people can avoid the anxiety of attending the accident and emergency
department - which is a huge bonus. We are all about giving the best help,
or signposting them to where they will find it.”
Service Manager

• Single point of access to a telephone help line enables triage of patients to the most appropriate service,
24 hours a day, seven days a week
• Direct GP referral and self-referral option for patients, as well as their carers, friends or family being able
to refer them too, with the client’s knowledge
• Rapid response (within one hour) home visit for face to face triage, risk/mental health monitoring,
signposting, brief therapeutic interventions, managing distress
• Multidisciplinary team clinical involvement supported by remote information technology
• Medication access to out of hours GP service to manage presenting symptoms, or signpost to service
users own GP
This service now enables all patients to have timely access to professionals within one hour and access to
the appropriate service. 100% of patients and families surveyed reported that they felt more confident in
the system and better supported. 100% of GPs surveyed reported that their calls were responded to
quickly (average response of nine seconds) and satisfied that their needs were met.

Spreading an older people mental health intermediate support model across Lancashire
Lancashire Intermediate Support Team (IST) provides a rapid response service to older people
with mental health needs for up to eight weeks in the own home or usual place of residence. This
model has been rolled out across Lancashire. There are three teams operating 12 hours a day, seven
days a week. The team has been successful in averting hospital admissions and reducing lengths of
stay. Of those people seen by the team, 94% were discharged sooner and none were readmitted
within 28 days.
Also see how mental health intermediate care teams in Nottinghamshire have prevented hospital
admissions and released 45 acute mental health beds – see page 39 for further details.

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LEVEL 4
Seven day services
integrated across
several departments
/organisations

Providing care closer to home
for frail and older people
The Pan Gwent Frailty Programme is a seven day integrated health and social care support
model for vulnerable elderly people, people with long term conditions and individuals with
health and social care or housing needs. The emphasis is on preventing unnecessary hospital
admissions, discharging patients from hospital at the earliest opportunity and providing care in the
community, wherever clinically appropriate.
There is also a protocol in place with Wales Ambulance Service, meaning that paramedics can refer
patients to the Pan Gwent frailty community service as an alternative to Accident and Emergency.
Achievements include:
• User and carer feedback has been overwhelmingly positive due to a focus on enabling frail people
to remain independent and having their needs considered holistically, rather than on a condition
led basis.
• Fall in readmission rates for chronic conditions to 13% (compared with average 15% across the
rest of Wales)
• Reduced A&E presentations
• Improved pathway for paramedics managing falls, freeing up time and availability to respond to
other calls.

Redesigning acute care for older people seven days a week – so
who said that seven day services are more expensive
At Sheffield Teaching Hospitals NHS Foundation Trust, seven day
service provision was a key solution in helping to improve patient flow of
frail and older people through the emergency care pathway. Bed occupancy
for emergency care for older patients has now reduced by more than 60
beds - see page 34 for further details.

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Improving access to diagnostics seven days a
week - reduces delays in treatment and
facilitates earlier discharge
LEVEL 2
Seven day services,
limited provision
on a Saturday
and Sunday

At Salisbury University Hospital the implementation of a seven day imaging
service has allowed requests to be dealt with in a timely manner, improving
reporting turnaround and making advice from radiologists more readily
available. Outsourcing of overnight Computer Tomography (CT) has enabled
extended working days and weekend working to meet the increasing demands for
imaging. Staff work a 12 hour day time shifts seven days a week.

Service changes include provision of on-site radiologists at weekends (9.30am to 12.30pm) and every
week day evening until 8pm to provide:
• Advice and reporting for emergency and inpatient examinations
• Plain film reporting for emergency and inpatient admissions as well as for GPs
• Dedicated MRI appointments for patients suspected of suffering transient ischaemic attacks
• Urgent CT scans are undertaken at weekends by the MRI radiographers, who are all trained in both
imaging modalities
• Visiting CT/MRI mobile van services are used to address capacity shortfalls
• On call systems - radiologists have protected rest periods
• Urgent ultrasound scans are available at weekends.
Service changes have led to the ability to provide stroke inpatient and outpatient services seven days a
week, as well as improving timely diagnosis, treatment and discharge as a result of improved
reporting turnarounds. CT reporting within one working day has improved from 60 to 90%, as well
as sustained improvements in plain radiology and MRI reporting of greater than 70%.

Interventional Radiology 24/7 services provision
A baseline survey of acute trusts (NHS Improvement, 2011/12), identified variation in IR service
provision across England. Interventional radiology departments were asked to self-assess their
service provision based on whether a formal on-call consultant rota and agreed formal
pathway of care were in place. Improvement work resulted in an increase in the extent of
24/7 provision across England. Maps demonstrating variation in formal 24/7 rota service
provision and case studies of how organisations have overcome challenges in service delivery
can be found in “Towards best practice in Interventional Radiology’ NHS Improvement (June
2012) available at www.nhsiq.nhs.uk/8796.aspx

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At Royal Liverpool and Broadgreen
University Hospitals NHS Trust, the
Seven day
service provision
endoscopy service is delivered seven
within an
days a week in response to
organisation
increasing elective and emergency
demand. The Trust operates a week
day 12 hour service (three sessions per day), scheduled
single sessions at weekends used solely for in-patients to
facilitate discharge and an on call 24/7 rota for
gastroenterology emergency endoscopy service.
LEVEL 3

• Waiting times for outpatient endoscopy has improved
from in excess of 13 weeks to five weeks
• Patients now have a greater choice of appointments
when seen as an outpatient
• Reduction in the number of endoscopies undertaken
by the on call staff during the week and weekends

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Productive Endoscopy
The 'Productive Endoscopy Series'
is a set of self-directed learning
resources that will help all staff
working in endoscopy units to
make better use of existing
resources, and deliver a more
efficient and effective service to
patients seven days a week. For
further information visit
www.nhsiq.nhs.uk/7923.aspx


LEVEL 2
Seven day services,
limited provision
on a Saturday
and Sunday

24/7 access to endoscopy specialists for patients
suffering from suspected gastric bleeding
University Hospitals Leicester NHS Trust developed a comprehensive out of hours endoscopy
service, seven days a week, for patients requiring an endoscopy for suspected upper
gastrointestinal bleeding.
•
•
•
•
•
•

Service provided 24/7
Gastroenterologist supernumerary from the medical on call rota
In reach out of hours on call service – 12 hours a day one consultant and two senior nurses
Shared reporting across three hospital sites
Endoscopists provide a one in ten consultant on call service
Average intervention rate of 17% for variceal bleeding and adrenaline injections

This service was developed in response to an untoward incident and an audit to define the workload
of an out of hours service. The indication, timing, findings, intervention and outcome of procedures
were audited from 2006:
• 83% of procedures were for gastroscopy
• 63% of the gastroscopies were performed for gastro-intestinal indications
• Over the five years out of hours endoscopies had increased where no pathology was found with
over 90% being returned to their base ward.
A likely contributory factor reported was that the increased shortage in medical beds had led to more
routine work being undertaken out of hours to expedite discharges.
These improvements also lead to improvements in the elective inpatient services which now operate
at weekends. An on-site service operates 9am to 1pm which has enabled earlier clinical decision
making and improved discharges at weekends and reductions in delays.

24/7 Endoscopy specialist service provision
A recent survey by NHS Improving Quality and
The British Society of Gastroenterology identified
current weekend provision as being variable
across the 152 endoscopy units, with some, but
not all, providing seven day services.
More case studies are available at:
www.nhsiq.nhs.uk/7923.aspx

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LEVEL 2
Seven day services,
limited provision
on a Saturday
and Sunday

At the Royal Free London NHS Foundation Trust a 24 hour seven days a
week microbiology service has been developed in response to managing
demand. Historically, staffing issues led to between 100 -150 samples being
discarded after the weekend because they were too old to process. Repeating the
sample could involve time tracing the patient or contacting the GP and a delay in the
patient’s diagnosis and treatment.

A new three shift system of working was developed which included changing staff roles, retraining of
staff and appointment of more associate practitioners to enable a more flexible pool of staff that
could work across all areas of the service. Despite rising activity this has been managed within the
same budget and sustained.
• Blood cultures are now processed more quickly and doctors are able to make treatment decisions
earlier. More effective MRSA screening services (three hours molecular and 24 hour culture) has
helped to achieve more effective treatment planning and bed management
• A new system for histology bronchial samples is currently being tested. In theory, pneumocystis
pneumonia (PCP) results could be confirmed in 1.5 days compared to five days for a histology
result; therefore treatment can commence or be stopped sooner, giving a better patient experience
and outcome as well as financial efficiencies

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At Papworth Hospital NHS Foundation Trust cardiac physiologists now work
12 hours shifts seven days a week, as well as an on call night rota, to provide
Seven day services,
limited provision
a Primary Percutaneous Coronary Intervention (PPCI)/ Heart Attack service
on a Saturday
seven days a week. This was in response to increased service emergency and
and Sunday
elective demand for service. As a result all patients admitted to hospital on a Friday
can be investigated and treated over the weekend and discharged earlier from
hospital, rather than waiting until the Monday.
LEVEL 2

This model of service provision is now being considered for the cardiac physiologist rota for
echocardiogram outpatient services.
The British Cardiovascular Society, in conjunction with other specialist bodies and with NHS IQ, is
currently working on a report commissioned by the Chief Scientific Officer and the NCD for
cardiovascular disease, to make recommendations on sustainable and affordable models of cardiac
physiology scientific services to meet future demands including seven day service provision.

Physiological sciences 24/7 service provision
There is significant variation in the provision and access to many physiology diagnostics and
services across the eight clinical specialties. The provision of services outside of the traditional
working week is very limited, most models of seven day service provision are predominantly to
provide ‘out of hours’, and Saturday and Sunday cover via an ‘on call’ service, rather than a shift
based model to provide full seven day provision. Ongoing work with NHS IQ will involve further
scoping of some of the issues in priority areas
.
Cardiac physiological diagnostics are fundamental to emergency and acute care and to
delivering improved cardiovascular outcomes. There is already, for example, on call cardiac
physiology support for catheter laboratories and for primary cardiac angioplasty and other
emergency interventions. However, for other tests such as echocardiography there is limited
provision outside of the traditional working week. From the recent Healthcare Scientific survey
92.3% of respondents, in 40 Cardiac Physiology Departments, believe there should be
delivering services seven days a week however, there was minimal evidence of ‘whole
department’ cardiac physiology service provision.

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LEVEL 3
Seven day
service provision
within an
organisation

Access to rapid access ‘onestop’ outpatient
services seven days a week prevents admission
to hospital
At University Hospitals of Leicester NHS Trust, a consultant led seven day rapid access onestop Transient Ischaemic Attack (TIA) outpatient service enables patients to be assessed and
receive appropriate investigations, diagnosis and treatment seven days a week.
• Consultant led clinic, 8am to 6pm, seven days a week
• GP referrals are made by fax or direct phone call to the clinic with appointments issued immediately
if the patient is still with the referrer
• Clinic staffed with clinical aid and clinic clerk
• Diagnostics performed in clinic - vascular technicians provide carotid doppler ultrasound,
radiographers provide MR on weekdays or CT weekends
• Any medication prescribed immediately
• Lifestyle adaptation counselling given
• Patient given GP letter outlining diagnosis and treatment, printed and faxed immediately to the GP
Prior to this, patients were only seen Monday to Friday and often admitted to hospital if at high risk.
As a result, the percentage of Transient Ischaemic Attack (TIA) cases with a higher risk of stroke who
are treated within 24 hours has increased from 13% in 2010/11 compared to 74% in 2012/13, across
two CCGs. Nurses, healthcare assistants, clinic aides and vascular technicians are all integral to the
delivery of the seven day specialist service.

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LEVEL 3
Seven day
service provision
within an
organisation

Telemedicine enables 24/7 physician assessment,
diagnostic, treatment and management of
patients across remote and rural areas
The Lancashire and Cumbria Stroke Network has enabled six acute Trusts to deliver 24/7
thrombolysis for patients suffering a stroke in a rural area. Telemedicine takes the physician to
the patient rather than moving the patient to the physician.
Telemedicine enables:
• Access to a stroke specialist 24/7 to assess the patient
• Stroke physicians review the CT head images
• Physician confirms the diagnosis, assesses the severity of the stroke, and excludes a haemorrhage
on the CT head scan.
Development of the system involved:
• Partnership working and collaboration. It crosses multiple organisations, NHS Acute Trusts, PCTs
and private companies (Virgin Media, Imerja Ltd, Multisense Communications)
• Co-operation from multiple departments, disciplines and individuals within those organisations
• Cross boundary working for all the stroke physicians on the rota
• Radiology clinical leads and imaging managers had to implement next slot CT scans for patients
in-hours and within 60 minutes out of hours
• Training radiographers to perform the scans, some sites to develop 24 hour working patterns
deployed the IT infrastructure to 16 homes and eight acute sites
• Development of an Acute Stroke CT Training and Assessment (ASTRACAT) programme for the
timely interpretation and assessment of stroke patients by the Stroke Physicians, therefore reducing
the necessity of involving the on call radiologist at local sites and streamlining the stroke pathway.

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LEVEL 4
Seven day services
integrated across
several departments
/organisations

Clinical decision making and treatment
of acute stroke – reducing delays in diagnostics,
treatment and rehabilitation
University Hospital of North Staffordshire NHS Trust has improved access to the stroke
team, diagnostics, treatment and rehabilitation for all patients with a stroke by developing
integrated working across the whole health economy seven days a week.
Services provided:
• Provision of thrombolysis for acute stroke 24/7
• Stroke Early Assessment multi-professional Team (SEAT), which operates 14 hours a day seven days
a week, to identify patients in A&E and ensure faster access diagnostic test and management on
the stroke unit
• Early supported discharge teams now work 12 hour shifts, seven days a week, to facilitate
discharge and ensure that appropriate care packages are in place to support people at home
• One budget with one manager, which has enabled teams to work together to remodel the
workforce to meet patient needs
• More effective rehabilitation goal setting has been achieved by nursing and therapy teams working
together more effectively.
Achievements include:
• Seventy five percent of patients now return to their normal place of residence
• Reduction in average length of stay on the acute stroke ward from 15 days in 2007/08 to 5 days
in 2012/13
• Savings released through reduced length of stay and reduction in care packages have been
reinvested into the service for medical and staffing infrastructure costs.

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LEVEL 2
Seven day services,
limited provision
on a Saturday
and Sunday

Nurse led triage, assessment and treatment of GP
referrals to avoid unnecessary emergency/acute
admissions
Responding to the rising number of inappropriate admissions, Pennine Acute Hospitals NHS
Trust has developed an Advanced Nurse Practitioner (ANP) role to take all referral calls from
General Practitioners (GPs). The ANP can provide advice, accept the patient into the Ambulatory
Care Unit for investigations or admit the patient to an alternative service. GPs also have access via a
hotline directly to the acute physician for advice.
•
•
•
•
•
•

The ANP triage model operates 12 hours a day, seven days a week
Reduction in the number of inappropriate admissions to Assessment Medical Unit
Reduced attendance at A&E
Virtual ward process for patients discharged
Reduction in waiting times to see doctor
69% (308 of 449) of patients seen in the Ambulatory Assessment Unit were discharged

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LEVEL 3
Seven day
service provision
within an
organisation

Seven day physiotherapy service to
enhance recovery
Physiotherapy teams at South Tees Hospitals NHS Foundation Trust have implemented
seven day physiotherapy services, across all surgical specialties, as an integral component of
Enhanced Recovery (ER) Pathways. Patients now receive an equitable service seven days a week
which enables patients to get better sooner.
• Physiotherapy assistant practitioner posts (band 4) work seven days a week to support rehabilitation
for all elective surgical patients
• A twilight physiotherapy service for intensive care and high dependency care to meet peaks in
clinical demand
• Seven day Rapid Response community services, incorporating physiotherapy seven days a week as
part of a multidisciplinary team to facilitate discharge.
As a result:
• Patients have earlier access to goal directed mobilisation and discharge sooner
• Average length of inpatient stay has reduced – reduction from 10.6 to 8.3 days for those patient
operate on a Friday compared to other week days
• Cardiac thoracic surgery - 426 bed days have been released which has reduce waiting times for
elective surgery
• Qualified physiotherapists have been freed up to focus on patients with more complex needs.
• Patients surveyed identified improvement patient preparation for surgery, 88% of patients surveyed
understanding their mobility goals and reporting high level of satisfaction with service.

Enhanced Recovery Care Pathways
Enhanced Recovery6 is a quality pathway with identified steps where marginal gains can be
made to improve patient experience and outcomes. The starting point is the five P's:
•
•
•
•
•

Primary care ‘fitness for referral’ for common conditions e.g. anaemia – managing the risk
Patient involvement: Shared decision making
Prehabilitation, assessment and care planning
Pain relief, fluid management, anaesthetics
Preparation for and effective discharge

The principles of ER as a good quality pathway are being extended into emergency care,
maternity care, and acute medicine. The future challenge is to ensure all patients get the same
standards of care seven days a week.
For further information: www.nhsiq.nhs.uk/enhancedrecovery

6

NHS Improving Quality (2013) Enhanced Recovery Care Pathway, A better journey for patients seven
days a week and a better deal for the NHS - Progress Review (2012/13) and level of ambition 2014/15.

www.nhsiq.nhs.uk/resource-search/publications/nhs-imp-seven-days.aspx
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LEVEL 3
Seven day
service provision
within an
organisation

Social care on acute medical unit, seven days a
week, improves discharges from hospital
Epsom and St Helier University Hospitals NHS Trust has a 56 bedded acute medical unit
across two wards with 16 assessment beds, and 40 short stay beds designed for patient
hospital stays of up to 72 hours. The unit is staffed by a multidisciplinary team that consists of
acute physicians, social care practitioners, physiotherapists and occupational therapists. The social
care team has been co-located within the assessment unit and take a lead role in daily meetings to
facilitate discharge
• The social care team lead the daily multidisciplinary team seven days a week to manage the
discharge process from the point of admission to hospital
• Daily meeting of senior members of the team meet together at a ‘noon huddle’ and discuss
the progress of patients on the assessment unit
• Average length of stay for patients discharged from acute medical unit has been reduced from
15 to 2 days
• Social care have an ‘open door policy’, staff no longer have to process lengthy referral forms to
social care, patients are seen within the day of referral – this has enabled a more person focused
care delivery
• This model of seven day social care service is now working across Surrey County with four
hospitals since November 2012

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LEVEL 3
Seven day
service provision
within an
organisation

Patients at end of life have a dignified death at
home supported by a 24/7 Hospice at Home
service
”It

was invaluable when you called day or night, there was a
voice at the end of the phone and someone with you as soon
as possible”

Carer in Torbay

The South Devon Hospital at Home service established by Rowcroft Hospital provides 24/7
service to support patients and their families where there is a sudden deterioration and the
patient is too unwell to move from their home. 400 patients are seen per year, this has
doubled since original service provision.
69% of referrers said that the service had reduced admissions to hospital. 84% of patients died at
home in their preferred place of care and 7% were cared at home until they could be transferred to
their desired place of care. Added to this, informal carers have increased confidence in their caring
role and there has been improved quality of life, as well as the promotion of dignity and self-worth
for patients.
www.rowcrofthospice.org.uk/hospiceathomeservice

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27


Patients and the public get them involved
Top tips
Make the links with your local
HealthWatch, patient forums and
patient groups and ask for their advice
Review patient complaints, incidents
and consider the root causes
Process map the patient journey over
seven days, find the waits, delays and
good practice (look at your last ten
patients as a starter)
Keep the service patient focused,
centred and value patients’ time
Use compelling patient and public
stories to evidence the need for change
and to engage others
Engage with patients and the public
continuously involve them in the
redesign of services
Patients play a key role in their own
care seven days a week – listen to their
ideas
The benefits of seven day services
affects everyone’s contribution to
society
Remember seven day services are
required by all patients - both elective
and emergency

Patients bring a unique perspective to developing
new ideas and ways of working. Involving them in
the beginning, along with carers and the public,
can provide a rich picture of what health and care is
really like. Their input is crucial to ensure that the
best possible solutions are reached to meet needs,
expectations and preferences.

‘‘

We needed the whole
system on board and
we consulted early and
created a culture of
incremental steps that
create momentum, it
was a gradual process…
.we kept talking to
people.

’’

Medical Director
Northumbria NHS Foundation Trust

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Foundation Trust Members and Governors identify need, inform design and proposals for
seven day services
Birmingham Community Healthcare NHS Trust has used its 15,000 strong membership group
to engage local people in service development and redesign proposals.
All service improvement plans are sent to members and the Trust asks for volunteers who may have a
particular interest in a certain aspect of service to join a service design forum, so that they can be
involved and can contribute their ideas, views and feedback.

Large scale, formal public consultation exercises
Northumbria Healthcare NHS Foundation Trust underwent a major redesign programme to
achieve a consultant led service across 10 inpatient and 20 outpatient sites. To support these
changes, the Trust first led a major consultation programme to hear the views of patients, the public
and staff. The consultation, which ran for a year, covered an 89 mile radius, and relied on a number
of methods to gain wide and far reaching views:
•
•
•
•
•

60 community based meetings were held
Flyers were sent to all households, outlining the proposed changes
Consultation with local MPs, GPs and ambulance services
Regular staff engagement forums
Mechanisms to capture regular public and patient feedback.

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Apply a systematic
improvement approach
Top tips
Use a systematic improvement
approach
Define and articulate what your vision
and ambition is for seven days services
Collect baseline information to identify
the need for seven day services
Draw on a range of perspectives patients, clinical, non-clinical,
managerial and look at the interdependences, including finance,
workforce, human resources and
public services
Process map and really understand
your current service – look at access,
sequencing of steps, benefits and
impact, capacity and demand
Develop a common shared purpose
of meaning and goals
Identify your champions and leaders
Test out your ideas and models of seven
day services care and evaluate the
benefits and look out for any
unintended consequences
Continuously capture and measure
the benefits
Take a whole systems approach – avoid
silos, remember you want to spread
good practice

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A trust wide strategic approach to develop
seven day services
At the Heart of England NHS Foundation Trust, following the inception of seven day
services across therapy staff and acute care physicians, there is now a Trust wide seven day
services strategy in place, which aims to achieve equality of outcomes and of standards of
care throughout the week. The project team responsible for delivering the strategy includes clinical
and operational leads from all departments within each directorate, and is accountable to a
programme board.
The Trust’s starting point was to build capacity before next winter to give more resilience to safely
cope with any surge in emergency activity. Each directorate has performed a gap analysis of provision
of seven day services, and has put in place plans to move towards seven day services, which are
overseen and monitored by the Trust board.
Data dashboards have been developed to monitor improvement metrics, these include:
•
•
•
•

Mortality rates
Length of stay
Readmission rates
Number of discharges.

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LEVEL 4 *
Seven day services
integrated across
several departments
/organisations

Applying a systematic improvement approach
to services required over seven days
Health and social care agencies in Bristol** worked together in partnership to launch a ‘do
and learn’ project in and around the emergency department and medical wards at Bristol’s
central hospital, the Bristol Royal Infirmary. A ‘seven day action team’ was formed with clinicians,
managers and commissioners from both the hospital and community health and social care providers
to systematically review and test what services would be needed over seven days to help ensure
‘equal care every day’.
• Performed a ‘Friday and Saturday fact finding audit’
• 454 patients across 19 wards in the Bristol Royal Infirmary were audited on a Friday afternoon to
assess what services (within and outside of the hospital) would have enabled their care to be
progressed over the weekend
• A ‘front door’ audit within the Emergency Department (ED) on Saturday morning, to identify what
additional services could have helped prevent hospital admissions
Gaps in service provision were identified which formed a plan for action. Over three weekends the
team ran ‘Plan-Do-Study-Act’ (PDSA) cycles, each of which was planned a month apart, to test out
some changes and interventions such as, having a senior nurse visit medical wards to identify patients
suitable for discharge and having GPs working within Accident and Emergency. The week after each
cycle, patients were ‘tracked’ to see what impact the changes had made and the team either revised
or re-tested those changes during the next weekend PDSA cycle.
Having taken a detailed look at the whole system this has enabled the Trust and community providers
to really understand what services need to be in place over seven days, to ensure positive and
consistent patient experience and improved patient flow across the week. Testing out changes in a
systematic way has also provided evidence of impact, helping build the case for change going
forward. For the teams involved, starting small helped them to see what is possible, and generated
enthusiasm to change.

*Working towards level 4 as there has been an integrated approach to testing work undertaken to date.
**This included: Bristol Community Health, Bristol Clinical Commissioning Group, University Hospitals Bristol
NHS Foundation Trust, Bristol City Council, South West Commissioning Support Unit, Bristol Intermediate Care
Service, and Bristol, North Somerset and South Gloucestershire Urgent Care Board.’

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Capture and measure the benefits
Top tips
Keep metrics simple - measurement is
not always easy
Identifying the impact will depend on
your starting position
Metrics can include:
• Patient expectations
• Clinical standards
• Value for money
• Patient outcomes
• Continuity of care
• Support for junior doctors
• Wider social and economic impact
• Measurement of improvement
• Patient experience
• Mortality rates
• Length of stay
• Readmissions
• Admission avoidance
• Incidents
• Complaints
• Response times
• Discharge times
• Activity levels
• Audits against local standards
• Workforce satisfaction.

‘‘

We have saved 50
unnecessary nil by
mouth days as our
patients now start to
eat and drink more
quickly and don’t have
to wait till Monday
before a speech and
language therapist
would come into the
hospital.

’’

Speech and language therapist

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LEVEL 3
Seven day
service provision
within an
organisation

Redesigning acute care for older people seven
days a week – so who said that seven day
services are more expensive?
At Sheffield Teaching Hospitals NHS Foundation Trust, seven day service provision was a key
solution in helping to improve patient flow of frail and older people through the emergency
care pathway.
Analysis of hospital data showed that more than a third of beds were occupied by patients over 75
years and an increasing number by patients over 90 years old. Weekly audits of the geriatric medicine
wards, using a tool developed by the nurses to measure ‘waste’ bed use, revealed that only 50% of
these patients were receiving acute specialist medical, nursing or therapy care. The other half were
waiting for discharge downstream into a range of services, primarily including intermediate health
and social care services outside the hospital.
The team identified, tested and have implemented a range of changes, designed to improve patient
flow, reduce waste and improve the quality of care. These included:
•
•
•
•
•
•
•
•

Matching specialist medical capacity to patient demand
16 Consultants agreed (in just one day) to change their job plans to seven day working
Moving from a traditional “post-take” working pattern to a responsive “on-take” system
Seeing patients in real time, on admission, identified the requirement to pool junior doctors
Developing a Frailty Unit - establish an MAU focused on frail older people
Taking initial steps to merge inpatient with some elements of outpatient care
Putting in place a multidisciplinary assessment team
Speeding up discharge - switch to a model of ‘discharge to assess’

Results have been very positive:
• A 37% increase in patients that can be discharged on the day or following day, with no increases in
the readmission rate, implying that patient outcomes have not been adversely affected by the
faster throughput
• Bed occupancy for emergency care for older patients has also reduced by more than 60 beds. This
allowed two wards to be closed
• A decrease of in-hospital mortality for geriatric medicine of around 15%. At a notional bed day cost
of around £300 per day there could be an estimated cost saving/avoidance of around £3.2m per
annum. This level of saving is largely theoretical and has yet to be realised
The new system is popular with local GPs. So who said that seven day services are more expensive?

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The importance of leadership and
teamwork at all levels
Top tips
Team working and leadership at all
levels, including clinical, managerial and
executive level, is crucial for success
Early and continuous consultation with
workforce, Human Resources and
professional groups
Strategically plan delivery across the
whole health and social care economy
Involve commissioners early in the
discussions
Work collaboratively with your other
local organisations and join up the
thinking between health and social care
There is not a one model fits all
approach
A locally owned, integrated approach is
the way to success

Leadership and team working at all levels of
a service and an organisation have been identified
as critical factors in enabling the spread and
adoption of seven day services at scale across the
health economy.

Executive leadership
Having executive sign up and leadership from all
organisations across a local health and social care
economy can build a common vision and purpose
for delivering seven day services, allowing
collaborative working at all organisational levels,
as well as joint management of risk.
The ‘Joined up Health and Social care Cabinet’ in
South Devon and Torbay gives an example of how
executives, managers and clinicians across a
number of health and social care organisations can
come together to jointly agree a vision, identify
improvement priorities for the whole system, and
work in partnership to manage and overcome any
risks to delivery.

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LEVEL 4
Seven day services
integrated across
several departments
/organisations

Joined up South Devon and Torbay Health and
Care Cabinet integrated approach to seven day
services
Building on the successes of seven day services established to date, including radiology and
reporting, hospital at night, integrated hospital and home care, intermediate care services,
acute care physician model and trauma and orthopaedic services (see Figure 1), South
Devon and Torbay have established a governance structure to help them take forward
further development of seven day services.
Chaired by the Medical Director of the acute trust, the Joined up Health and Social Care Cabinet is
made up of executives and clinicians from across all local healthcare trusts, GPs, Social Care, Health
and Wellbeing Boards, Healthwatch and public health. It enables those organisations and
representatives to jointly manage barriers and risk to delivering more effective services seven days a
week, so as to improve the quality and safety of care for patients.
The cabinet agrees priorities for service improvements by jointly identifying variations and problems in
healthcare across the whole health economy system and developing improvement plans to test.
Newsletters are produced to keep all stakeholders informed of work and how they can get involved.

Figure 1. Torbay and South Devon Journey
Torbay & South
Devon Health &
Care Trust
2005

Hospital
@ Night
2004

Radiology
Services
2000+

Integrated
Health &
Care
Zones
2007

Extended
ward
round

South Devon
Healthcare NHS
Foundation Trust
2007

Enhanced
Recovery
in surgery

T&O
service
#NOF

South Devon
& Torbay CCG

Intermediate
care services
2009

Acute
physician
model

Joinedup
Health &
Care Cabinet
20011

Hospice
@ Home

JoinedUp
Leadership

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Enhanced
recovery in
medicine

System
modelling,
mapping &
understanding

Combined ICD
2014

Weekend
working Trainee
doctors

Sunday
test of
change discharge

Norman
Lamb
Pioneer
Bid

Redesigning
the front
door

JoinedUp


Clinical leadership
Clinical leadership at all levels within organisations
is needed to support changes in clinical behaviours,
to encourage effective team working and
incentivise staff to work differently for the benefit
of the patients, and to make sure that there is
ownership for finding solutions to particular issues.
Clinical leadership is also about making sure that
patients have access to early senior clinical decision
making, so that decisions about their diagnosis and
care are made promptly, and so that there’s no
delay in their care, treatment, recovery and
discharge. Ensuring the availability of senior clinical
decision making seven days a week is key to
avoiding unnecessary admissions, making sure that
the right tests are ordered, and that patient
pathways are optimised.
Some organisations have implemented acute care
physicians in medicine to enable consultant led
inpatient ward rounds seven days a week.

‘‘

I had a simple referral
on Friday from
oncology, for blood
transfusion and
platelets. I should have
been discharged
Saturday morning. I
was still in Sunday
morning because
nobody had the
authority to decide
whether I could be
discharged.

’’

Patient experience story

Consultant led ward rounds
seven days a week
LEVEL 2
Seven day services,
limited provision
on a Saturday
and Sunday

In 2007, Heart of England NHS Foundation Trust implemented acute care
consultant led medical ward rounds seven days a week. The Trust
supported the increase of consultant staff from six to ten consultants,
which has enabled a consultant led multi-disciplinary ward round seven
days a week for all emergency admissions within 24 hours. The model,
which is also supported by therapy staff, provides an outreach service to enable
patients to return home with the required services and equipment in place.

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Team working
Team working across traditional organisation
boundaries is an essential component of
successfully delivering seven day service models. A
number of organisations have described how this
has been achieved to provide co-ordinated care for
patients across the whole system.

Doncaster integrated working – health and
social care in partnership
LEVEL 4
Seven day services
integrated across
several departments
/organisations

Doncaster Metropolitan Borough Council, Rotherham, Doncaster and South
Humber NHS Foundation Trust and Doncaster and Bassetlaw NHS Foundation
Trust, have worked together to look at how they could improve patient
outcomes and experience by improving discharge processes, preventing hospital
readmission and reducing direct admissions into long term nursing care on
discharge from hospital. Two integrated service models have been introduced.

The first of these has been redesign of the discharge pathway. All patients who are admitted are now
entered onto a computerised system (‘I –tracker’) with an estimated date of discharge set within 24
hours. Healthcare professionals, including GPs can log into the system at any time to see where a
patient is in their pathway of care, and identify reasons for any delays to their discharge. Patients who
are able to be discharged are referred into a single point of contact, enabling prompt discharge and
assessment within their own home within two hours. More complex patients are referred to an
integrated health and social care discharge team, which works across boundaries seven days a week.
The result has been a reduction in direct admissions into permanent care from hospital and a saving
of 4,176 bed days over a nine month period.
The second change that has been introduced is a multidisciplinary rapid assessment programme team,
focussed on admission avoidance within the Emergency Department and the Medical Assessment
Unit, with acute physician consultant cover across the seven days. Since introducing this service, 76%
of patients within the Emergency Department or Medical Assessment Unit have had an admission
avoided, following an assessment and an alternative community based package of care put in place.

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Working across boundaries to support
seven day services in mental health care
Nottinghamshire Healthcare NHS Trust, Nottinghamshire County CCGs and
Nottinghamshire County Council Social Care has a community mental health
Seven day
service provision
team in place, which works across care settings. The team manages the care
within an
organisation
of older people with both dementia and other mental health conditions.
The local GPs have found this helpful as they have ‘one place to go’ to refer older
patients for mental health care. The service operates seven days a week (7am to
9pm) and is staffed by healthcare support workers and professionally registered mental health nurses.
The expansion into community helps improve patient discharge and so reduce length of stay, and
enables the service to operate across the whole system. Implementation of this model across five
CCGs has enabled closure of 45 acute mental health beds in Nottingham.
LEVEL 3

Workforce modelling – innovative
opportunities, new ways of working
Continuous consultation with workforce and
a culture of openness can help facilitate the
willingness of staff to want to do the right thing for
patients, and build enthusiasm, support and
ownership for change. A variety of models exist to
enable the provision of seven days services through
workforce redesign. Some organisations have
invested to save through implementation of acute
care physicians who can help facilitate earlier
discharge and admission avoidance, others have
looked at skill mix within a range of clinical staff.
Developing seven day service models may not
always require financial investment. There are
examples of organisations that have found creative
solutions to support changes in working patterns.

‘‘

Top tips
Workforce remodelling does
not always mean more money
Engage with Clinical
Commissioning Groups (CCGs)
to identify levers to support
delivery of seven day services
View organisation competition
as an opportunity not a risk

’’

People’s lives don’t happen on a five day basis
they happen on a seven day basis.
Clinician

www.nhsiq.nhs.uk

39


Engaging with workforce to redesign urgent
and emergency care pathways
University Hospitals South Manchester NHS Foundation Trust engaged extensively with
staff to help formulate tests and implement seven day services to acute internal and
general medicine services. Over a number of months conversations with staff were held to
identify what and how improvements could be made.
This helped build agreement and consensus around what changes were needed to deliver high
quality care over a seven day period. Proposals put forward by clinicians were brought together into
a single proposed service model, and this was presented to staff to initiate a consultation process,
which then ran for six weeks and included dialogue with staff from across the entire organisation. At
the end of the six week period, people’s views were taken on board and used to refine the new care
model.
Early findings from implementation of the seven day consultant led multidisciplinary ward rounds
and the integrated emergency assessment teams are positive. There has been a 20% increase in the
discharge of patients admitted to the medical assessment unit and a reduction in the number of
patients on non speciality wards.

Changing the way we work in therapy services
seven days a week without additional investment
Heart of England NHS Foundation Trust’s model of seven day therapy services has been set
up at no additional cost. Across the whole Trust, this has been achieved by utilisation of
the out of hours on call budget to enable the development of a comprehensive and
flexible therapy bank service. Integral to this has been an early and continuous three year
engagement and consultation exercise with therapy staff and the inclusion of managers working
alongside therapists to ensure they feel supported. This model has generated a large amount of
interest from other organisations around the country.
South Tees Hospitals NHS Foundation Trust has developed a physiotherapy assistant
practitioner role to support rehabilitation seven days a week for patients on an enhanced
recovery pathway7. The requirement for weekend physiotherapy was evidenced by an audit
highlighting that up to a third of patients could have been assessed, treated and discharged by staff
with different skills and competencies. As a result, patients have more timely access to assessment
and rehabilitation, average length of stay has reduced by two days and qualified physiotherapists
have been freed up to focus on patients with more complex needs.

7

Available at: www.nhsiq.nhs.uk/enhancedrecovery

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LEVEL 2
Seven day services,
limited provision
on a Saturday
and Sunday

Developing a flexible pool of radiology
workforce to support clinical decision
making and discharge seven days a week
At Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, CT, MRI, general
radiology and ultrasound are operational seven days a week at the Grimsby and Scunthorpe
hospital sites. Initially, this was in response to clinical service reviews and recommendations, such as
the Network Vascular Review, Network Major Trauma review and the NHS Yorkshire and Humber
Stroke Services Accreditation. Latterly, the diagnostic services were reconfigured to support other
clinical groups operating within the Trust, to enable more timely clinical decision making and
diagnosis and in turn lead to more effective discharge planning. Previously there was inconsistent
provision of seven day diagnostics services across the sites with a reliance on staff volunteering to
work additional hours. This was both expensive and unreliable for the hospital site.
A larger pool of more flexible staff is now available to meet the demands as a result of:
• Staff moving from a locally agreed on call payments to an out of hours three session day
shift system
• A protection period was offered to staff to ensure they receive no income loss during the
protection period
• Development of a local competency package for those staff wanting to move from general
radiography to CT/MRI
• More sonographers trained and supported by local radiographers - course fees are supported
• Contracts of all staff now include working across the two main sites, and both days and nights
• Staff in CT, MRI and general radiology rotate through modality areas to support
maintenance of skills
• Additional staff recruitment.
The service reconfiguration strategy was developed by:
• Review of the number of staff required to deliver safe and effective diagnostic imaging services
• Capacity and demand analysis to help understand how services could be delivered to support
waiting times and patient choice
• Review of skill mix of staff at all levels to ensure career opportunities
• Review and development of staff contracts and shift systems (including the on call service).
The strategy went through a 90 day staff and public consultation exercise prior to implementation in
June 2013. The widening of access does bring in additional income to the Trust as more diagnostics
are being undertaken per week, income therefore off sets expenditure on staffing.

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LEVEL 4 *
Seven day services
integrated across
several departments
/organisations

Junior doctors join forces to change working
activities at weekends using an improvement
methodology to more effectively manage
workload
At South Devon Healthcare NHS Trust junior doctors Foundation Year 1 (F1) and
Foundation Year 2 (F2) working across assessment units in medicine and surgery, decided
to work together to streamline working activity to improve flow of patients thought
medical and surgical pathways.
Junior doctors and staff on the wards identified that there were delays in timeliness from request to
completion of certain tasks which effected quality of care, safety and patient experience and
outcomes. The delays were more common for medical patients. There were a smaller number of
foundation doctors to cover wards at weekends. Tasks were split into separate medical and surgical
lists with variation and disparity in the number of medical and surgical F1 tasks.
Using a quality improvement approach supported by a consultant surgeon and the Trust quality lead,
the doctors tested whether combing the F1 (surgical and medical) ward cover role at the weekends
to cover F1 surgical and medical tasks was more effective than the current system.
Following the test cycle they found that there was:
• Faster completion of F1 tasks, allowing them to deliver care more holistically
• Better experience of F1s with better teamwork
• Ward staff were more satisfied
• Patients had more effective and efficient care
• Better communication with ward teams.

‘‘

When doctors arrived... they did all the jobs
[medical and surgical] meaning patients were
not left for hours in pain or without fluids.
Ward Nurse

42

*Currently testing working towards level 4.
www.nhsiq.nhs.uk

’’


Some organisations, for example, Northumbria
Healthcare NHS Foundation Trust, have also looked
at how they can embed changes in working
patterns to sustain delivery of seven day service
models. For example, by building seven day service
provision into recruitment, job planning and
appraisal processes. This can help create a sense of
common purpose to underpin organisational
delivery.
Consider the interdependencies for seven day
service delivery
Seven day services can be perceived as only being
about increasing consultant presence seven days a
week. But, increasing presence of one professional
group may not optimise the care or flow of
patients across the system. Similarly, changes in
one part of the care pathway and service provision
can affect another part of the pathway and
services. Taking a whole system approach will help
to avoid unintended consequences.

Top tips
Remember to check the
external and internal
interdependences
Ensure you include ancillary,
administration, facilities,
external support services as
well as clinical

There needs to be capacity within the whole
system and identifying early on the interdependencies is crucial to success. It is important
to consider the whole picture including services
such as pharmacy, diagnostics, transport, GP,
access to information, administration, medical
records, portering, security, telephonists,
equipment loans, social care, public transport and
catering services.

‘‘

We decided to run an
outpatient clinic on a
Saturday, we arrived
to find patients waiting
in the corridor……. the
doors were locked, we
forgot to tell security.
Clinician

’’
43

www.nhsiq.nhs.uk


LEVEL 1
Extended hours,
Monday to Friday
e.g. 8am to 8pm

Seven day pharmacy services
At Oxford University Hospitals NHS Trust extended weekend opening hours and a
pharmacy residency service were introduced in 1991. This provides 24/7 timely advice on
all aspects of medicines use and supply of urgent and emergency medicines, including
discharge medicines. The service has been constantly reviewed and modified to meet changes in
demand and service configuration whilst maintaining the principle of providing equitable and
consistent pharmacy services irrespective of day of week or time of day.
The main pharmacy department is open from 8am to 5pm, Monday to Friday and 10:30am to 2pm,
Saturdays, Sundays and bank holidays. Outside of these hours pharmacists provide a 24 hours
service seven days per week with resident pharmacists working on site until midnight and then on
call from home via a radio-page overnight; the maximum response time of 30 minutes.
Health care staff now have consistent services irrespective of the day of the week or time.
This service enables:
• Staff to access non-stock medicines from the emergency drug cupboards, on all sites; although
some items also require prior authorisation from the resident pharmacist
• Timely discharge of patients as urgently required discharge medicines and treatment regimes are
available 24 hours a day
• Earlier facilitated discharge for patients as discharge drugs can be made available more quickly,
leading to reductions in length of stay for patients
• Continuity of drug therapy and treatment for patients as pharmacist more available to give advice
• Consistent application of formulary management, drug expenditure control and medicines safety
protocols whenever the medicines are prescribed or administered.
Pharmacy is considered a core clinical and out of hours service for delivery of safe quality of care for
patients seven days a week.

44

www.nhsiq.nhs.uk


Summary

‘‘

Patients who are
admitted to hospital
believe that they are
entering a place of
safety, where they,
their families and
carers, have a right
to believe that they
will receive the best
possible care. Yet there
is evidence to the
contrary. Patients who
are unwell, or become
acutely unwell in
hospital, may receive
suboptimal care.

’’

Dr Mary Armitage, Guideline Development
Group Chair, Royal College of Physicians

The spread and adoption of seven day service
models at scale and pace across England will
require courage, commitment and collaboration
across the whole health and social care system.
This publication, along with the NHS Improving
Quality Seven Day Services Improvement
Programme and the Seven Day Services Self
Assessment Baseline Toolkit, provides the first step
to support organisations and their teams to deliver
services seven days a week, so they can improve
patient outcomes and experience.
Working in partnership NHS England and NHS
Improving Quality will support organisations across
England to further build the body of evidence on
the benefits of seven day services for patients. This
is a quality driven improvement approach that aims
to ensure equity in care for all regardless of the day
of the week, because… every day counts.

45

www.nhsiq.nhs.uk


References
1. NHS Improvement (2012) Equality for All: Delivering safe care - seven days a week
2. NHS Services, Seven Days a Week Forum: Summary of Initial Findings 2013'
3. www.guardian.co.uk/society/2013/may/28/death-risk-higher-nhs-fridays
Sunday Times Article, Sunday, 14 July 2013.
4. Dr Foster Intelligence. Inside your hospital. Dr Foster hospital guide 2011–2011.
5. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shanian D, Roche WR, Stephens I,
Keogh B, Pegano D (2012): Weekend hospitalization and additional risk of death: An analysis of
inpatient data J R Soc Med 2012 Feb;105(2):74-84
6. NHS England (2013) The evidence base from the urgent and emergency care review Available at:
www.england.nhs.uk/wp-content/uploads/2013/06/urg-emerg-care-ev-bse.pdf
7. Delivering a 12-hour, 7-day consultant presence on the acute medical unit – Royal College of
Physicians www.rcplondon.ac.uk/resources/acute-care-toolkit-4-delivering-12-hour-7-day-consultantpresence-acute-medical-unit
8. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Available at:
www.midstaffspublicinquiry.com/report
9. Keogh B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in
England: overview report Available at: www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/
outcomes/keogh-review-final-report.pdf
10.Care Quality Commission (2012) Inpatient Survey 2012 Available at: www.cqc.org.uk/public/
reports-surveys-and-reviews/surveys/inpatient-survey-2012

46

www.nhsiq.nhs.uk

Acknowledgements
Case study organisations
Aneurin Bevan Health Board
Birmingham Community Healthcare NHS Trust
Bristol, North Somerset and South Gloucestershire BNSSG Urgent Care Board
Doncaster Metropolitan Borough Council
Doncaster and Bassetlaw NHS Foundation Trust
Epsom and St Helier University Hospitals NHS Trust
Heart of England NHS Foundation Trust
Lancashire and Cumbria Heart and Stroke Network
Lancashire Care NHS Foundation Trust
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Northumberland Tyne and Wear NHS Foundation Trust
Northumbria Healthcare NHS Foundation Trust
Nottinghamshire County CCGs
Nottinghamshire County Council Social Care
Nottinghamshire Healthcare NHS Trust
Oxford University Hospitals NHS Trust
Papworth Hospital NHS Foundation Trust
Pennine Acute Hospitals NHS Trust
Rotherham, Doncaster and South Humber NHS Foundation Trust
Rowcroft Hospice/South Devon Healthcare NHS Foundation Trust
Royal Free London NHS Foundation Trust
Royal Liverpool and Broadgreen University Hospitals NHS Trust
Salisbury NHS Foundation Trust
Sheffield Teaching Hospitals NHS Foundation Trust
South Devon Healthcare NHS Trust
South Tees Hospitals NHS Foundation Trust
Torfaen County Borough Council
University Hospital of North Staffordshire NHS Trust
University Hospital South Manchester NHS Foundation Trust
University Hospitals Bristol NHS Foundation Trust
University Hospitals Leicester NHS Trust

NHS
Improving Quality

To find out more about NHS Improving Quality:

www.nhsiq.nhs.uk

enquiries@nhsiq.nhs.uk

@NHSIQ

Improving health outcomes across England by
providing improvement and change expertise
Published by: NHS Improving Quality - Publication date: November 2013 - Review date: November 2014
© NHS Improving Quality (2013). All rights reserved. Please note that this product or material must not be used for the
purposes of financial or commercial gain, including, without limitation, sale of the products or materials to any person.

Every day counts

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