27 October 2013
The BMA is supporting a move towards making more NHS services available over seven days as part of a drive to ensure acutely ill patients have access to high-quality care throughout the week.
In a paper published today, the association says it ‘stands ready’ to work with other stakeholders to develop a model for delivering high-quality emergency, urgent and acute care to patients.
BMA consultants committee chair Paul Flynn (pictured right) says: ‘Most doctors recognise the difficulties that now exist in the NHS at weekends. We have to make sure that patients have access to high-quality urgent care no matter the day of the week.’
The BMA believes that NHS care should be of the same high quality across seven days. However, in the current economic climate, with huge financial pressure on the NHS, the BMA does not believe that resources could be freed up to deliver routine and elective services seven days a week. Instead the focus should be on delivering more and better urgent and acute care, which should help to reduce unacceptable variations in mortality.
A Seven Day Services Forum, led by NHS England national medical director Professor Sir Bruce Keogh, is also looking at issues of finance, workforce, clinical standards, commissioning levers and future service models. The forum is due to report next month.
How would seven-day services affect doctors?
Improving care quality for acutely ill patients means more NHS staff, especially senior doctors, on hospital sites at weekends and evenings, as well as doctors being able to access other therapies needed for their investigations.
Many consultants already provide on-call, or on-site, hours during weekends and evenings, but there has not been any robust modelling yet to indicate how many more would be needed to do this in a standardised way.
Dr Flynn says: ‘An appropriate consultant presence is central to ensuring high-quality emergency, urgent and acute care throughout the week but this is just one part of a service which needs to be fully resourced to achieve its aims.
‘That does not just mean that doctors will have to be there, it means doctors also being able to access therapies they may want to use for investigation.
‘Clearly, a seven-day service means having more doctors working at weekends and evenings and is going to create pressure on services during the rest of the week.
‘We have to make sure that resources are there so we are not just moving pressure on from one part of the system to another.’
While much of the focus of seven-day working has been on secondary care, there have been recent policy announcements about increasing access to general practice.
In England, a pilot scheme will give patients access to their GPs from 8am to 8pm, seven days a week. The BMA will support doctors taking part in the pilot and believes the findings should also be used to assess the cost-effectiveness of delivering extended hours in primary care.
What is the evidence for supporting this move?
The driving force behind changing the current model of care towards more seven-day services lies in a raft of studies offering evidence that quality is compromised in the current system.
According to these, hospitals are not delivering equally high standards of care to patients at night and at weekends compared to during normal working hours.
For example, a 2012 Journal of the Royal Society of Medicine study analysed 14.2 million NHS hospital admissions in England and found patients were 16 per cent more likely to die if admitted on a Sunday, rather than a Wednesday.
Fit for the Future?, a 2012 Dr Foster Intelligence report, found higher mortality rates for patients admitted at weekends. Higher levels of senior medical staffing at weekends were associated with lower mortality rates.
In 2010, the Royal College of Physicians of London published this statement: ‘Any hospital admitting acutely ill medical patients should have a consultant physician on site for at least 12 hours per day, seven days a week.
‘That physician should have no other duties scheduled during this time.’
These studies do not explain the differences in these figures. There are a range of factors that need to be taken into account, including the health of patients admitted over the weekend compared with during the week, and the availability of support services such as diagnostics or pharmacy, as well as the availability of staff, especially consultants.
In addition, the traditional model of primary and secondary care is under major pressure to improve quality and efficiency, whether through service reconfiguration or greater integration of health and social care.
Where is it already happening?
Seven-day services are already in evidence in certain trusts around the country — there are 30 case studies on the NHS Improving Quality website, although not all of these are in emergency, urgent or acute services.
Those that are include the Oxford Radcliffe Hospitals NHS Trust where, for the last 20 years, a 24/7 consultant-led and delivered orthopaedic trauma service has been in place.
Patient length of stay reduced while the number of operations performed has steadily increased.
After the first year the inpatient annual bed requirement fell, leading to a ward closure and ward reconfiguration. This, in turn, created a recurrent ward pay budget saving of £100,000 per annum.
A seven-day acute cardiology service at Royal Berkshire NHS Foundation Trust has led to changes in the emergency care pathway, with a 29 per cent reduction in emergency department admissions in its first year.
CC specialty lead in emergency medicine Simon Walsh says a resident consultant at night was introduced at his hospital, the Royal London, several years ago to ‘add value’ to the management of acutely unstable patients coming in to the emergency department at night.
‘The additional benefits included better supervision and training for our junior doctors and hands-on management of the shop floor late into the night, reducing risk and improving quality of care,’ he says.
‘We aspired to 24/7 consultant presence but it was not until a major trauma centre designation three years ago that we were able to secure the workforce expansion required to achieve this.’
Dr Walsh says local negotiations at the time led to a team job plan acceptable to employer and employees. This agreed the need for a resident consultant 24/7 in the emergency department and an understanding of the value added by this.
It also agreed a reasonable and sustainable frequency of weekend and night work with suitable recovery time and a healthy work-life balance, as well as appropriate remuneration.
Problems that were overcome included it taking time for the employer to recognise the level of workforce expansion required, especially in the face of financial pressures, which drive attempts to reduce cost while maintaining the same level of cover.
‘The positive aspects are that we are able to offer consultant-led and delivered care to those who most need it at any time of the night and day, in our emergency department this has clear, demonstrable value.
‘This comes at a cost though,’ he adds.
‘It is crucial that in any setting, either in emergency medicine or other acute specialties, the anticipated benefits are quantified and supported by evidence, before being weighed against the cost.’
The BMA plans to play a full role in achieving a clear understanding of what will be required to make seven-day services, which achieve the best outcomes for patients and are fair for doctors, a reality.
Read the BMA position paper
Read BMA council chair Mark Porter's blog
Read about the seven-day service case study in Oxford