In 2013, NHS England proposed that the NHS should provide seven-day access to routine services, claiming that this would lead to more patient-focused care, improve clinical outcomes, and reduce cost. It set up the NHS Services, Seven Days a Week Forum to identify how a seven day service could be achieved, initially looking only at access to urgent and emergency care and supporting diagnostic services (like X-rays and scans).
A seven-day NHS was later flagged up in NHS England’s plan for 2015-2020, the Five Year Forward View (FYFV), which called for hospital patients to have access to seven-day services “where this would improve the outcome of their care”. Many health workers have been infuriated by the suggestion that they and the NHS are not already at work seven days a week.
Worryingly, the NHS Services, Seven Days a Week Forum noted in their report that NHS organisations would have to plan how they would move towards a seven day NHS without increasing the overall cost of healthcare. Suggested solutions included a ‘change’ in weekend pay premiums for staff, and a ‘reconfiguration of services’ (https://www.england.nhs.uk/wp-content/uploads/2013/12/forum-summary-report.pdf (p19). Quite what this meant was not spelt out but there were nods in the direction of closures or ‘consolidation’ of some hospital services; the introduction of new ‘models of care’; and changes to the mix of staff in the workforce (for example the report clearly suggested the increased use of ‘generalist’ roles, such as physician associates who cost less to employ than fully trained doctors).
In arguing for a 7-day NHS, the Secretary of State for Health has claimed that 11,000 deaths a year are caused by a lack of the right staff on duty at weekends – the so-called ‘week-end effect’. He drew on research claiming that patients admitted on a Sunday are around 16% more likely to die within 30 days than those admitted on a Wednesday. But this research has been challenged (https://www.theguardian.com/society/2016/sep/15/the-evidence-of-an-nhs-weekend-effect-is-shaky?CMP=share_btn_tw). For example, a different study comparing patients admitted through A & E during the weekend with those admitted during the week found – perhaps unsurprisingly – that death rates are higher for weekend admissions because these patients are typically more ill when they arrive at hospital. (https://www.research.manchester.ac.uk/portal/en/publications/higher-mortality-rates-amongst-emergency-patients-admitted-to-hospital-at-weekends-reflect-a-lower-probability-of-admission(939c2149-80f0-4208-9194-bacfb4840209).html).
Significantly, a number of prominent academics, including Stephen Hawking, have written to the Prime Minister, calling for an inquiry into the Secretary of State’s claims about the weekend effect. They accuse the Secretary of State of misrepresenting evidence, ignoring the findings of robust ‘peer reviewed’ studies, and selecting the findings from weaker research that help him make his case. The result, they suggest, is a devastating breakdown in trust between the government and the medical profession (https://www.theguardian.com/society/2016/sep/15/stephen-hawking-robert-winston-inquiry-jeremy-hunt-nhs-weekend-patient-deaths).
What is meant by a seven day NHS?
The seven-day NHS seems to mean different things to different people. The Conservative Party’s Manifesto for the 2015 election, for instance, promised patients would be able to see a GP and receive the hospital care they need, seven days a week by 2020. It also promised that hospitals would be properly staffed so that the quality of care will be the same every day of the week. Rather differently, according to a spokesperson from the Department of Health giving evidence to the Health Select Committee in the House of Commons, seven-day working was “very much about around urgent and emergency care admissions at weekends” and “ensuring that there is the right senior clinical decision-making support at weekends”.
According to the Medical Director of NHS England, the 7-day NHS will start initially with urgent and emergency care services. Then, over time, there will be extended access to
- primary care, especially GPs services, with extended opening hours during evenings and weekends
- many hospital services (including consultant-led assessment, diagnostic and routine services) currently not available over weekends, and
- out of hospital care, so that people can be discharged at weekends.
How feasible is a seven day NHS?
A report on costings by the NHS Services, Seven Days a Week Forum suggests that the expense of implementing a 7-day NHS will vary between Trusts but that it will probably add 5% to 6% to the cost of emergency admissions. The main costs, the Forum suggests, are to do with the recruitment of more consultants. These costs, the report says, “could be greatly reduced if fewer trusts provided emergency services in certain specialties”. In other words, it looks as though the new 7-day NHS means that patients will have greater access to fewer services on the ground. While there may be some savings due to fewer unnecessary admissions or shorter stays in hospital, the Forum acknowledges that investment in seven-day services after admission would involve additional costs too – at least with the way services are organised at the moment: the report notes that “reconfiguration of services may reduce the cost” but had not tested this possibility (https://www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf). This hint of possible reconfiguration is where the plan for 7-day service dovetails with NHS England’s new models of care programme.
The British Medical Association, among others, have expressed concerns that expanding NHS services at weekends will inevitably mean fewer clinics, operations and staff on duty during the week. As the health spokesperson for the Liberal Democrats put it,
My fear is that, unless you can guarantee there will be more junior doctors employed, imposing a change which involves more hours being worked at weekends will inevitably reduce the number of hours worked during weekdays, when the pressure is at its greatest. This could result in real safety concerns. https://www.theguardian.com/politics/2017/jan/02/jeremy-hunt-accused-of-compromising-weekday-hospital-care
Recent research by High-intensity Specialist Led Acute Care (HiSLAC) also flags up safety issues. Their study, commissioned by the National Institute of Health research but ignored by the government, found that providing more services at weekends could increase the risk of patients dying during the week because there would be fewer doctors on duty. According to one of the health economists involved in the study,
“There is no evidence to support the move to seven-day services, there is no evidence of what is going to happen if we divert our resources away from the week to weekends. We don’t know what is going to happen to patient outcomes and we don’t know what is going to happen to costs.”https://www.theguardian.com/society/2016/jul/18/seven-day-nhs-unachievable-for-20-years-expert-claims?CMP=share_btn_link
The same study suggests that the government’s pledge to implement a 7-day NHS would cost between £1.07 billion to £1.43 billion, and cannot be met for 20 years because of chronic underfunding and staff shortages.
A 7-day NHS and new contracts for junior doctors
Initially, when speaking about a ‘seven day service’, the Minister for Health argued for a new contract for consultants that would remove their ability to opt-out from week-end working so that they were more available to support junior doctors. Subsequently, he argued that both consultants’ and junior doctors’ contracts had to be revised to ensure seven day services.
While NHS England says that, with the new contracts, doctors will not be expected to work extra hours, but it is clear that, among other things, they will be expected to increase the amount of weekend work that they do.
Negotiations on new contracts started with junior doctors. They didn’t accept the new contract for a number of reasons, such as the existing shortfall of 70,000 staff in the NHS, which meant there were already major gaps in staff rotas and overstretched and demoralised staff. The new contract, it was argued, would stretch staff further, undermine safeguards on the number of hours junior doctors were expected to work, have implications for training, the continuity of patient care, doctors’ work/life balance and the future recruitment of doctors willing to work in highly pressurised emergency specialties – all of which would raise serious concerns about patient safety. Doctors would also be paid less for working weekends and nights, which might mean some doctors would be paid less than they currently earned. The contract was also seen to penalise parents and those with caring responsibilities, holding them on lower pay when they return to work,. In particular, it discriminated against female doctors and it was feared that the new terms would discourage women from entering the medical profession. There were additional concerns about inadequate protection for whistleblowers.
For the dispute to end, junior doctors issued a number of demands including recognition that a truly seven-day NHS cannot be delivered with five-day resources in a health service that is already buckling. And they called for a clear, costed plan from the government as to how a seven-day NHS could be sustainably delivered (https://www.bma.org.uk/collective-voice/influence/key-negotiations/terms-and-conditions/junior-doctor-contract-negotiations).
After a serious of unprecedented strikes, and the junior doctors’ rejection of a revised contract, the Secretary of State for Health decided to impose the new contract. In response a group of junior doctors took the Department of Health to court on grounds including that, following the Health and Social Care Act (2012), which limited the role of the Secretary of State for Health to setting the broad strategic direction of the NHS, he or she does not employ staff providing NHS services and has no power to make decisions about the terms and conditions of junior doctors’ employment (http://www.justiceforhealth.co.uk/#press-release).
The junior doctors lost the case. During the dispute, the Secretary of Sate for Health had explicitly stated that he would impose the new contract on junior doctors (for example he announced he would be doing this in the House of Commons, the day after it became clear that junior doctors had rejected the revised version of the contract: https://www.theguardian.com/society/2016/jul/06/jeremy-hunt-to-impose-new-contract-on-junior-doctors). However, in court it was argued that he was not imposing the contract, and had never intended to suggest that he was.