Towards the end of my fellowship at NHS England, the main story dominating the health sector was the provision of seven-day services, with a focus on consultant cover at weekends. Since I have returned to my final year of clinical practice as a trainee in respiratory and general medicine, the story has taken several twists – having narrowly avoided junior doctors taking industrial action for the first time since 1975. How did we get to this point?
Not long after my return to clinical practice, I was thrown into the stretched and frequently stressful environment of a weekend on call. Afterwards, I took some time to reflect on the arguments for seven-day services.
NHS England’s seven-day services forum
To implement seven-day services across the country, NHS England set up a forum in 2013 and developed 10 clinical standards around which change would be based. Four of these standards have recently been selected as a priority based on their impact in terms of improving services. These include: time to clinical review, access to diagnostics, access to consultant-directed interventions and access to ongoing review.
Importantly, the initial focus of this programme is around urgent and emergency care. Current estimates of the cost of providing this service are around 1.5 to 2 per cent of the running costs of hospitals. Even with the additional funding outlined in the Spending Review, it will be a stretch to cover the cost of these services, and it is important that money channelled for this is used as effectively as possible without impacting other services.
Evidence around the ‘weekend effect’ is patchy
Recently, the Secretary of State asserted that 11,000 deaths per year could potentially be prevented if a more comprehensive service was delivered. The 'weekend effect' has been hotly debated, and a recent article in the BMJ highlighted that there is evidence of a statistical excess of deaths in patients admitted over the weekend. Crucially, however, the authors take care to stress that these deaths cannot be attributed to any single factor and there is no evidence that these deaths are avoidable.
During my weekend on call, the main observation I made was that there were lots of consultants present – doing post-take ward rounds, offering advice, and being available when needed as senior decision-makers. This was true virtually across the board, and I felt supported at all times. Specialties not physically represented were easily contactable. This has almost always been my experience, although I appreciate that this may not be true at all hospitals across the country.
So where do the problems lie?
For urgent care, part of the problem is the lack of support services: limited diagnostics, phlebotomists and allied health professionals mean normal weekday practice becomes a bottleneck at the weekend. In the absence of a phlebotomist, a junior doctor may have to take all blood tests, detracting from other duties that are part of their remit as doctors and preventing them from working most effectively at the top of their capability.
My weekend on call highlighted what could be done at organisational level to improve cover. However, hospital care is part of a continuum of primary care, social care and community-based services to support patients. There is a complex interplay between health and adult social care and over the weekend this comes under more strain, resulting in poor flow across the system.
Adequately funded and functional social care is imperative for hospitals to run at weekends and this will be even more crucial if routine elective care is introduced at weekends.
A demoralised workforce is unconducive to change
In tandem with plans for seven-day services, there have been negotiations on both consultant and junior doctor contracts. All sides agree that the delivery of urgent and emergency care at weekends, with adequate staffing and safe levels of cover, are essential for patient safety.
However, the breakdown in negotiations and the controversy over the proposed changes to junior doctor contracts in particular has resulted in the first vote for a full strike by junior doctors in 40 years. It is true that shortfalls in recruitment to acute and emergency specialties such as A&E are already very real, with a drop in the number of applicants in recent years, and contracts need to be designed to ensure this is not exacerbated further. The removal of the nurse training bursary is likely to have an additional impact on a stretched workforce.
While breakthrough talks may have avoided strike action for now, morale among junior doctors is worryingly low and there are concerns about how the system will be able to tackle staffing and safety.
A way forward
The system is not perfect: with variation in the quality of care between weekdays and weekends, we are all too aware that things need to change for it to be improved. However, providing a seven-day service by stretching a staff and budget designed for a five-day service will not work.
Effective delivery of a five-day service requires a comprehensive strategy encompassing not just consultant cover, but more social workers, health care assistants, nurses, junior doctors, porters and radiographers. And this is just to ensure that acute and emergency services are functional before even thinking about routine elective care at weekends.
The main focus of the seven-day services argument up to this point has been on doctors. Yet the health service is not made up of one profession; it relies on the professionalism and team working of all members of staff across the system to ensure the delivery of patient care. Alongside improved outcomes, lower costs and better patient experience, we need to focus on the fourth aspect of the ‘quadruple aim’: to improve provider experience as well. To achieve the dream of a comprehensive seven-day service that truly delivers, we must match it all with the funding, staff and resources with which to do so. More cannot be done with the same if we are to uphold the quality and safety of services for all.
Dr Saira Ghafur is a Specialist Registrar in Respiratory and General Medicine and was a National Medical Director’s Clinical Fellow (2014–15).
Ghafur S (2015) ‘Seven-day NHS: a frontline perspective’. Nuffield Trust comment, 14 December 2015. https://www.nuffieldtrust.org.uk/news-item/seven-day-nhs-a-frontline-perspective