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Switch to seven days a week working in NHS 'is already underway'
NHS bosses have told hospitals they need to move towards round-the-clock working. Health and Education Editor Barry Nelson hears how one North-East trust is rising to the challenge.
IT came as no surprise to senior doctors in the North-East when the medical director of the NHS, Sir Bruce Keogh, ordered a far-reaching shake-up in the way the Health Service is run.
Concerned at higher death rates at weekends, Sir Bruce has asked for hospitals in England to ensure that senior doctors and vital diagnostic tests are available seven days a week and 24 hours a day.
Initially the aim is to apply this new policy to urgent and emergency services over the next three years but in the long term the intention is to introduce seven days a week working to other parts of the NHS.
While the announcements about improving overnight and weekend care made headlines, senior NHS leaders in the region's hospitals are already looking at ways to move towards seven days a week, round-the-clock working.
Professor Chris Gray, medical director at the 1,000 bed County Durham and Darlington NHS Foundation Trust, argues that his organisation - which runs Darlington Memorial Hospital and the University Hospital of North Durham and a string of community hospitals - is already working towards extending the working day for senior doctors, without breaking directives on working hour limits and putting intolerable burdens on senior staff.
Prof Gray, who took over as medical director at the trust earlier this year, is still professor of clinical geriatrics at Newcastle University, although he gave up a full time role as a senior clinical academic at the university earlier this year.
He has a particular interest in stroke medicine and has been impressed at the way the County Durham and Darlington trust recently centralised all its acute stroke services at the University Hospital of North Durham.
Although this involved the closure of the acute stroke unit at Darlington Memorial Hospital by concentrating highly specialist services at one site, it has allowed the trust to provide a full 24 hours a day service, resulting in improved care for acutely ill stroke patients.
That model, concentrating expertise where it is needed, points the way to changes to other hospital departments - although Prof Gray thinks this can be achieved by concentrating assessment and admissions at one rather than two sites overnight and at weekends, rather than closing down entire hospitals.
"What happened here is clear evidence of how you can do better. Sir Bruce is setting a benchmark but we are already some way along that road," says Prof Gray.
While every NHS hospital trust in the country will face the same problems in switching to seven day week working, Prof Gray, as the former postgraduate dean for the Northern region, is acutely aware that the North-East NHS, despite out-performing much of the rest of the country, has a chronic problem in recruiting and retaining nurses and senior doctors.
That issue, which will not improve overnight, is likely to force North-East hospital bosses to consider radical solutions to provide 24 hour working, particularly across trusts which run more than one acute hospitals - such as County Durham and Darlington.
"The ultimate goal for us is that all of our patients should see the right person in the right place at the right time seven days a week and 24 hours a day," says Prof Gray.
"We don't think it is unrealistic but to get to that point you have to look at re-configuring services," he adds.
An example of a new way of working is the County Durham and Darlington trusts changes to maternity care.
Prof Gray explains: "In maternity care we already have two consultants who provide resident cover at night, sleeping on the unit when it is not busy. We think we can continue to develop this so that consultants can be there to give support with any complicated deliveries."
In emergency care, the trust has already extended the working day of the consultant on call. The next step is to extend this to 8pm and - assuming the trust can hire sufficient consultants in the months and years ahead - extend the cover to midnight.
Ultimately, to meet Sir Bruce's objectives, the trust will probably have to have a resident consultant sleeping on the unit overnight.
"The problem is, like the stroke model, you cant do that over multiple sites. The staff are just not there. It is all about moving the patients to the right place and to make sure it is safe," says Prof Gray.
The trust's paediatric services have also demonstrated the clear benefits of having a consultant-led service.
Since the introduction of arrangements which mean that a consultant is in the paediatric department until 10pm, the trust has seen big reductions in emergency admissions because senior doctors have been able to sort out which children need to be admitted and which can go home.
"We are ahead of the game on this but we are currently doing this across two sites and you wonder, can we sustain this?"
Hand in hand with gradually switching to seven day operation in some areas, hospital bosses at County Durham and Darlington are also working closely with the local GP-run Clinical Commissioning Groups to try to ensure that patients are given the maximum support in their own homes and to reduce the number of unnecessary hospital admissions.
"Irrespective of age, every person should have a correct assessment. Our vision is to provide an outreach services supporting GPs and making better use of our community hospitals, working with primary care and social care," he adds.
"We must always ask what is the correct course of treatment? If you are dealing with a frail elderly patient would it be more appropriate for them to see a specialist nurse or therapist in their own home rather than being admitted to hospital?" says Prof Gray.
"If we can deliver the quality by managing people closer to home then that will have an impact on inpatient care," he adds.
He forsees greater use of smaller community hospitals as "resource centres".
"For instance, you might go to your local community hospital for 24 hours care or for investigation. We need to change the model," the professor says.
"The bottom line is that the status quo cant continue. It is about the quality we deliver and patients expect more so we have to deliver more."
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