Introduction: physiotherapy and seven-day services
People require NHS services 24 hours a day, seven days a week.(1) A current lack of some clinical services and senior decision-makers over weekends means that quality of care is sometimes compromised leading to delays, poor patient experience, and an increased risk of complications and mortality during these periods.(2)
Seven day services including physiotherapy afford patients the care and treatment they need, irrespective of the day of the week. They also facilitate safe discharge at weekends, achieving the best possible clinical outcomes and use of resources.(3)
The NHS is committed to developing high quality services and new models of care that better address patient needs, and improve clinical outcomes and patient experience outside of the normal working week.
Seven day services need to become routine in most areas of both community and secondary care where there is evidence that this will improve patient outcomes and experience.(4)
Most clinical specialities require access to physiotherapy to enable successful patient recovery and rehabilitation, and physiotherapy tailored to meet patient needs should be integral to the provision of seven-day services.(5)
Seven-day services increase quality of care
Emergency physiotherapy practitioners and therapy-led assessment and treatment teams work seven days a week in A&E departments and medical admission units (MAU).
They provide additional knowledge and skills to support or replace medical staff managing patients with musculoskeletal problems streamlining care and avoiding unnecessary admission.(6)
However physiotherapy should not be seen in isolation and pathway redesign must include all the professions required to provide integrated service delivery avoiding delays, repetition, and inefficiencies.
To avoid delayed discharge especially for older people, seven day services need to include community and social care services; for example, community pharmacists, nursing and support agencies.(7)
Resourcing seven-day services
Seven day services should be properly resourced and funded to enable the same quality of care to be delivered every day of the week while ensuring that additional provision does not undermine the existing Monday to Friday physiotherapy establishment.
Service redesign should:
- Use innovative approaches to skill mix (for example expanding the role of support workers) whilst taking into account advanced knowledge and skills enabling senior clinicians to work productively in their area of expertise,ensuring that clinical standards and safety are maintained(8)
- Ensure sufficient staff are available to optimise patient safety and provide appropriate clinical supervision to less experienced staff(9)
- Consider the work/life balance of staff with consultation on proposed changes to working patterns
- Consultation with staff and their trade union representatives should be undertaken(8)
Newton Abbot Hospital, Torbay & Southern Devon Care Trust
- Average length of stay reduced by two days
Consultation with Stroke Rehabilitation Unit service users was key to developing a patient-centered plan to extend stroke therapy services from five to seven days within existing resources.
Funds were reallocated to create three new band 3 rehabilitation support workers to work over seven days, supported by qualified staff from both hospital and community services.
Discussion with nursing staff led to the implementation of a joint working strategy. Therapists start earlier and work alongside nurses incorporating a therapeutic and enabling approach to getting patients up and ready for the day.
Reviewing, auditing, evaluating
Other developments included reviewing paperwork and a service audit and evaluation using existing data as a baseline. The work is split between ward work (stroke rehab) and community neurological rehabilitation (any neurological conditions) depending on the priorities identified by the staff.
Since the service was introduced in 2010 the average length of stay has been reduced by two days. 100% of patients are fully assessed and have rehabilitation goals agreed within 24 hours of admission complying with NICE quality standards.
The rehabilitation ethos within the unit has improved and feedback from patients and carers has been positive. Including community staff has increased the weekend resources, improved efficiency and streamlined the transfer of patients to community settings.
Although not entirely attributable to seven day working SSNAP (Sentinel Stroke National Audit Programme) data has shown a significant improvement in recent months and the stroke unit is now achieving an ‘A’ grade.(11)
Guys and St Thomas’ NHS Foundation Trust
- More intensive rehabilitation leads to improved function and contributes to reduced time on ventilation
In 2010 a seven day respiratory physiotherapy service was introduced to provide specialist treatment to patients on critical care (ICU), surgical, and medical wards. The increased service, which has been positively received by service users, provides access to consistent and comprehensive specialist respiratory physiotherapy irrespective of time of day. More intensive rehabilitation has lead to improved function and contributed to reduced time on ventilation and, on acute medical & surgical wards, a 2 day reduction in length of stay.
Significant savings in the first year
During its first year, the new model of working resulted in significant savings for the Trust, achieved by reducing costs of staff sickness (45k), employment of temporary staff (52k) and out of hours payments (45k); reviewing skill mix was responsible for a further saving of £60k. The service model was initially set up with a £500,000 investment to run for a 6-month period; it continues to be commissioned and developments are now focused on rolling out seven day services to all areas of physiotherapy as appropriate. The challenge has been to obtain sufficient funding so that patient care is enhanced and not adversely impacted by spreading 5-day’s resources over 7-days.
South Tees Hospitals NHS Foundation Trust
- 426 cardiothoracic surgery bed days released reducing waiting times for elective surgery
As an integral component of the Enhanced Recovery Pathway(12) physiotherapy teams provide an equitable seven day physiotherapy service across all surgical specialties enabling patients to get better sooner.
Band 4 assistant physiotherapy practitioners provide rehabilitation for all elective surgical patients, and a twilight physiotherapy service for intensive care and high dependency units meets peaks in clinical demands.
High patient satisfaction
A seven-day Rapid Response multi-disciplinary community service facilitates discharge and supports ongoing rehabilitation.
Patients receive earlier rehabilitation and the average inpatient length of stay has been reduced by two days. 426 cardiothoracic surgery bed days have been released reducing waiting times for elective surgery.
Patient satisfaction with the service is high. Increased skill mix has freed qualified staff to manage patients with more complex needs.
Heart of England NHS Foundation Trust
- Rotas and rest days refined through regular consultation and evaluation
Since April 2011 the Therapy Directorate (Physio, Occupational and Speech Therapy) has provided seven day services across three hospitals for inpatients and attendees at A&E.
The weekend service, delivered by 45-50 therapists (approximately 25% of the usual workforce) across the three sites, facilitates daily discharge planning by avoiding delays due to therapy needs, progessing treatment and rehabilitation, and improving clinical safety by ensuring senior staff are available at all times.
Physiotherapy and occupational therapy are provided 8am till 4pm Saturday and Sunday across all hospital wards and in A&E and MAU.
Increased support for seven-day services
To improve staff satisfaction with the new model, rotas and rest days have been refined through regular consultation and evaluation, and are produced six months in advance where possible.
The weekend service and weekday backfill is supported by trust therapy bank staff.
Service users report high levels of satisfaction with the weekend therapy service, and support from staff for seven day services has increased from 72% (2011/12) to 87% (2012/13). In 2013/14 A&E/MAU therapists avoided 40-50 new admissions per weekend and weekend discharges enabled by therapy increased to more than 60.
All new stroke patients are assessed within 24hrs of admission. The weekend service saw a total of 5,030 new inpatients and provided 21,037 follow up inpatient treatments in 2013/14.
Costs have not increased since the seven day service was introduced. However the cost of weekend services is not included in the therapy budget and a cost pressure of £350k per annum remains.
Northumbria Healthcare NHS Foundation Trust
- Workload levelled out across seven days
The seven-day working project aimed to provide timely assessment and rehabilitation to all in-patients in three hospitals within the Trust using the principles of enhanced recovery.(12)
The new model maximises rehabilitation potential and ensures that it continues, uninterrupted, seven days a week. Some staff work across acute and community settings improving continuity of care and facilitating safe early discharge.
The model has received favourable feedback from both service users and the multidisciplinary team who value the increased physiotherapy input at weekends.
Increasing weekend staffing
Workload has been levelled out across seven days and Monday peak in demand has been alleviated. Using robust audit data the service has continued to develop and now includes weekend posts (22.5hpw Friday/ Saturday/ Sunday) for orthopaedics; a model which is also being piloted in elderly care.
A six-month rotation for acute respiratory care (Wed-Sun or Sat-Wed) which increases weekend staffing has been implemented, as well as a weekend service developed for maternity/gynaecological inpatients staffed by band 3 and 4 support staff.
Weekend commitments of 1:6 are acceptable to staff. Occupational therapists now work seven days a week and there are plans for speech and language therapists to work six days a week in the stroke
Golden Jubilee National Hospital, Scotland
- 2014 Excellence in Quality Service Award for team’s ‘can do’ approach
As part of a Scotland wide enhanced recovery model the therapy team (physiotherapists, occupational therapists and rehabilitation assistants) at GJNH introduced a seven-day working model in January 2014 for elective orthopaedic surgery (hip and knee) and cardiothoracic services with the aim of improving access to therapy and delivering quality treatment independent of the day of surgery.(13)
Drivers for change included therapy delayed discharge, patient experience, and concerns about service quality and fluctuating workloads. Plan, Do, Study, Act (PDSA) methodology was used to match capacity to demand and staff consultation addressed concerns about the new working pattern.
Implementation took two years and the new service, which provided an increase in therapy hours of 50% on Saturday and 400% on Sunday, commenced January 2014.(13)
Consistent and effective service
Early achievements (to July 2014) show that a consistent therapy service is being delivered across seven days resulting in earlier orthopaedic discharge (average three days post op) and more effective utilisation of orthopaedic beds and resources (length of stay reduced by one day on average).
200 additional cardiothoracic patients were treated per month and 80% of cardiothoracic patients were discharged from therapy four days after routine procedures regardless of the day of surgery.
The rehabilitation team achieved an award for ‘Excellence in quality service’ in 2014 for their ‘can do’ approach to overcoming challenges to introduce and deliver seven day
Seven-day services: conclusion
There is a broad consensus that, when introduced appropriately, seven-day services improve patient care, optimise the use of resources, increase efficiency, and lead to better clinical outcomes.(5)
In some conditions such as stroke, national guidelines recommend multidisciplinary assessment and intensive rehabilitation begin as soon as possible and this necessitates provision of daily physiotherapy services.(14)
In other conditions the drivers for the development of seven-day physiotherapy services focus on enabling timely and safe discharge as soon as clinically indicated, avoiding delays or interruptions to patient care, improving rehabilitation outcomes, and enhancing patient experience.
This service model is seen as key to reducing workload fluctuations and in particular the Monday morning peak in demand.(4)
Physiotherapy should not be seen in isolation but as part of an integrated seven day service pathway.(14) Currently most seven-day services are provided in hospital but, to achieve comprehensive seven-day care, services need to include primary, community and social care provision.(2)
The interface between physiotherapy services in hospital and in the community needs to be addressed to ensure continuity of care, to facilitate discharge and to avoid unnecessary readmission.
In most of the examples cited above service redesign has included revision of skill mix and consultation with staff to optimise service delivery and staff work / life balance.
Common concerns focus on the impact of seven day services on Monday – Friday physiotherapy provision and it is essential that service change is sufficiently well resourced to enable consistency of care seven days a week.
Careful and on-going audit and evaluation of clinical outcomes and cost savings is essential to obtain robust data to justify continuing commissioning and service expansion.
More resources for GPs:
The CSP would like to thank the following people for their input: Rhoda Allison, Torbay & Southern Devon Health & Care Trust, Christine Divers, Golden Jubilee National Hospital, Jacky Jones, Guys and St Thomas’ NHS Foundation Trust, Karen Renforth, Northumbria Healthcare NHS Foundation Trust, Mary Ross, Heart of England Foundation NHS Trust, Caroline Thomas, Torbay & Southern Devon Health & Care Trust.
- NHS Improving Quality. Seven day services. NHS Improving Quality. URL: http://www.nhsiq.nhs.uk/7860.aspx
- NHS England. Nhs services, seven days a week forum summary of initial findings. NHS England 2013. URL: http://www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/
- Holdsworth LK, Douglas L, Hunter E, et al. Social media: Raising the profile of AHPs. British Journal of Healthcare Management. 2013;19(2):85-92
- NHS Improving Quality. Nhs services open seven days a week: Every day counts. NHS Improving Quality 2013. URL: http://www.nhsiq.nhs.uk/8763.aspx
- Academy of Medical Royal Colleges. Seven day consultant present care: Implementation considerations. London: Academy of Medical Royal Colleges; 2013. URL: http://www.aomrc.org.uk/projects/seven.html
- Crane J, Delany C. Physiotherapists in emergency departments: Responsibilities, accountability and education. Physiotherapy. 2013 Jun;99(2):95-100. URL: http://www.csp.org.uk/professional-union/csp-publications
- Age UK. Nearly 2 million nhs days lost from delayed discharge. AgeUK 2014. URL: http://www.ageuk.org.uk/latest-news/nearly-2m-nhs-days-lost-delayed-disc...
- The Chartered Society of Physiotherapy. Seven day physiotherapy services: Meeting the challenge. London: The Chartered Society of Physiotherapy; 2014. URL: http://www.csp.org.uk/publications/seven-day-physiotherapy-services-meet...
- NHS Improvement. Equality for all. Delivering safe care - seven days a week.Leicester: NHS Improvement; 2012.URL: http://www.nhsiq.nhs.uk/resource-search/publications/nhs-imp-seven-days....
- Royal College of Physicians. Ssnap (sentinel stroke national audit programme). Royal College of Physicians, 2012. URL: https://www.rcplondon.ac.uk/projects/ssnapclinical-audit
- Enhanced Recovery Partnership. Fulfilling the potential: A better journey for patients and a better deal for the NHS Leicester: NHS Improvement 2012. URL: http://www.nhsiq.nhs.uk/8228.aspx
- Divers C, Shirley M. Seven day rehabilitation service at golden jubilee national hospital [powerpoint presentation]. 2014. URL: http://www.qihub.scot.nhs.uk/media/664486/quest%20-%20flow%20-%20events%...
- National Institute for Health and Clinical Excellence (NICE). Stroke rehabilitation. National Institute for Health and Clinical Excellence 2014. URL: www.pathways.nice.org.uk/pathways/stroke/stroke-rehabilitation