Title: The future of 24/7 care: investigating the links between staffing levels patient access and inequalities in health outcomes
Funder: Department of Health (England)

Abstract: BackgroundThe National Health Service (NHS) was founded on fundamental principles of equity and the current Government’s long-term vision is of an NHS that eliminates discrimination and reduces inequalities in care [Department of Health 2012]. However patients’ outcomes are strongly dependent on the time that they are admitted to hospital. At night and during weekends staffing levels are lower clinical support services are unavailable or are functioning on an on-request basis and senior clinical staff are located off site. Current evidence suggests that patients presenting to health services at these times suffer higher complication and mortality rates than patients admitted at times when services are fully operational. Extending the hours for which the NHS is fully operational therefore has the potential to improve access increase the use of inputs by health service providers and improve outcomes for patients. However extending fully operational hours could also decrease efficiency by raising input costs and providing services that are relatively under-utilised.Research AimsIn order to understand how extending fully-operational hours will affect costs and outcomes research is needed into the relationships between staffing levels costs patient outcomes and quality of care. These relationships are poorly understood because the rich information routinely collected in patient healthcare records is not linked to the data collected by employers on staff inputs and costs. We propose to link these data in an acute Trust – Salford Royal Foundation Trust (SRFT) – that has gradually extended its hours of full operation since 2007 culminating in the implementation of an ‘Emergency Village’ service in 2012 providing consultant-led care from 7am to 11pm seven days per week. We will link these data to identify for each patient care episode the staff available to provide direct patient care and the availability of direct patient care support services. We will exploit the natural variability in staffing composition and levels over time of day day of week and week of year to estimate the association between staff inputs and aspects of patient care including length of stay in-hospital complications and mortality. We will also identify the effect on patient care and outcomes of service reconfigurations that extend fully-operational hours. This will enable us to answer four key questions: •What is the impact of changes to fully-operational hours on access to services for different population and patient groups?•How do service re-configurations affect quality of care and patient outcomes for different population and patient groups?•How should staff be best deployed to deliver care throughout the week?•What balance of fully-operational hours represents the most cost-effective use of NHS resources?Data SourcesSRFT is at the leading-edge of electronic patient record linkage across primary secondary and community care. In partnership with Salford Primary Care Trust it has created the Salford Integrated Record (SIR) with 165 million medical records for over 300000 patients. SRFT has also been routinely collecting staffing information electronically since 2007. These data can be integrated to generate a unique dataset including information on:•Patient episodes: admission time diagnosis procedures and interventions length of stay. •Patient demographics: age sex ethnicity postcode general practice.•Quality of care: patient experience complications readmissions mortality.•Staffing data: number grade specialty skill-mix remuneration and compensation (hourly pay rates time in lieu).•Primary care provision: general practice working hours quality of care practice characteristics (list size staffing qualifications disease prevalence) prescribing.Comparative patient-level data are also available (from the Advancing Quality Initiative) for all 24 Trusts in the North West of England on quality of care for pneumonia heart failure acute myocardial infarction stroke and for hip or knee replacement surgery. Analytical ApproachIn the first phases of the study we will examine whether achievement of process measures for quality of care and patient outcomes vary by time and day of admission. For Salford Royal we will link these process measures to staffing levels at the relevant times to identify whether staff availability predicts variations in achievement. Staff costs will be decomposed into variations in the volume of staff on duty and individual-level linked staff information will be used to examine the implications of anti-social working for staff turnover. The estimated models will enable us to compute the additional costs that would be incurred if staffing levels at anti-social times were to be equalised to staffing times in preferred working hours. The linked data from primary care records will allow us to follow individual patients across sectors and over time in order to examine how patient pathways across care interfaces vary by time of day and day of week. For example we can examine similar entry and exit points with primary care services on weeknights and weekends and determine whether exacerbations of symptoms first treated in primary care are more likely to lead to A&E presentations if they occur out-of-hours compared with in-hours. We will also examine whether health care needs are met in an integrated health system including the impact of service reconfigurations in one sector – for example the hospital – on service providers in other sectors. Using data on the adoption of extended opening hours by individual general practices we will also examine how initiatives to extend opening hours in primary care impact on demands placed on the hospital sector. In the third phase we will extend the study to other hospitals. For all 24 Acute Trusts in the North West of England we will examine whether achievement of process measures of quality vary by time of admission and day of admission. For at least one Trust in the NHS QUEST Network we will examine in detail the relationships between processes of care and staffing levels and compare these relationships to results for Salford Royal.Research ImpactThis research will provide vital information on the costs benefits and potential unintended consequences of extending the hours of full operation of services.


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