What you need to know about the seven day NHS
Over the past two decades there has been a rise in the opening hours of many industries, such as supermarkets, transport, and retail, where you can access a broad range of services 24 hours a day. Despite this, many parts of NHS care are reduced at weekends, with primary care commonly unavailable and hospital staffing often run at lower levels.
However, this may be about to change. In his first major speech after being re-elected in May 2015, David Cameron reiterated the government’s drive towards providing a comprehensive seven day NHS service, which was initially set out in the Conservative Party’s 2010 manifesto. His speech included plans to open general practitioner surgeries from 8 am to 8 pm every day, alongside better provision in seven day hospital care.
Although extending the opening hours of the NHS will be a popular policy for the public, how will it work in practice and what will be the effect on the staff being asked to deliver it?
The move towards a more comprehensive seven day NHS has been driven by a combination of political and patient safety factors. Increasing evidence suggests that care is less effective at weekends. Often quoted figures in a study published by the Journal of the Royal Society of Medicine reported that patient death rates from weekend admissions compared with Wednesdays were 16% higher on Sundays and 11% higher on Saturdays. Evidence from Dr Foster Intelligence also links higher death rates at weekends to fewer senior doctors being present on the wards. These figures have raised serious questions about weekend care, even though the reasons behind the numbers have been contested. The evidence prompted NHS England, the national independent body set up to help improve patient outcomes, to initiate a Seven Days a Week forum in 2013. Led by NHS England’s national medical director, Bruce Keogh, the forum was to assess the possibility of making seven day access more comprehensive to improve patient outcomes. In the words of a patient representative to the forum, “Our illnesses and conditions don’t limit themselves to office hours. So why does the NHS?”
The forum, and subsequent reports, such as NHS England’s Everyone Counts, recommended several changes as part of wider reforms on how the NHS should be run. Suggestions in the reports focused initially on providing seven day diagnostics, urgent care, and emergency care provision, but they also set the goal of extending primary care opening hours and rolling out routine and support services at weekends over several years. The proposals included 10 clinical standards for providing better care over the seven days, with at least five to be reached by 2016-17 and the rest from 2017 onwards. Keogh has outlined the extent of the vision: “If you wanted a day case operation, and you didn’t want to take a day off work, why can’t you have it on a Saturday or Sunday?” However, NHS England has not yet defined the time frame and details of what a seven day NHS will look like, so it remains unclear when these plans will come into effect.
Will it make a difference?
Many hospital trainees and consultants, such as those in emergency medicine and acute care, already offer relatively consistent seven day services. Less acute wards can be left with junior doctors on the wards, registrars covering multiple wards, and consultants on call at home.
NHS England has provided an evidence base that suggests these standards improve factors such as readmission rates, length of hospital stay, and patient experience, and also reduce patient death rates. However, a study published in Health Economics argued that introducing more comprehensive seven day services in an attempt to reduce death rates would not be cost effective. The authors compared the health gain of avoiding emergency hospital admissions with the National Institute for Health and Care Excellence’s quality adjusted life years ratio and found that the cost of avoiding these deaths would far outweigh the average maximum spend on individual treatments.
To test the waters of extended GP opening hours, the government initiated the Challenge Fund in 2014 and launched a series of pilot schemes trialling daily 8 am to 8 pm opening hours as well as innovative techniques, such as Skype and email consultations. The first wave of schemes included 20 pilot sites covering seven million patients. The second wave will be even more extensive, covering 10.6 million patients. Analyses of the pilot schemes have not yet been released by NHS England, but reports on the success of different schemes have been varied. The GP magazine Pulse suggested in an investigation that five of the GP surgeries involved in the first pilot have reduced opening hours at weekends or evenings owing to a lack of demand from patients, with a further scheme abandoning evening and weekend consultations altogether.
The question of funding extended services also looms large over this ambitious project. NHS England estimates a £30bn (€42.5bn; $46.5bn) gap in funding by 2020, with £8bn promised from additional government spending each year by 2020, and the remainder made up by efficiency savings. Uncertainty exists over the proposed costs of seven day services, with analysts such as Chris Ham, of The King’s Fund, suggesting that the increase in government spending won’t currently be sufficient for the additional services.
Reactions within healthcare
Bruce Keogh has said that there is a moral duty to improve weekend services, a perspective shared by the BMA in their official position on the subject. In BMA surveys, weekend provision was supported by most members of the public and physicians “in principal.”  The finer details of the plans, however, have caused much debate about how they are to be implemented. In their position paper on the seven day plans, the BMA stated a need to focus on urgent and emergency care as a priority, highlighting the excessive costs of extending weekend hospital care within the economic climate. The union has repeatedly asked for clarification on what the plans will entail—BMA chair Mark Porter recently commented: “The government should clearly define what it means when it uses the term ‘seven-day service’ so that we know how much the additional services would cost, and how many extra doctors . . . would be needed to deliver them.” In July 2015, despite serious reservations from the BMA, health secretary Jeremy Hunt signalled his intention to push through a new deal for consultants that will remove the option for any newly qualified consultants to opt out of providing non-emergency care at weekends.
This is perhaps the biggest controversy that surrounds the extended primary care proposal, which comes amid a crisis in GP workforce levels. A BMA survey of current GPs reported that one third of GPs were considering retirement in the next five years; added to this are shortages in recruitment, with one in eight GP trainee posts not filled nationally. Similarly, Health Education England is targeting half of medical students to become GPs—the figure is currently only 20%. The health secretary has already promised 5000 new GPs by 2020 to meet the demand of extending practice opening hours. However, questions have been raised about the timing of these plans—Chaand Nagpaul, BMA GP committee chair, stated that “at a time when the government recognises general practice is under-resourced, it is not logistically possible for GP surgeries to be open nationally seven days, without stretching GPs so thinly so as to damage quality.”
As seven day working would likely contravene the European Working Time Directive (which stipulates working weeks of no longer than 48 hours), the reality is that England would simply need more doctors to deliver the broader care being discussed. In addition to more GPs, consultant cover, and nurses, extending opening hours would also necessitate the need for more staff such as physiotherapists, clinical laboratory staff, care homes, porters, and secretaries. Andrew Goddard, council member of the Royal College of Physicians, suggests that lack of staff could seriously hamper the speed of implementation of a seven day service. “It seems very unlikely there will be any more trainees in hospital medicine given the focus on primary care and this will both limit the rate at which seven day services for all hospitals can be achieved and also means we will have to look at how we can utilise other healthcare professionals to support patient care.”
The next steps for seven day working depend heavily on NHS England’s recommendations. Until we have sight of them, the extent of what services and personnel will form the seven day NHS remains largely unknown. Apart from possible changes to social hours in their contracts, the effect for junior doctors is likely to be small compared with consultants, with potentially more supervision time if consultants’ ward time increases out of hours. Medical students should see a cultural shift in NHS working times, with a better service during evenings and at weekends. A move towards encouraging careers in general practice might also occur, which would be in line with attempts to train more generalist doctors, as set out in the Shape of Training review. The details of seven day working will not be finalised overnight, but it is important that it meets its original aims to reduce the death rates from weekend admissions and improve access to primary care services. The change presents a challenge in terms of working with financial and staffing limitations, while ensuring patient safety is not compromised.
What we know
- Politicians and patients want a more comprehensive seven day NHS
- Pilots are under way to test the impact of extending opening hours of primary care services to 8 am to 8 pm
- Even if GP opening hours were extended, England faces a huge shortfall in the number of GPs to deliver these changes
- A seven day NHS will need more senior doctors working at weekends in hospitals
- Changes are likely to include consultants, acute care staff, and support staff
What we don’t know yet
- Whether the proposed changes will be cost effective for patient outcomes
- When these changes will fully come into effect
- How extensive seven day working will be. Whether weekend working will be as optimal as weekday care
- Where the additional staff will come from, and how the changes will be funded
1University of Nottingham
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h4037