Dr John Havard: What about seven day working in the NHS?

Jeremy Hunt, Secretary of State for Health, has been at the centre of the seven-day working debate.

Jeremy Hunt, Secretary of State for Health, has been at the centre of the seven-day working debate. - Credit: Sarah Lucy brown

What is the background?

Since death rates were thought to be higher in hospitals at weekends there has been a growing force towards more NHS services becoming available on Saturdays and Sundays.

The death rates usually quoted are the “30 day mortality” statistics for those who are admitted at the weekend. During the week healthier patients are admitted for low risk procedures which must distort the figures. You can see that if admissions include patients for routine operations then weekend data is bound to be worse because so few routine operations are done then.

Just like in other health systems in the world, a greater proportion of sicker patients will be admitted at weekends because there is much less routine work, so it is no surprise that a higher percentage will die within 30 days. Intuitively it seems more efficient to keep all the services running at full throttle so that patients can be managed more closely and discharged more promptly so average lengths of stay can be shortened.

Nevertheless the figures are not quite what they seem. There remains no clear definition from the Government of what seven day working really means. There is however the reality that if weekend staffing was the same as weekdays then NHS bankruptcy could be brought forward dramatically.

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What about Primary Care?

The BMA have noted that the Government has been forced to row back on a pre-election pledge. This was to recruit 5,000 additional GPs to allow all Practices to open seven days a week after it had proved to be ‘mere rhetoric and completely undeliverable on the ground’. If you want to expand the service then it requires more staff and more money - and in the present financial climate this is a toughie!

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What are the implications?

Everyone shares a desire to improve quality of care along with access and convenience. However as well as more NHS staff, especially senior doctors on site at hospitals at weekends and evenings, it will also require other services being available to enable clinicians to provide high quality care as usual. This includes diagnostics, clinical support, social care, transfer services and administrative support.

Social Care is in an even worse cash situation than the NHS and so is probably the weakest link in the chain. It seems clear that some ‘robust modelling’ on the impact of seven day working will be needed to study both financial and clinical outcomes.

Aspiration and reality

It is just not fair for politicians to offer the public an appealing policy without working out all the implications. Of course they are indeed much craftier at managing public relations. They have manipulated the situation so it looks as if they are offering free milk and honey and the BMA are saying no. Just like with free hospitals and schools on PFI, someone will have to pay so we need to be clear about this at the outset.

What would I do?

It is easy to criticise and much harder to offer potential solutions that will certainly upset someone. But who cares! It seems to me that competent senior clinical assessment at both entry in and exit from hospital is key. I would therefore invest in both A&E and Emergency Assessment Units to ensure that only patients with appropriate clinical needs were admitted and would provide short term 72 hr ‘InstantCARE’ supported solutions for appropriate patients at home.

Time for comprehensive assessment is crucial so I would remove the 4 hour target as this is simply increasing unnecessary admissions at 3 ½ hours. The plan would mean a carer could return home with an elderly patient with complex needs after assessment to support him or her in the short term. If these patients are admitted then they risk both getting really ill and also long stays in dangerous unfamiliar environments.

A full assessment means immediate access to a range of diagnostics so the goal is to formulate an informed and supported ‘discharge plan’ before admission.

We also need experienced GPs in A&E to both prevent unnecessary admissions and to teach patients how Primary Care works. Of course inpatients would benefit from Consultant review at weekends but discharge requires both weekend Social support and transport. I would suggest the InstantCARE live-in carer solution until Social care can pick up the reins on Mondays.

A few cases every day will make an enormous difference. We certainly need to use hospital beds much more efficiently since the future NHS is going to require smaller hospitals.

Experienced gatekeepers seem the most sensible choice to contain costs throughout the NHS. Admissions can be prevented and discharges happen sooner if a few days of round the clock caring is fixed at home to help patients find their feet while being assisted in their treatment.

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