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We need joined up thinking on seven day services
Professor Norman Williams, Academy of Medical Royal Colleges Seven Day Consultant Presence Care Group Chair and President of the Royal College of Surgeons, calls for collective responsibility:
Illness is no respecter of time or boundaries. It can occur anywhere, at any time of the day or night, and a sudden onset of sickness or pain can be frightening for the bravest soul.
As the NHS is our safety net, patients rightly expect to receive high standards of care seven days a week and yet the health service still runs, for the most part, on a weekday timetable.
Perhaps most seriously of all, there is now clear evidence that mortality increases by approximately 10 per cent at weekends in the UK with some areas of medicine seeing even higher increases.
Some of these patients will be emergency admissions, where it is vital they are triaged and treated whenever they need it. The NHS already provides emergency cover at the weekends, and many doctors are involved in the care and treatment of very ill patients throughout the nights and across weekends.
As clinicians, the question we have to address is how we find a way of providing the right balance of care so the medical actions that need to happen urgently are taken urgently, that there is better awareness of emerging problems on a ward, and better access to treatment as soon as possible.
The patients that concern me are the non-emergency patients who are not seen by a senior clinician from Friday until Monday or even later during Bank Holidays: we know their chances of a full recovery would be better if they saw a consultant during that period.
As the debate about this intensifies, it needs to be said the NHS working across seven days is not the same as the NHS providing 24/7 care for every single condition. Many areas of care, particularly if it involves a small specialist team, are better managed on a Monday- Friday work pattern.
For the past year I have been chairing a steering group set up by the Academy of Medical Royal Colleges’ to examine the problem and make recommendations. Our first document, entitled Seven Day Consultant Present Care, was published earlier this year and highlights substantial variation in the availability of consultants and other senior doctors across different locations and areas of medicine at different times in the week.
The report recommends three standards should be set and met:
Firstly, hospital patients should be seen by a consultant or senior doctor at least once every 24 hours, 7 days a week. This should be mandatory unless it has been determined that this is not necessary for the patient, for example, if they are waiting for a placement in a care home or to see a social worker.
Secondly, consultant supervised interventions, investigations and reports should be provided daily if the results will change the outcome or status of the patient’s overall care before the next ‘normal’ working day.
The final requirement is for support services in hospital and community settings to be available daily to ensure the next steps in the patient’s treatment can be taken, as determined by daily consultant review.
Our group recognises that such recommendations will not be easy to implement and without major reconfiguration will require extra resources at a time when the NHS budgets are sorely stretched. However, there are trusts and services across the country where such changes to some extent have been, introduced.
We are working on practical guidance to support these standards which will be published later this year. This will reiterate the value of multi-disciplinary teamwork and co-ordination between hospital and community-based health and social care, as well as describing the key investigations needed at weekends.
I know from personal experience how frustrating it can be to need a scan for a patient while working on a Sunday only to find this cannot be delivered until the start of the ‘normal’ week. Similarly, as a surgeon I have waited hours for an operating theatre to become available at weekends and have had problems in arranging the discharge of a patient back home.
Many consultants already work at weekends, and many come in to see patients on whom they have operated in the previous week, but they cannot work effectively if the back-up services, such as pharmacy and physiotherapy are not there. We also need access to radiology and pathology services so that decisions on a patient’s care can be made at the right point. When a doctor does a ward round, they rely on the whole team behind them, including administration support. That support also extends in to the community, where we need to integrate with social care services so a patient can return home to be cared for when they no longer require a hospital bed.
All of this will cost the NHS money. We need to have robust economic modelling for whatever solutions we arrive at. Indeed, in some cases money will be saved as patients aren’t left to deteriorate over the weekend and can be treated right the first time.
As the debate on how best to provide a seven day service gathers pace, conversations about how services are organised cannot be avoided. As a college, we support reconfiguration when there is a strong clinical justification for change. We must ensure that services are designed to enable patients in less populated areas to receive the right continuity of care, and patients and their families must be fully involved in any decisions made.
The challenges ahead for reconfiguration will mean clinicians, managers and politicians working collaboratively to support the changes which will deliver the benefits we all want to see.
Medicine has never been a Monday to Friday, 9 to 5 occupation and nor should it be. While there is no silver bullet, medical professionals must take collective responsibility for patient care and work cohesively to deliver a true seven day service.