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)

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 (ethnograph