Seven-day NHS: seven questions answered

http://www.theguardian.com/society/2015/may/18/seven-day-nhs-seven-questions-answered

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1: What is David Cameron proposing?

A: He is pledging that England will have “become the first country in the world to deliver a truly seven-day NHS” by 2020. This repeats a key promise in the Tories’ election manifesto and takes much further the prime minister’s plans, first unveiled at his party’s conference in October 2013, for seven-day access to GPs. In his speech on Monday he guaranteed that patients would be able to receive care and treatment “wherever they are and whenever they need it”.

But there is considerable scepticism about how fast that ambition can be made a reality, given the NHS’s chronic financial and staffing problems. The responses from health unions, the NHS England chief, Simon Stevens, and ex-health minister Norman Lamb, underline that.

2: Has the prime minister spelled out exactly what he wants to happen?

Related: NHS England chief: cash shortages could hit plans for seven-day health service

A: No. Cameron’s pledge raises a large number of questions, none of which are easy to answer, especially – despite his rhetoric – given the lack of detail about the services he intends to run 24/7. He could mean just urgent and emergency services, such as potentially life-saving surgery, backed up by the diagnostic tests they inevitably involve, such as blood tests, X-rays and scans. But he may also mean that patients will in future be able to have their check-up or outpatient appointment on a Saturday or Sunday, to save them taking time off work during the week.

He has also given no timetable, so measuring progress towards his ambition may be hard.

3: Why is he pledging this?

A: Because of what he called the “shocking fact” that death rates among patients, especially the seriously ill, who are admitted on a weekend can be up to 16% higher than for those come in during the week. Work by NHS England’s seven-day services working group has found that: “Evidence shows that being admitted to hospital at the weekend is associated with a significantly increased risk of dying within 30 days of admission compared to being admitted on a weekday.”

It is thought that some of those who end up in hospital then, especially those with serious or life-threatening illness – such as those who have had a heart attack or stroke or an accident or who are complicatedly unwell – can receive poorer care because there are fewer senior, experienced doctors (consultants) on duty and the more junior staff who are looking after patients may not make the right decisions. In some hospitals an inability to diagnose the patient’s illness or get a full picture of their condition, because X-rays or CT or MRI scans are not available 24/7, can also be a problem.

Downing Street said that: “The shift to seven-day-a-week opening will help to deliver a safer NHS and more lives saved.”

But Cameron also plans to drive forward on a 24/7 NHS because he sees it as an important way of relieving the rising pressure on both hospitals and GP surgeries. Jeremy Hunt, the health secretary, said during the election campaign that greater weekend working would be the most efficient way of meeting rising demand for services caused by the ageing, growing and increasingly unwell population.

4: But isn’t the NHS already a seven-day service to some extent?

A: Yes and no. Ambulance services, maternity services, out-of-hours GP services, accident and emergency care and some other acute hospital services already operate around the clock across all seven days in all parts of England. For example, many hospitals also provide emergency surgery outside normal working hours. Those are urgent and emergency services. But few routine services, such as planned surgery, outpatient clinics and GP visits, are available at weekends.

The British Medical Association says that “many GP and hospital services are available around the clock, seven days a week”. However, in October 2013 the Guardian found that only a tiny minority of GP surgeries are open on a Saturday and Sunday. More have expanded their opening hours since then, partly as a result of Cameron making money available for them to do so through his Challenge Fund.

5: What does the NHS itself think about becoming a seven-day service?

A: It declared in 2013 that it intended to transform itself into that. The view of its seven-day services working group is that: “The demand for urgent and emergency care does not follow a pattern that is consistent with the traditional working week of Monday to Friday, nine to five. If a profession, service or facility is important to the care of patients, the NHS cannot justify a delay in its availability based solely on the fact it is the weekend.

“Accepting the limitations of NHS resources, and the inter-dependencies of care which make providing an equitable service a challenge of viability as well as one of principle, every effort should be made to ensure that the standard of care a patient receives, their experience of it and the outcome as a result, are not impacted by the day of the week.”

6: How much would it cost?

A: No one knows. A figure of £2bn has been suggested. But Prof Sir Bruce Keogh, NHS England’s medical director, rejected that figure as unreliable. Work by the Healthcare Financial Management Association commissioned by NHS England concluded that it was difficult to say exactly how much it would cost for the NHS as a whole.

However, their research (pdf), centred on eight hospitals, said that costs would vary but the typical cost would be 1.5% to 2% of a hospital’s budget.

Costs would be higher for small hospitals and those outside cities, and recruiting extra consultants would be the main cost involved, it found.

The British Medical Association maintains that it would cost much more than that, given their view that the switch to seven-day working could add as much as 40% to the NHS’s workload. Deloitte has also been commissioned by NHS England to do more work on costings, the Health Service Journal reported earlier this year. But nothing further has been heard about the findings.

The key to the eventual cost of a seven-day NHS, if it happens, is the attitudes of consultants and the BMA, the doctors’ union. It walked out of negotiations with NHS Employers about the contractual implications of seven-day working last October, although it has since made conciliatory noises about resuming discussions. However, it is keen that there are safeguards to prevent senior hospital doctors working excessive hours and a 24/7 service being properly funded.

7: How feasible is a seven-day NHS?

A: At the moment it is hard to see that Cameron’s ambition will be achieved any time soon. Privately some senior doctors call it “impossible” and “pie in the sky”.

The NHS’s deepening financial problems are a major obstacle, though the PM could potentially make some further extra money available for that purpose. NHS leaders say that the additional funding the Conservatives have promised, rising to £8bn by 2020, is only enough to keep up with rising demand, not to provide extra services too.

However, the main stumbling block is the increasingly chronic shortage of many different types of medical staff – nurses, GPs, paramedics, radiologists, A&E doctors and many others – that the NHS is facing. No one expects those to be alleviated any time soon.

There is also doubt as to how many patients want to visit a GP on, say, a Sunday, early evidence from those which have recently begun opening longer suggests.