In recent years, there has been growing evidence of the ‘weekend effect’, i.e. that outcomes are worse for those patients who are admitted to hospital during weekends. The weekend effect is expensive too: patients with high mortality risk who are admitted at weekends tend to have a longer length of stay than similar patients who are admitted during the working week.1
In response to this evidence there has been renewed focus on reducing the difference in clinical outcomes during the weekend. Led by the NHS Services Seven Days a Week Forum, new clinical standards and priorities were developed in 2013.
Together, they underpin the vision of a 7-day NHS, where all citizens by 2020 should have:
- Access to GP appointments in the evenings and at weekends;
- Access to urgent healthcare advice 24/7 via NHS 111;
- Quality hospital care with access to the same level of consultant assessment and review, diagnostic tests and consultant-led interventions regardless of the specific day of the week.
The challenge to deliver
The ambition is great, but delivery is hard. The idea of introducing 7 day NHS services has been challenged on many fronts.
Firstly, many academics, health professionals and politicians doubt that 7 day services can actually be achieved in the current financial climate. According to NHSE estimates, the cost of transforming the current system into a full 7 day NHS is between £1.07 and £1.43bn, and – while it would bring with it improved patient experience, access to services and likely greater health outcomes – it is at best unclear how we can pay for this, given existing budget constraints.
Secondly, there are widespread arguments that a budget to implement 7 day NHS could be better spent elsewhere. Meacock et al. have considered the costs of extending normal operational hours against the predicted benefits. Using NICE threshold figures to assess value for money, they put forward an argument that the NHS should spend no more than £595m to £731m to justify the investment – i.e. only around half of what NHSE estimate it costs to implement 7 days services. Opposition to the idea of a 7 day NHS has also come from senior clinical figures, such as the Chair of the BMA GPs committee, Dr Chaand Nagpaul, who expressed doubts that there would be enough demand for weekend GP appointments to justify opening surgeries every day.
Thirdly, there are some who question the fundamental evidence-base behind the change. The business case for 7 day services is based on an assessment about cost and impact – informed judgements and assumptions of what might happen. However, the numbers and the qualitative analysis have been subject to some debate. For example, Meacock et al. (2015) conclude that ‘There is as yet no clear evidence that 7-day working will, in isolation, reduce the weekend death rate’,3 whilst others challenge the notion that the weekend effect even exists.
Finally, perhaps the most fundamental challenge to the introduction of a fuller 7 day NHS is related to the capacity in the system to deliver.
Despite all this, the majority of policy makers and practitioners agree that 7-day services are a powerful way to improve quality of care, build greater capacity in the system and give citizens greater flexibility and choice in where and when to access services.
We argue that three fundamental things are needed in order to drive sustainable change: workforce transformation; shifting patterns of demand; and focus on outcomes.
- Workforce transformation: A 7 day NHS requires new ways of working, different incentive structures and staff being able and willing to work flexibly. The latest controversy around junior doctors’ contracts is a powerful example of how difficult this is to achieve in practice. Amongst a number of other changes, the Secretary of State for Health Jeremy Hunt sought to include Saturdays and weekday evenings from 7pm to 10pm as normal working hours. Junior doctors did not feel the new contract offered sufficient remuneration for flexibility and were concerned about the safety of patients under the proposed change in their working hours. As a result, they met the new contract with fierce resistance and strikes. Naturally, the need for greater flexibility goes for all clinical and non-clinical staff including nurses, radiologists, pharmacists, biomedical scientists, health care assistants, porters, cleaners and admin staff.
- Shifting patterns of demand: A cornerstone of the business case for 7 days’ services is a need to shift health and care provision from hospitals into the community. Introducing 7-days services requires close collaboration with citizens to shift perceptions of who – and where –can best meet their needs. This can be supported by effective prevention strategies and by enabling people to take greater responsibility for their health. In practice, this means self-caring for minor ailments; supporting self-management for people diagnosed with long-term conditions; and building resilience in the communities, to prevent people from getting ill in the first place
- Focus on outcomes: Ultimately, health and wellbeing cannot be achieved without active involvement and engagement of citizens; patients, service users, carers and communities. In designing 7-days services, it is crucial that investments are made on services that are actually achieving the best outcomes. Targets are clearly important to make sure that standards of care are high and consistent across the country, but the focus should be on measuring meaningful metrics that drive service improvements and better quality of care.