Title: Stepping Up: A Phased Evaluation of the Impact of High-Intensity Specialist-Led Acute Care (HiSLAC) of Emergency Medical Admissions to NHS Hospitals (Commissioned call 12/128)
Funder: Department of Health and Social Care

Abstract: Our proposal evaluates high-intensity specialist-led acute care (HiSLAC) as a device to improve the care of acutely ill medical patients admitted as emergencies to English hospitals, with a particular emphasis on weekend admissions. The rationale for this proposal is based on research in diverse health systems demonstrating poorer outcomes for patients admitted to hospitals at weekends. The case for undertaking the project is predicated on the following logic: Acutely ill patients are the largest patient population in hospitals, and the highest risk. Weekend admissions to hospital have a higher standardised mortality than weekday admissions. Studies suggest opportunities to improve safety and reliability of care at weekends. Generic non-specialist interventions (outreach, hospital-at-night) have been unable to identify strong evidence of effectiveness in improving patient outcomes. Weekends are associated with reduced intensity of specialist (ie: consultant) input into patient care, as well as reduced access to investigations, support services, and primary and community care. We hypothesise that specialist-led acute care will improve processes of care and outcomes for patients undergoing emergency admission to hospital. To test this hypothesis, we will perform a two-phase study to determine whether increasing the intensity of specialist-led care at weekends improves outcomes for patients and the cost-utility of increased intensity of specialist provision. The study combines rigour with pragmatism by building professional consensus and triangulating quantitative and qualitative measures of process and outcome. Specifically we will: 1. Develop a score to assess the fidelity with which high-intensity specialist-led acute care (HiSLAC) is implemented and use this to map current and future practice across the NHS. 2. Undertake systematic reviews to examine the magnitude of the weekend mortality effect and explore the mechanisms behind the weekend effect using framework synthesis. 3. Use mixed methods to evaluate the effect of HISLAC on differences in quality of care between patients admitted at weekends versus weekdays. 4. Determine the effects of HiSLAC on hospital-level measures such as length of stay. 5. Use ethnographic exploration to improve understanding of factors facilitating or impeding the uptake and effectiveness of HiSLAC. 6. Develop a health economics model to estimate the costs and health outcomes (QALYs) associated with increased specialist provision. We will do this using a decision-gated two-phase study design. Decision gates will be controlled by the independent Oversight & Governance Committee. Phase 1 is the developmental and modelling phase. During this phase we will develop methods and metrics to measure HiSLAC using an expert consensus approach, establish a collaboration of participating acute Trusts across England, undertake a national mapping exercise to obtain intensity measurements in participating Trusts and use staff and patient focus groups to explore the mechanisms behind the weekend mortality gap. In Phase 2 we will prospectively monitor changes in specialist intensity over time and the impact this has on patient outcomes, develop a programme theory of specialist impact, and investigate the factors facilitating/impeding the effectiveness of specialist input. The programme theory will contribute to the development of a health economics model to link the unit costs of HiSLAC to measures of effectiveness. Phase 2 consists of two workstreams: an NHS-wide comparison of HiSLAC penetration with NHS performance and outcomes using Hospital Episode Statistics (HES) data; and a detailed quantitative and qualitative study of 10 HiSLAC and 10 low-intensity (LoSLAC) hospitals which combines data from HES & local healthcare databases with case note reviews of quality of care, and on-site ethnographic exploration. The project will therefore triangulate quantitative analysis with qualitative (ethnographic) research to measure quality of care and to explore cultural and behavioural aspects of a fundamental change in service delivery. At the end of the study we will be able to test whether care at the weekends is worse in low than in high provision hospitals and whether the difference between weekdays and weekends is also greater in the low provision hospitals. Implementation of a prospective study will enable us to monitor and evaluate in real time the effect of increased specialist-led care at weekends. Anchoring the difference at weekends in the weekday performance offers protection against bias over and above that which statistical control alone can provide. If there are differences in observable quality of care in patients admitted over week-ends and if these differences correlate with HISLAC fidelity, then a cause-effect explanation of studies showing associations between mortality, specialist availability and weekends will gain credibility. The case will be even more compelling if differences diminish as HISLAC is instituted. This research is important for patients and for NHS strategy because it offers a unique opportunity to evaluate the impact of the transition to seven-day working and to understand factors likely to impede or enhance the effectiveness of this change in practice.

Lay abstract: Patients admitted to hospital with an acute medical emergency at weekends apparently have a higher rate and risk of complications and death than patients admitted on weekdays. In separate studies, a more favourable ratio of specialists to patients appears to be associated with improved outcomes. Combining these two findings, the HiSLAC project will test the theory that increasing the amount of specialist clinical care provided at the weekend will improve patient outcomes to a level comparable with those admitted on weekdays. We refer to high-intensity specialist-led acute care as HiSLAC. At the end of the HiSLAC project, we will be able to show: whether care at the weekends is better in hospitals with HiSLAC, whether the differences in outcomes between weekdays and weekends is less in hospitals with HiSLAC, and whether HiSLAC is cost-effective. The HiSLAC project is organised into two stages over a five year period. Phase 1 A base-line view of current practice with clear definitions. Phase 2 Evaluates the effect of changing specialist intensity based on the differences in quality of care between patients admitted at weekend vs weekdays using a causal and cost-effectiveness model. Delivery in Phase 1 a. Development of measures of the intensity of specialist provision at weekends. b. A national map showing current levels of provision of specialist-led care across acute Trusts in England. c. Web-pages to communicate the scope and progress of the project and facilitate feedback and input. Delivery in Phase 2 a. A prospective NHS-wide comparison of HiSLAC saturation/practice with NHS performance and outcomes using national mortality data. b. A comparison of ten hospitals classified as having HiSLAC with ten hospitals with low-intensity specialist-led care. Activities to support the comparison will include: i. Review of anonymised case notes to determine quality of care. ii. Review of processes and outcomes from relevant hospital statistics iii. On-site observations and interviews to explore cultural and behavioural aspects of working practices thus identifying what helps and what hinders the effectiveness of HiSLAC. c. A cost-benefit model for HiSLAC. d. Lessons learned, hints, tips and guidance for hospitals implementing HiSLAC e. Materials such as documents, presentations, and scientific articles to inform decisions relating to HiSLAC provision Project Management and Governance The project will be run through a team at the University of Birmingham led by Professor Julian Bion, and governed by an independent Steering Committee, chaired by Professor Sir Michael Rawlings and including patient and Academy of Medical Royal Colleges representation. Strengths of this Proposal Timeliness: Four recent national policy initiatives have focussed on specialist-led care in the health service, including the Department of Health, Professional Organisations, and the Academy of Medical Royal Colleges. NHS England’s working group on seven-day services has now mandated Trusts to meet 10 standards for 7-day services by 2018 of which specialist interventions are a major part. Given the implementation of this policy initiative, this study offers the most comprehensive national research initiative to evaluate and accurately predict the putative association between specialist intensity and patient outcomes. Willingness of hospitals to participate: Over 80 per cent of acute hospitals have agreed to participate. Capacity of the project team: Members of the research team have nationally and internationally recognised skills in diverse areas including: frontline acute care clinical practice, the patient perspective, complex service evaluation, quantitative and qualitative research methodologies, statistics, data acquisition and analysis, healthcare management, health economics, and project governance. Separating effect from noise at a time of major change in the health service: Phase 2 has been designed to enable triangulation between qualitative and quantitative measures. This will strengthen the evidence for cause and effect. It will provide the opportunity to demonstrate a relationship between the time of the intervention and qualitative patient outcomes. Patient and public perspectives: Captured in both the project management team and the Steering Committee. Additional input will also be gathered throughout the project in collaboration with Patient Liaison Groups & Lay Committees of the participating professional organisations. The HiSLAC project responds to the NIHR-Health Services Delivery Research Programme’s commissioned call 12/128 for the organisation and delivery of 24/7 healthcare. This addresses the second of the four evidence gaps: Assessing the effectiveness and cost-effectiveness of different models of organising acute care at nights and weekends. It will bring scientific evidence to several national policy initiatives and will address the issue of the cost-efficacy of a major change in health service provision. The results of the project are likely to improve the outcomes for the many millions of NHS patients admitted as emergencies.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE