Analysis

Final pieces being put in place to enable seven-day working

News that the British Medical Association has agreed to renegotiate the clause in consultants’ contracts that allows them to opt out of non-emergency weekend duties makes seven-day services in the NHS even more likely

News that the British Medical Association (BMA) has agreed to renegotiate the clause in consultants’ contracts that allows them to opt out of non-emergency weekend duties makes seven-day services in the NHS even more likely.

The BMA’s offer came after health secretary Jeremy Hunt gave the union until mid-September to come to the table or face the imposition of a new contract on newly appointed consultants.

Momentum gathering

Many months of detailed talks are likely, with the BMA saying they want certain safeguards to be put in place. But, with momentum gathering, it seems almost certain this parliament will see changes to how services are organised, particularly in urgent care.

So, what will happen on the front line in England? The clearest indication of priorities first came in a letter NHS England sent to hospitals over the summer.

The letter, also signed by Monitor and the Trust Development Authority, asked trusts to focus on four of the ten seven-day standards that were published at the end of 2013.

Access to consultants

Two of the standards are solely about access to consultants. The first relates to how quickly consultants see and assess patients after emergency admission, while the second states that all highly dependent patients, such as those in intensive care and acute medical units, must be seen and reviewed by consultants twice daily. However, the other two standards are about access to wider services and, therefore, affect nurses and other staff more directly.

The letter also discussed access to diagnostic services such as X-rays, ultrasound and computed tomography scans, and insisted that results are seen and investigated by multidisciplinary teams.

It stated that there should also be 24-hour access, seven days a week, to complex interventions such as interventional radiology, emergency general surgery, urgent radiotherapy and cardiac pacing.

'Most impact'

These four standards, the letter said, will have the ‘most impact’ on improving weekend care, and progress in relation to them will be tracked from now on.

RCN professional lead for acute, emergency and critical care Anna Crossley thinks the standards could affect emergency departments (EDs) significantly. ‘EDs are already staffed 24/7 and the provision of nursing care in them is generally good, but access to support services is variable,’ she says.

‘At present, patients who arrive at the weekend and are admitted to hospital are likely to be sicker, and we need to make sure the services are in place.’

Leadership

She says that achieving this will require senior nursing leadership, careful workforce planning and more staff, including consultants.

‘An appropriate level of acute-care specialist nurses, for example those who work in interventional radiology and emergency surgery, will be needed at all times,’ she adds.

But she urges caution about how the seven-day drive is pursued. ‘It is a whole-system problem and is as much about ensuring there are the right resources and services in the community to support discharge and prevent admissions, as it is about the acute sector.’

Scotland

Nor, it should be said, is this an England-only issue. Of the other parts of the UK, Scotland has been the most active in trying to improve services at weekends.

The Scottish Government has established a sustainability and seven-day services taskforce, which earlier this year called for better access to hospital diagnostics and interventions, as well as improvements to the availability of local services.

In Wales, there have been moves to introduce more weekend access to diagnostic tests, pharmacies and therapies.

In Northern Ireland, meanwhile, staff say they welcome the debate and want to see services ‘moving progressively’ towards a seven-day NHS, although no firm plans for this move have yet been proposed.

Investment need

However, extending services in this way needs investment. Research by the Healthcare Financial Management Association for NHS England suggests that seven-day care could cost between 1.5% and 2% of a trust’s budget.

Nuffield Trust policy fellow Helen Crump says this raises ‘some major questions’. ‘For a trust with a £200 million turnover, this would equate to up to £4 million and could be enough to push any remaining hospitals just about managing to maintain a surplus into deficit,’ she says.

She also questions the rationale behind simply putting extra resources into the hospital system.

Against the grain

‘Regardless of whether additional funds are available to pay for it, pumping more money into the acute sector goes against the grain of other policies aimed at shifting activity away from hospitals.’

Of course, there are plans to increase access to care outside hospitals at weekends. As part of the seven-day drive, ministers want to see routine GP care available on Saturdays and Sundays, and have promised 5,000 extra GPs and 5,000 extra support staff to deliver this.

Not every GP practice will be expected to open their doors, however; instead, services are being encouraged to work in partnership to share the responsibility.

This, in theory, should help relieve demands on EDs, although both the Royal College of General Practitioners (RCGP) and the BMA have questioned how achievable it is, given the shortage of doctors.

'Could backfire'

RCGP president Maureen Baker even thinks the seven-day push could backfire and ‘destabilise’ existing services such as NHS 111. ‘That could increase the pressure on hospitals. We need to think carefully and make sure we prioritise the right things,’ she comments.

NHS Confederation chief executive Rob Webster agrees, suggesting a more holistic approach is needed if the policy is going to succeed.

He says: ‘The NHS is currently open for business seven days a week, 365 days a year. But we need to ensure all parts of the service, from ambulances to hospitals, community and social care, work together so patients are treated at the right time in the right place.

‘This will mean changes to working patterns and service provision. We need clarity around health and social care funding on the back of the spending review so that already stretched services can plan these changes effectively.’

Mortality rate

The issue of hospital mortality has been a topic of much debate as the push for seven-day services has gathered pace.

Health secretary Jeremy Hunt said weekend hospital admissions accounted for 6,000 ‘avoidable deaths’ every year, when he gave the British Medical Association the ultimatum over the consultants’ contract in July.

The figure is based on an analysis published in the British Medical Journal in September, whose authors include NHS England medical director Sir Bruce Keogh.

The analysis found that death rates within 30 days of hospital admission were 10% higher among patients admitted on Saturdays, and 15% higher among patients admitted on Sundays, than for mid-week admissions. When added to the higher mortality rates on Fridays and Mondays, of 2% and 5% respectively, the result is a ‘weekend effect’ of 11,000 more deaths a year.

This supports research conducted by the same authors and published in 2012, which found death rates were 11% and 16% higher among patients admitted on Saturdays and Sundays respectively, than among patients admitted on Wednesdays. But the authors are clear it would be ‘misleading’ to assume all these could have been prevented.

Nonetheless, Sir Bruce, who has long campaigned for more extensive services at weekends, thinks the evidence is strong enough to warrant action.

‘The moral and social case for action is simply unassailable and there is widespread clinical consensus about that,’ he says.

‘I’m not talking about offering people whatever they want, whenever they want it. The priority is to reduce mortality by concentrating on improving the way we design and deliver urgent care for our sickest patients.’

Steps to improved weekend care
  • Time to consultant review: all emergency admissions must be seen and thoroughly assessed by a consultant as soon as possible. For high-risk patients, this should happen within an hour with the longest wait being 14 hours.
  • Ongoing consultant review: all high-dependency patients in areas such as intensive care and acute medical units must be seen and reviewed by a consultant twice a day.
  • Access to diagnostics: hospital inpatients must have seven-day access to services such as X-ray, ultrasound, computed tomography, magnetic resonance imaging, endoscopy and pathology. Access should be within one hour for crucially ill patients, 12 hours for urgent patients and 24 hours for non-urgent patients.
  • Consultant-directed interventions: patients should have 24/7 access, on site or through formally agreed networks, to treatments such as interventional radiology, endoscopy, emergency general surgery, renal replacement therapy, thrombolysis and cardiac pacing.
More information

Healthcare Financial Management Association report on costing seven-day services

Weekend hospitalisation and increased risk of death: An analysis of inpatient data

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