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Medical college report calls for seven-days-a-week hospital care

Hospitals must be reorganised so patients do not have to move beds or wards unless medically necessary, a new report says.

Care must also be provided seven days a week, with full access to scans and lab testing even at weekends.

The study, from a commission set up by the Royal College of Physicians (RCP), makes 50 recommendations on the future of NHS hospital care.

It says a rise in admissions and more older patients with complex needs means “hospitals are struggling to cope”, while units are not equipped to provide excellent care on weekends.

“All too often our most vulnerable patients - those who are old, who are frail or who have dementia - are failed by a system ill-equipped and seemingly unwilling to meet their needs,” the report said.

It is not unusual for patients to move beds several times during a single hospital stay which “results in poor care, poor patient experience and increases length of stay”.

The study said that, in the future, moves between beds and wards will be minimised. “Once admitted to hospital, patients will not move beds unless their clinical needs demand it.”

And the authors call for a shift to seven-day working, with consultants having a presence on wards and the full range of tests available every day of the week.

Several studies have shown that patients admitted to NHS hospitals at weekends and on bank holidays have higher death rates and poorer outcomes.

The report said: “Acutely ill medical patients in hospital should have the same access to medical care on the weekend as on a week day.

“Services should be organised so that clinical staff and diagnostic and support services are readily available on a seven-day basis.

“There will be a consultant presence on wards over seven days, with ward care prioritised in doctors’ job plans.

“Rotas for staff will be designed on a seven-day basis, and co-ordinated so that medical teams work together as a team from one day to the next.”

Under the plans, arrangements for discharging patients from hospital will also operate on a seven-day basis, with closer links with community services and social care.

The report comes from professor Sir Michael Rawlins, chairman of the Future Hospital Commission which was established by the RCP last year.

It acknowledges that “tough decisions lie ahead” including the reorganisation - and possible closure - of existing services.

“Reconfiguration will almost certainly be needed,” it said. “No hospital can provide the range of services and expert staff needed to treat patients across the spectrum of all clinical conditions on a seven-day-a-week basis.”

The study calls for a new model of “hub and spoke” hospital care.

“It is likely that in many areas, large health economies will be served, not by a number of district general or teaching hospitals, but by a smaller number of acute general hospitals hosting emergency departments and trauma services, acute medicine and acute surgery.

“These hospitals will be surrounded by intermediate ‘local general hospitals’ which, while not directly operating their own emergency department and acute admitting services on site, will contribute to step-down inpatient and outpatient care, diagnostic services and increasingly close integration with the community.”

Sir Richard Thompson, president of the Royal College of Physicians, said: “This is a once in a generation opportunity to improve the way that we care for medical patients.

“When I set up the Commission in March 2012, it was intended to review all aspects of the design and delivery of inpatient hospital care, and to make recommendations to provide patients with the safe, high-quality healthcare that they deserve.

“It has done much more than that. The Commission brought together patients and medical and healthcare experts to develop a vision of the future hospital, a hospital which is no longer bound by its walls, but reaches out into the community to care for medical patients.”

The report said effective alternatives to hospital admission must also be found, including better managing people in their own homes or other community settings.

And it calls for all doctors to feel responsible for the quality of basic care given to patients - for example hydration - and “take action whenever they become aware of this being inadequate”.

New roles will be created in hospitals, according to the proposals, with a chief of medicine having ultimate responsibility for all adult patients and a new “buck stops here” approach.

A new chief resident will work with junior doctors and help plan service design and delivery, including rotas, duties and workload.

The report said care should be organised so patients are reviewed by a senior doctor as soon as possible after arriving at hospital, and should see a specialist in their condition as soon as possible.

This might mean seeing multiple specialists for some patients, with care co-ordinated by a single doctor.

An “acute care hub” in the hospital will focus on accommodating patients for up to 48 hours and consultants from a range of specialties will spend time here to offer expert opinion.

A separate “clinical co-ordination centre” will act as a control room for real-time patient information, handover and transfer briefings, and organisation of care for all acutely ill medical patients , whether inside or outside the hospital.

Dr Cliff Mann, president of the College of Emergency Medicine, said: “This report has major implications for emergency medicine. The emergency department is reliant on comprehensive medical services from a range of other specialties.

“The implementation of this report will be a challenge - but we agree that it must be addressed. Unifying and integrating the hospital and wider healthcare facilities, including those related to primary and social care will benefit the care for our present and future patients.”

Peter Carter, chief executive and general secretary of the Royal College of Nursing, said: “The Future Hospital Commission looks at some of the most pressing challenges facing the NHS, including rising emergency admissions and how to provide better care for patients with increasingly complex conditions.

“The commission rightly focuses on a patient-centred approach to care, and the smooth and safe transfer of patients from hospitals to the community,2 he said. “Nurses play a vital role in delivering community services so are perfectly placed to work with patients, their carers and other agencies to help keep people as healthy as possible and out of hospitals.”

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Readers' comments (10)

  • how the hell are we we to go to 24/7 working when hospitals are cutting thier staff to save money...you will need more staff for this surely!!!

    Sorry I forgot it's the tories running the nhs now...should of remembered!!!

    Just heard hospital number 3 is to be privatised....we have Hinchingbrooke, soon George Elliot in oxfordshire and anounced 10 mins ago peterborough and stamford foundation trust....the tory privatisation of our nhs is full steam ahead, at this rate in another 5-10 years more than half of the nhs will be in private hands!!!!

    just great all you tory voters must be so proud putting profit befor the health of the people of this country...I hope you can sleep at night!!!

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  • I agree with everything the RCP say. Whilst people enjoy having a local District General Hospital, but it isn't always the best place to be when you're acutely ill - particularly out of hours and weekends.

    What we need is for Trusts in geographical areas to merge to allow the 'hub and spoke' model to be implemented. It makes sense, to have all acutely unwell patients in one area, where there are consultants on site 24 hours a day where patients can get the care and interventions that they need when they need them rather than having to wait until office hours.

    I'd go further: rather than having 3 or 4 hospitals in an area offering elective orthopaedic surgery, I'd mandate that services be concentrated on one site; I'd do the same with all specialties to enable 24 hour consultant cover, and make each centre a specialist unit which will improve patient care.

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  • I don't see why the NHS needs to service all and sundry at weekends just to suit their lifestyle or working patterns unless it is affordable and would create more jobs without creating further stress and cause deficiencies elsewhere.

    However, it is essential that all hospitalised patients and any new admissions and other urgent consultations get all of the care they need to avoid exacerbation of their condition.

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  • Anonymous | 12-Sep-2013 2:52 pm

    I hope you're never unwell at night or on a weekend as you will see - quite quickly - why change is required.

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  • Anonymous | 12-Sep-2013 4:35 pm

    Anonymous | 12-Sep-2013 2:52 pm

    thanks. you spotted my omission and my apologies on rereading my comment I see the second para. was not well expressed and posted in a rush.

    It would have been clearer if I had said "...get all the care they need at all times..."

    I support this absolutely and it should never be otherwise but I was just trying to make the point at the beginning that if it is too costly or unrealistic, I don't see the necessity of providing full healthcare to everybody and to non-urgent cases just for their own convenience at weekends although it could be argued that it would help reduce waiting lists and now live in a 24/7 society there is a need for this. it is all a question of balance between meeting needs and with what is affordable and realistic in terms of staffing and all other resources but without excessive waste.

    The last thing I wish to see is anybody suffering as a result of long waiting lists, long waits in A&E or any other difficulties in getting treatment through inadequate staffing and other resources and hope like most that all of these problems will be taken by the roots and improved as soon as possible so they do not just pop up some time further down the line as the tend to with (dare I say, the usual) patching up and sticking plaster method.

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  • "Anonymous | 12-Sep-2013 2:52 pm

    I don't see why the NHS needs to service all and sundry at weekends just to suit their lifestyle or working patterns unless it is affordable and would create more jobs without creating further stress and cause deficiencies elsewhere"

    That is exactly what is wrong with the NHS: its not run with patients in mind, but rather to suit managers budgets and Consultants contracts.

    Most of us work, so why should you have to take a day off work to see your GP etc. Having a full suite of services running 24/7 will actually save money.

    Where I work, it is not unusual for a patient to stay in over a weekend for no other reason than to see the Consultant on Monday morning or to have a scan etc. Its crazy and costly. If there was a Consultant on over the weekend then the patient could go home 2 days earlier or if X -Ray was staffed, the patient could have their scan sooner.

    Its not the 1960's, I think its time the NHS moved into the 21st century.

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  • 24/7 Hospital care! Great idea, ground breaking in fact. We can now announce, that after almost 70 years of the NHS' existence, at no little expense and deep innovative thought, that the wheel has truly been re-invented.

    Perhaps the egg heads who championed this radical new scheme will even suggest more hospitals, more beds and hands on staff be available in-situ rather than 'clinical co-ordination centres, acute care hubs' and yet another flock of 'specialists'.

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  • Anonymous | 13-Sep-2013 0:38 am

    from Anonymous | 12-Sep-2013 2:52 pm

    fine if the authorities see it from this point of view and they agree to set it up. If it is affordable and actually saves money I am sure nobody will object and would be only to pleased to receive routine care at the weekends or at their own convenience. Perhaps it would also see the end of unacceptable waiting lists. Obviously there would need to be a large increase in staffing at all levels working and on call during what are currently considered as unsocial hours and the staff would expect considerably more pay.

    It might also be unique as I am sure no other services run full steam across Europe evenings and weekends (although they normally have senior staff on duty or at least on call and in close proximity) although I don't know about the USA and whether they run full services 24/7. In that respect it might encourage even more visitors from abroad either non-paying or if the NHS is more canny made to pay in order to increase its revenue.

    However, I think the first priority must be to ensure patients get adequate emergency cover 24/7 both in hospitals and in the community and there is a clear distinction between those who require GP and nursing services at home, ambulance services, A&E and hospitalisation so that not everybody lands up in the same chaotic 'pot of stew' which is unable to cope and with managers harassing staff and chasing their delusional targets which have little to do with providing safe and effective care!

    I strongly agree the NHS has to keep up with the times so everybody gets the best available care but we will see in which direction it will progress when politicians eventually manage to come to some decisions for action, although I believe it will be nothing more than the usual non-cost effective and wasteful patch up and make do strategy so it always remains decades behind the times and fobs off many of whom it is supposed to serve, whilst those who are more fortunate and depending among other factors on their location, continue for the same price to get excellent, but not usually seamless care, in the various hospital and community services.

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  • I don't blame anyone for going to A&E rather than waiting a week to see their GP or to try and navigate the OOH's 'phone systems etc. If I thought I was that unwell, A&E is where I'd be heading.

    Patients, in my experience, no longer accept being palmed-off with the 'lets watch and wait' ethos of many GP's. Time was you went to see a Dr who knew you well, you accepted his prescription for painkillers or antibiotics or whatever he doled out and that was it. Things have changed, patients want blood tests, XRays and MR scans, not a prescription for 100 Paracetamol and sicknote for a week.

    Until we get primary care sorted either by resurrecting the polyclinic idea or something similar the problems in hospitals are going to continue.

    Any large structure that you want to last must be built on solid foundations; primary care being the bedrock of the NHS. Until we get the foundations right, we don't stand "a cat in hell's chance" of getting the rest to work as it should!

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  • I agree with the 24/7 working but will we get the staff? A&E targets draw what slim medical staff away from the patients already admitted onthe wards. I agree also that being able to discharge patients 7 days a week would be excellent as well! However, the community care is struggling to cope with the so called 'care closer to home' with less staff and patients being discharged with more interventional post surgical care (drains, antibiotics etc.) If the medical college can influence and be successful in achieving a safe whole system 24 hour NHS that would be fantastic. Tories and Llib Dem (if the Conservatives allow you), just listen and plan and act!

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