In 2015 the Conservative Party set out to deliver a ‘truly 7 day NHS’ in their election manifesto. This was clarified further, resulting in a goal of anyone being able to see their GP any day of the week during normal working hours, and hospitals being staffed adequately for the quality of care to be the same no matter what day of the week.
The initial research done on the ‘Weekend Effect’ that triggered this move from the Conservatives was performed by Nick Freemantle et al in 2012, and reinforced by further work in 2015. They found that patients admitted to the NHS on Saturdays and Sundays had an increased risk of death (within the next 30 days) of 10% and 15% respectively. There was also a smaller increased risk on Mondays and Fridays. They concluded that around 11,000 more patients died each year if admitted on the weekend as opposed to during the week. With adjustment made for the fact that those admitted on the weekend are more sick, the increased risk diminishes, but is still present.
The BMJ, having weighed up the evidence, concluded that there was indeed a verifiably increased risk for those admitted on the weekend – but decried the Conservative’s decision to move on the research before some was published, and before time had been given to understand if understaffing was the cause of the increased mortality. To quickly summarise some of the evidence that shows notable excess deaths: in 2010 Imperial College found 3400 excess deaths associated with emergency admissions to NHS Hospitals in England on the weekend between 2005-2006, Nick Freemantle’s group published their research, and in 2015 University of Manchester researchers found either 4400 or 5400 excess deaths between 2010-2011. This may make it seem like the move to a 7-day NHS is logical.
However, you must remember that excess deaths does not mean preventable deaths. As the 2012 researchers themselves said when updating their research recently, ‘It is not possible to ascertain the extent to which these excess deaths may be preventable; to assume that they are avoidable would be rash and misleading.’ Some of the excess deaths may be caused by poor care, but we simply do not know how many yet. Recently, researchers led by Dr Yen-Fu Chen have found that sicker patients on the weekends are the cause of more of the excess deaths than was previously believed.
We must also consider that if the deaths are caused by understaffing, and it is that simple, then we cannot just increase staffing on the weekend with no tradeoff. There is a limited workforce, who are provided salaries and budgets from a limited pool of funds. By increasing staff on the weekend we would necessarily lower staffing during the rest of the week, potentially resulting in a lower standard of care at other times. The NHS works to balance its care carefully based on the quality of life improvements it can deliver to its patients, and how long its patients will live to enjoy that increased quality of life.
The NHS sought to make the following changes by 2020: routine general practice access at the weekends and in the evening, access to healthcare advice 24/7 via NHS 111, and quality hospital care providing 100% of the population with the same level of consultant assessment, review and diagnostic tests on any day of the week.
What do you know about the 7-day NHS?
The 7 day NHS was part of the 2015 Conservative manifesto and set out the goal of anyone being able to see their GP any day of the week during normal working hours, and hospitals being staffed adequately for the quality of care to be the same on any given day of the week. This was based on research done on the ‘Weekend Effect’ performed by Nick Freemantle et al in 2012 and reinforced by further work in 2015. They concluded that around 11,000 more patients died each year if admitted on the weekend vs if admitted during the week.
Do you think that the government was right to work towards a 7 day NHS?
The BMJ concluded that there was indeed a verifiably increased risk for those admitted on the weekend. Summarising some of the evidence that shows notable excess deaths, Imperial College in 2010 found 3400 excess deaths associated with emergency admissions to NHS Hospitals in England on the weekend in 2005-2006, additionally Nick Freemantle’s group published their research upon which the government first based its policy, and in 2015 researchers at the University of Manchester found either 4400 or 5400 excess deaths in 2010-2011. This may make it seem like the move to a 7-day NHS is logical. Overall, I believe that a properly instigated move to a 7 day NHS – one that takes into account the thoughts of doctors and healthcare professionals working in hospitals and GP practices – is a sensible and correct decision but would require huge investment and the training of additional staff.
What problems are there in trying to maintain the same level of staffing on the weekend as during the week?
First and foremost is the obvious fact that no-one – not even the most hardworking doctor or nurse – is likely to actively enjoy working on the weekend or elect to do so. There must therefore be some consideration given to their pay on the weekend, although the Conservatives new Junior Doctor Contract was pushed through with little regard for doctors’ thoughts on this matter. If we are to increase staffing on the weekends, this additionally raises the question of where the extra staff come from – understaffing is already an issue. Unless we are able to train large numbers of additional healthcare workers, we must make use of the existing pool. Therefore, using them on the weekend would mean for less availability during the week, and possibly therefore reduced standards of care during the week.
Why do you think that being able to see the GP during the evening or at the weekend is so important for many people?
As it stands, seeing one’s GP can be a far more complex and time-consuming procedure than it ought to be. Additionally, many people may have an urgent complaint that does not fit with what might be suitable for an A&E, and therefore wish to see their GP on short notice. Many people who have work or children to care for will simply be unable to attend a GP surgery at the times that they are open and offer appointments. As we move into the future, I would expect telemedicine and wearable technology to relieve some of this pressure, with people being able to remotely consult their GP and GPs being able to better monitor their patients.
Do you believe that doctors thought a 7-day NHS was in the best interests of their patients?
Doctors did not support the move – not out of self-interest, but because they believed it would be damaging to patients. The President of the Royal College of Physicians, Prof Jane Dacre, explained that there simply were not enough doctors in the country to run a 7 day NHS, and that the service was already understaffed. If the doctors were therefore forced to work weekends, these issues with staffing would become even more pronounced, leading to serious issues in the week as well. Junior doctors chose to strike over their new contract, chiefly because it was designed to make it cheaper to rota staff over the weekends – essentially meaning they would be working more weekends and less weekdays.
When answering, remember to consider both sides of the debate and refer to the difficulty of making conclusions on the research for this topic. Due to the (relatively) low number of deaths being assessed, and the inherent difficulties in conducting research in this area, only large trusts have been able to provide sufficient data to work off. Remember to explain that you believe decisions should be made based on published evidence, and in the best interests of patients – but that a demoralised workforce, or one that is overworked, and is a risk to patients as well.
You can readily link this topic to a discussion on evidence based medicine, on whether doctors should be able to strike (research the Junior Doctors’ Strikes) and on the structure and history of the NHS.
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