It is a mistake to use seven-day standards as the basis for deciding to downgrade or close down hospital services, new research by the Nuffield Trust suggests. A extensive review of the London Quality Standards (LQS), the London-wide precursor to the Seven Day Services Standards being incorporated into plans across England, finds that the threat of closure is counterproductive. It also shows that the evidence for benefits to patients is not clear enough to be compelling.
The LQS aimed to reduce excess weekend deaths in NHS hospitals as part of a wider programme to enhance the quality of care patients can expect when admitted to hospital. As well improving outcomes for patients at weekends by having consultants work seven days, the LQS aimed to speed up when patients get scans or other tests, improve the assessments patients get on arriving at hospital, and enhance communication between patients and doctors.
The Nuffield Trust’s review of the 21 standards for acute medicine found they worked well as a quality improvement programme, successfully engaging frontline clinicians and managers. Over half the organisations questioned said standards led to major change and improved care, and many said it raised the importance of patient safety and led to better ways of working. This was achieved with relatively little central financial investment. However, our initial analysis found no statistical evidence that the programme improved weekend mortality rates or rates of discharge from hospital compared with the rest of the country.
In some areas, commissioners threatened to use the standards to drive plans for downgrading A&E and other acute departments. The analysis found that using the standards in this punitive way undermined clinical engagement, demotivated staff and detracted attention from the aim of patient safety, the Nuffield Trust found.
Commenting on the research, Dr Louella Vaughan, Fellow in Health Policy at the Nuffield Trust said:
“Where the LQS was successful, this was due to high levels of engagement from clinicians. That evaporated where the threat of hospital closures or downgrades was used as a ‘stick’ to enforce adherence to the standards.
“This should act as a warning sign for anyone currently involved in the Sustainability and Transformation Plans being put in place across the country. Many of these imply that the ability to comply with national seven-day standards – the successor to the LQS – will influence which hospitals stay open.
“Our research shows that using standards in this way would be a serious mistake. Not only could it harm crucial working relationships between doctors and managers, but it could mean major decisions being made on evidence not strong enough to justify them.”
The Nuffield Trust’s report is the culmination of a year-long research project exploring the development and implementation of the London Quality Standards. It draws on a wide range of research techniques, including seminars, focus groups and interviews with everyone from those who developed the standards to the frontline staff who directly implemented them; and an initial quantitative analysis of the impact of the standards on patient care.