The Five-day versus Seven-day Bun-Fight

Saturday, July 18, 2015

Dr_Bob_ThumbnailThere is a big bun-fight kicking off on the topic of 7-day working in the NHS.

The evidence is that there is a statistical association between mortality in hospital of emergency admissions and day of the week: and weekends are more dangerous.

There are fewer staff working at weekends in hospitals than during the week … and delays and avoidable errors increase … so risk of harm increases.

The evidence also shows that significantly fewer patients are discharged at weekends.

So the ‘obvious’ solution is to have more staff on duty at weekends … which will cost more money.

Simple, obvious, linear and wrong.  Our intuition has tricked us … again!

Let us unravel this Gordian Knot with a bit of flow science and a thought experiment.

1. The evidence shows that there are fewer discharges at weekends … and so demonstrates lack of discharge flow-capacity. A discharge process is not a single step, there are many things that must flow in sync for a discharge to happen … and if any one of them is missing or delayed then the discharge does not happen or is delayed.  The weakest link effect.

2. The evidence shows that the number of unplanned admissions varies rather less across the week; which makes sense because they are unplanned.

3. So add those two together and at weekends we see hospitals filling up with unplanned admissions – not because the sick ones are arriving faster – but because the well ones are leaving slower.

4. The effect of this is that at weekends the queue of people in beds gets bigger … and they need looking after … which requires people and time and money.

5. So the number of staffed beds in a hospital must be enough to hold the biggest queue – not the average or some fudged version of the average like a 95th percentile.

6. So a hospital running a 5-day model needs more beds because there will be more variation in bed use and we do not want to run out of beds and delay the admission of the newest and sickest patients. The ones at most risk.

7. People do not get sicker because there is better availability of healthcare services – but saying we need to add more unplanned care flow capacity at weekends implies that it does.  What is actually required is that the same amount of flow-resource that is currently available Mon-Fri is spread out Mon-Sun. The flow-capacity is designed to match the customer demand – not the convenience of the supplier.  And that means for all parts of the system required for unplanned patients to flow.  What, where and when. It costs the same.

8. Then what happens is that the variation in the maximum size of the queue of patients in the hospital will fall and empty beds will appear – as if by magic.  Empty beds that ensure there is always one for a new, sick, unplanned admission on any day of the week.

9. And empty beds that are never used … do not need to be staffed … so there is a quick way to reduce expensive agency staff costs.

So with a comprehensive 7-day flow-capacity model the system actually gets safer, less chaotic, higher quality and less expensive. All at the same time. Safety-Flow-Quality-Productivity.