Intended for healthcare professionals

Head To Head

Should the NHS work at weekends as it does in the week? Yes

BMJ 2013; 346 doi: (Published 21 February 2013) Cite this as: BMJ 2013;346:f621
  1. Bruce Keogh, NHS medical director
  1. 1Richmond House, London SW1A 2NS, UK
  1. Bruce.Keogh{at}

Some royal colleges recently advised that patients should get the same consultant led care at weekends as they do on weekdays. Bruce Keogh agrees that this would benefit patients, but Paul Flynn (doi:10.1136/bmj.f622) sees little justification for elective care at weekends and asks who’s going to pay

Initially conceived in 1940s America to respect Christian and Jewish practices, the weekend has been universally adopted in Western countries as protected personal time. In the UK challenges from high street retailers resulted in a change to the Sunday trading law in 1994. Since then, social behaviour has changed profoundly. Public expectations of service provision for customer convenience have resulted in the provision of routine services seven days a week in many industries—but not in healthcare.

This is a shame because extending the service would offer the opportunity to improve clinical outcomes with the added benefit of a much more patient focused service.

Weakness of current system

The NHS provides essential emergency care but not regular routine services on Saturdays and Sundays. Yet we have hard evidence that mortality for patients admitted to hospitals on both sides of the Atlantic is higher at weekends,1 2 3 4 that our junior doctors feel clinically exposed at weekends,5 and that hospital chief executives are worried about weekend cover.6 This has led to calls for greater consultant presence in hospitals at the weekend from Medical Education England,7 8 9 the Academy of Medical Royal Colleges,10 the Royal College of Physicians,11 and Royal College of Surgeons.

It is also clear that the lack of many seven day services has an adverse effect on measurable outcomes in each of the five domains of the NHS outcomes framework: mortality amenable to healthcare, treatment of long term conditions, outcomes from acute episodes of care, patient experience, and safety.12

We must ask why, in many hospitals, expensive diagnostic machines and pathology laboratories are underused, operating theatres lie fallow, and clinics remain empty. Yet, access to specialist care is dogged by waiting lists, and general practitioners and patients must wait for diagnostic results.

Imagine finding yourself in need of a blood test result, a diagnostic test, or specialist advice but having to wait an additional two days—for what reason? Intuitively many of us find this frustrating and unacceptable. Imagine, also, a young woman who finds a breast lump at 4 pm on a Friday. How easy is it for her to get a diagnosis and good advice before the beginning of the next week? What kind of weekend will she experience?

Making it work

The clinical, compassionate, and patient convenience arguments in favour of change are compelling. However, there will be difficult problems to solve, not least around the economics. This is not just about hospitals; it is about the whole system. One part cannot function efficiently at the weekend if other parts don’t. Progress will be contingent on improving primary and social care services at weekends as well as tackling some difficult problems in workforce planning if we are not to dilute the efficiencies of the standard working week.

It is right to try because it would enable us to be truly patient centred for the whole of the week, rather than two thirds of it, and we could improve access, shorten diagnostic response times, shorten hospital stay, and improve training.

This is why in its first iteration of planning guidance for the NHS the new NHS Commissioning Board has committed to looking at this matter in detail, with a broad range of interested parties.13 We cannot solve this in one go—the question is where to start. On advice from the medical royal colleges and the BMA we will begin by considering how to improve diagnostics and emergency and urgent care at weekends.

The proposal comes at a time when many doctors are worried about the effect of the global economic crisis and structural changes on the future of the NHS and the personal effect of NHS pension reforms and changes to the clinical excellence reward scheme. Many are worried that the NHS is being commercialised and that their professional values and commitment are being devalued.

This should not detract from the recognition that healthcare is a seven day commitment, and this is something doctors feel, believe, and understand. This proposal is based in the knowledge that doctors are good at solving problems and are the natural leaders for clinical change. The NHS Commissioning Board is offering an opportunity for our profession to step forward to consider the challenge of delivering seven day healthcare purposefully and constructively to secure benefits for our patients, our society, and our NHS.


Cite this as: BMJ 2013;346:f621


  • 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.


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