Head To Head

Should the NHS work at weekends as it does in the week? No

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f622 (Published 21 February 2013) Cite this as: BMJ 2013;346:f622
  1. Paul Flynn, chairman
  1. 1BMA Consultants Committee, London, UK
  1. PFlynn{at}bma.org.uk

Some royal colleges recently advised that patients should get the same consultant led care at weekends as they do on weekdays. Bruce Keogh (doi:10.1136/bmj.f621) agrees that this would benefit patients, but Paul Flynn sees little justification for elective care at weekends and asks who’s going to pay

Over the past two decades the NHS has been afflicted by the application of policies and practices copied from the world of business, where they have often already become obsolete. From fundholding onwards, policy makers have steadfastly ignored the obvious difference in the NHS, which is that NHS providers have only a limited ability to seek out new revenue in the way that other businesses can. What the NHS does is to care for people, and it is when it stops doing that in favour of providing services to customers that the rot really sets in.

It is inarguable that patients who need to seek medical care at weekends should receive the same standard of care as they do during the week, and the Academy of Medical Royal Colleges1 and individual royal colleges have set standards to reflect this.2 3 To achieve this will be no mean feat because in addition to ensuring that there are adequate numbers of consultants present it will require prompt access to diagnostic and therapeutic services, not to mention social services if discharge is to happen at weekends. Although acute care of this sort must take place on a seven day basis, there is little to justify the same approach to elective care.

Problems of extending elective care

One argument made for organising elective care over seven days is that it is necessary to meet the demands on the NHS and to bring down waiting times. Those of us working in the NHS are often frustrated at being prevented from doing our job as efficiently as we know we can. The BMA’s 2010 survey of consultants showed that they were most frustrated by their inability to effect change.4 The systems of finance and organisational structures often stand in the way of delivering efficient healthcare. It flies in the face of all logic to reward a system that is not using its existing resources to best effect over five days by giving it the opportunity to mismanage them over seven.

Any clinician can tell you off the top of his or her head three things that will make their clinic more efficient. Any surgeon can tell you three things that will make his or her operating list more efficient. It is time the NHS listened to the doctors who can tell it how to solve these problems and stopped just throwing a longer working week at it.

Another reason offered for operating elective services seven days a week is that the public expects it. The fact that shops now open at weekends is often quoted, as is the economic cost of workers taking time off to attend hospital appointments. However, although the distinction between the weekend and the rest of the week is less marked than it was in the past, society as a whole does not operate on a seven day basis. Schools and many businesses do not open at weekends, and much of the other infrastructure of society such as public transport does not operate a full service at weekends either.

A few years ago I moved one of my clinics to the early evening and was begged by many patients to move it back because there was no public transport home after 6 pm. Similarly, mothers with young families asked to have daytime appointments as outside school hours they would have to organise childcare. I fear that an entirely seven day NHS is catering for the convenience of the middle class and not the needs of those who are the greatest users of the NHS. A few clinics in evenings or at weekends will cope with this demand; the wholesale operation of the NHS seven days a week is a gross over-reaction.

All of this debate ignores the most important question: who’s going to pay for this? Many NHS providers are already in dire financial positions to the extent that some of them are consulting on making staff redundant.5 It is inconceivable that they will be able to staff operating theatres and clinics seven days a week, let alone provide all the other resources that this activity will consume. The public, I think, would rather such resources were focused on the sickest people who come to hospital.

If as a doctor I want to try a new way of treating my patients, my employer will quite rightly want me to show that there is proof that the treatment is safe and effective, not to mention cost effective. Sadly, rarely is such scrutiny applied to the re-disorganisations that the NHS is periodically afflicted with. One study even showed a poorer outcome for patients admitted for elective surgery at weekends.6 There should be no move to seven day elective working without piloting and careful evaluation of the outcomes.

As an obstetrician and gynaecologist, I’m already familiar with working at nights and at weekends, babies having a preference for arriving at night.7 I and my colleagues will always be willing to be there when patients need us, but we cannot be expected to have the same sense of commitment to addressing either management inadequacy or a small measure of public inconvenience.

Notes

Cite this as: BMJ 2013;346:f622

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References