Why services aren’t working seven days a week

In November a one-day NHS England conference entitled “Delivering seven day NHS services, seven days a week” was held in Birmingham – on a Saturday.

There were a few wry chuckles among the audience when one speaker suggested he really should have been at the rugby. But the choice of day was making an important point – everyone in the NHS, including consultants, ancillary staff and administrators, needs to start working in a different way to provide consistent services across the whole week.   

There’s a clear message from NHS chief executive Sir David Nicholson and national medical director Bruce Keogh that these changes in working practices need to be broad – from commissioning to employment contracts.

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Media scrutiny

It is not surprising that seven day services are high on the public agenda as well as that of policy makers and politicians. There have been many media reports on poorer outcomes for patients at weekends, including a Sunday Times Safe Weekend Care campaign, as well as continuing coverage on pressures on emergency care and lack of out of hours’ access to GPs.

‘Patients are just as likely to require emergency medical admission on a Saturday or Sunday as on a weekday’

Sir Bruce has established a “seven day services forum” which reported to the NHS England board in December. By the autumn, he is due to present a proposal to the NHS England board on what should go in the NHS planning guidelines for next year to make it a reality.

Some believe he is pressing on an open door. An HSJ online conversation with 1,000 readers found many accepted that seven day services were vital. Miles Scott, chief executive at St George’s NHS Foundation Trust in south London, agrees: “Let’s be clear: this is desirable, it’s inevitable and I think it’s essential.”

In some respects, it can be argued that the UK is leading the way on this issue. In its private sector, the US does have wider opening times of hospital and outpatient clinics but this is due to convenience and patient choice, rather than the driving factor for the NHS – patient safety.

Patients are just as likely to require emergency medical admission on a Saturday or Sunday as on a weekday. However, there is a growing body of evidence that patients who are admitted as an emergency at weekends are at higher risk of death than those admitted during the week, and that mortality in hospital generally is higher during the weekend.

Britain’s most senior doctors, represented by the Academy of Medical Royal Colleges, say treating patients in inadequately staffed hospitals at weekends is “ethically unjustifiable” and must end urgently.

Scale of change

So, what scale of change is needed? There are five work streams within Sir Bruce’s forum: clinical standards; organisational development and workforce; finance; commissioning levers and incentives; and provider models.

So far, NHS England has launched a set of 10 clinical standards representing the minimum quality of care that patients who are admitted in an emergency should expect to receive, seven days a week. These include consultant review within 14 hours of arrival in hospital, and twice daily review for patients who are managed on an acute medical unit, as recommended by the Royal College of Physicians and Society for Acute Medicine.  

Further extension of seven day services to involve routine hospital services such as outpatient clinics and elective surgery may be desirable for patient convenience, but most clinicians believe that this is unlikely to be achievable in the foreseeable future.

Making progress

Some trusts have already made considerable progress in the delivery of seven day urgent and emergency care. For the past 20 years, the Oxford University Hospitals Trust has had a 24/7 consultant-led and delivered orthopaedic trauma service in place. As a result, length of stay reduced while the number of operations performed has steadily increased.

After the first year, the inpatient annual bed requirement fell, leading to a ward closure and ward reconfiguration. This, in turn, created a recurrent ward pay budget saving of £100,000 per annum.

At the Royal Berkshire Foundation Trust, a seven day acute cardiology service has led to changes in the emergency care pathway, with a 29 per cent reduction in emergency department admissions in its first year.

And at University Hospital Southampton FT, there has been a consultant present in the A&E department until midnight and in the acute medical unit until 10pm, seven days a week for the past five years.

However, most hospitals currently struggle to provide this level of consultant care in less acute areas. Dr Chris Roseveare, chair of the Academy of Medical Royal Colleges’ seven day working subcommittee and consultant in acute medicine at Southampton, suggests that a group of patients across the UK are currently being let down by the system at weekends.

“There is a group of patients whose condition is not critical, but who are not well enough to be discharged from hospital. Frequently their care goes into ‘hibernation’ over weekends, with decisions, investigations and treatment changes being deferred until Monday,” he says.

One major issue is whether the establishment of seven day services can be achieved within current resources. The Academy of Medical Royal Colleges’ recent publications suggest that this cannot be “cost neutral”. In order to deliver a daily consultant review for 30 patients, the Academy estimates that six hours of consultant time will be needed per weekend day. Most hospitals are some way off being able to deliver this with their current staffing level.

Lack of resources

Mr Scott agrees there are resource issues, and believes there will be “double running costs” initially to set up a new system. Also, he says there will be increased costs due to out of hours working on current contracts. In addition, he says “there’s an ongoing debate with the BMA about whether we have the rights to change – even if we could afford it”.

An acknowledgement that extra funding is needed is suggested by the fact that the DH has given 13 “early adopters” extra resources and support in their seven day services pilots (see box, above). 

‘It’s no good if only half the system is working. It’s not OK if a consultant comes in but can’t get an X-ray or find a physio’

Another problem is how to make seven day services appealing to the clinical workforce.

One attendee at the Saturday conference made the point privately that if you look at any hospital staff car park at the weekend it is close to empty, compared with overflowing during the week. Although many employees – particularly nurses and junior doctors – are used to regular shift working on weekends after 5pm, many are not. Mr Scott says at St George’s, most of his community services, outpatient services and therapists not only don’t work seven days a week but don’t even work on call.

It is important to get them on board and shift their mindset. One doctor says: “It’s no good if only half the system is working. It’s not OK if a consultant comes in but can’t get an x-ray or find a physio – the whole system needs to work to ensure good will.” Mr Scott says he will persuade these staff by “being clear that it’s the right thing to do, and that it’s how we’re going to work” – aided by the fact that the whole NHS is in the same position.

It is also important to emphasise to them that delivery of seven day services does not imply that staff will need to work seven days every week – staff will continue to work five days per week, it will just be a different five days. Consultants working in some specialties will be harder hit than others; smaller specialities and those where there is less opportunity for cross cover will find it more difficult to deliver a weekend service.

The challenge ahead

Dr Roseveare says: “It’s going to be an enormous challenge; we will need more consultants to make this work, but we will also need existing consultants to work differently. We must ensure that those specialties providing high intensity weekend working patterns remain attractive to the future workforce; this may require changes to the way in which weekend working is remunerated and reconfiguration of services to ensure sustainable rota patterns.”

On a positive note, the November conference heard from some women doctors who thought the new system would actually work better for them – being able to work at the weekend while a partner looked after the children, then being able themselves to be with their families during the some of the week.

Mr Scott concludes: “Transition will be complex and demanding, and easy to underestimate. However it is the right thing to do, and something that we all want to do.

“The biggest threat to it is operational complexity and difficulty, and that, I think, is where the resources come in. At least in the short term, this is going to have to cost more, and if we confront that, then I think there’s a potential for us to make some positive change.”

Jacqui Thornton is a freelance health journalist and former health editor of The Sun, tweeting on @jacquithornton