All across England, sustainability and transformation plans have committed to the seven-day working agenda developed by the government.
With workforce shortages and the need for savings at the top of the agenda, in many areas the ability to comply with NHS England’s Seven Day Services Standards will be a major factor in reconfiguration, including the downgrading and even loss of emergency departments and other acute services. The spectre of outright hospital closures has been raised.
At least in part of the country, we have been here before. The standards draw directly on the London Quality Standards (LQS) introduced to the capital in 2011. These too were rolled out with the stated aim of reducing excess weekend mortality, and with the threat of reconfiguration wielded as a motivator for trusts. They cover identical domains, and several of the standards were carried across exactly into the national programme.
Did it work?
Five years on, the Nuffield Trust has conducted an evaluation of how they were introduced. We draw on a survey of acute trusts, interviews with everyone from those who developed the standards to the frontline staff who directly implemented them, and an initial crunching of the numbers on mortality and length of stay.
The good news is that the LQS did lead to real change. They were successful in focusing minds and organisations on improving the quality of care. In many places, they led to concrete changes in how people worked, often from the bottom up. All this was achieved with very little financial support.
The bad news is that it is not clear this demonstrably improved outcomes. Furthermore, threatening to use the standards as the basis for deciding to downgrade or close down hospital services turned out to be a serious mistake.
The big stick
Initially, it was unclear whether the LQS were aspirational or compulsory: they were commissioned across London from 2012, but at no point were there penalties or incentives for compliance. As a result, some organisations abandoned them as a priority.
The “stick” emerged later in the process, when non-compliance with the LQS was used as a threat for service reconfiguration at some hospitals. This was generally not seen as helpful. We found that the driving factor where the standards were introduced was the commitment of clinicians, who genuinely believed they would improve quality and safety for patients and address unacceptable variation in outcomes.
The switch to a punitive way of driving the standards undermined this. It paralysed service change, demotivated staff and detracted people’s attention from the original aim of improving patient safety.
Given this, it is troubling that Dave West’s recent overview of STPs finds the drive for seven day working serving as a driver for reconfiguration. Commissioners and STP leads need to make sure they do not roll out London’s mistakes nationwide. Making professional standards work depends on backing from professionals, not threats to their managers.
The case for change
Another issue was a mismatch from the start between hard evidence that something needed to be done, and the vaguer evidence that the standards specifically would lead to improved care. Few disputed that there was a problem in the variation of mortality between hospitals and across the week. But most individuals we spoke with underlined that the LQS exclusively focused on processes and did not have this, or any other outcome, as a measure.
There needs to be a clear cause-and-effect relationship between the interventions required to meet the standards and the outcomes they aim to achieve for patients. Those involved need to know what they are working towards. Again, it is worth asking how often reconfiguration clears this bar.
Paying the price
It did not come as much of a surprise that the most significant challenge to implementation was the direct financial cost attached to the LQS. Some organisations saw the LQS as entirely unrealistic, partly because, unlike the earlier stroke and trauma reconfigurations in London, they were not accompanied by supporting resources.
A stretched workforce combined with a growing clinical workload meant that staff had no capacity for strategic thinking or managing change. One clinician we spoke with was sceptical of the hospital’s workforce capacity “to even provide the five-day service, let alone the seven-day service.”
The experience suggests that careful use of funding will be required to make the standards work at a wider level, as well as specific support and guidance on how to get there. STPs should give thought to how much seven day services will cost and what can be done to help, or risk this becoming all too apparent further down the line.
The way ahead
Are these the right standards to be rolled out across England? Over half of the organisations in our study told us that implementing the LQS led to major change and improved quality of care. Many described improvements in patient pathways. But our initial analysis of selected health outcome measures did not show a direct impact of the LQS on outcomes, beyond initiatives to improve care undertaken across the rest of England – although we plan to look more closely in future analysis.
With heavy political backing for the principle of seven day working, STPs may feel they have little choice but to incorporate some of these standards into plans for the hospital sector.
But the lesson to learn from London’s experience is that changes like this live or die by clinical involvement. Commissioners and STP leads should reflect on whether they have the evidence to honestly tell clinicians that changes will improve care for patients. And they should think twice before picking up the reconfiguration stick.
Machaquerio S (2017) 'The dangers of tying reconfiguration to seven day standards'. Nuffield Trust comment,15 February 2017. https://www.nuffieldtrust.org.uk/news-item/the-dangers-of-tying-reconfiguration-to-seven-day-standards