Should the NHS work at weekends as it does in the week? No
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f622 (Published 21 February 2013) Cite this as: BMJ 2013;346:f622
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It is all too easy to move from the finding of an association to an assertion of causation but we should expect more of the Medical Director of the NHS. A recent research report suggests that, at least in respect of acute medical care, the NHS is doing much better than he implies. Goldacre and Maisonneuve reported on ‘Mortality from meningococcal disease by day of the week’ (1). They concluded: ‘There are few, if any, other acute diseases in which the difference in mortality outcome between no treatment and effective treatment is so great and unequivocally related to care itself. There was no evidence of excess deaths from meningococcal disease associated with weekend care.’
1 Goldacre MJ, Maisonneuve JJ. J Public Health 2013 Feb 1. PMID: 23378233
Competing interests: No competing interests
The current “5 day workforce” is currently unable provide consistently high quality standards of care in today’s NHS. Further expansion of this to cover a 7 day working week will without doubt compound those problems already present, unveil many more and lead to further wasted resources.
There has been a tendency to compare the NHS to the business model of a large supermarket chain, as an example of successful 7day service provision.
Although there is a demand to address weekend service provision it would seem far more sensible to concentrate on improving efficiency during our 5 day normal working week and expand emergency provision at weekends rather than totally remodelling our current system.
Morale is already at rock bottom, as command and control continues to thrive in NHS culture. The 7 day working week will not be popular with an already over stressed workforce. In light of the Francis report, is time for the pendulum to swing back to consider the staff’s needs, wellbeing and their engagement. It is well known that staff satisfaction is reflected in patient satisfaction and outcome. In addition, the financial crisis and its associated cost constraints make these proposals untenable.
Competing interests: No competing interests
Whilst I fully support the call for continuity of emergency care to be provided across the 7 days, and also 24 hours a day, I cannot see how the NHS, and its workforce can offer the same "service" at weekends as during weekdays. Not only would costs be astronomical, but the chances of providing the beds needed to carry out a normal working day would be impossible. In addition, would doctors, radiographers, porters be paid much more for their weekend work, as a weekend is different to a weekday. Most social and sporting activities take place at weekend therefore the cost of the salary bill would be off putting.
The Royal Colleges are already promoting consultant presence on site for 12 hours a day, and this is ensuring quick review of sick patients. 10 day referrals ensure that patients ARE seen promptly, if used appropriately and not abused to get a patient in via the back door, and ensures that anxiety is kept to a minimum and clinical assessment is still delivered in due time.
More importantly, perhaps we need to look at why hospitals are dangerous places at weekends and work on these issues. Teams need to be more proactive and responsible, leaving clear plans for patients over the weekend. In addition, hospitals need to employ more doctors to cover the wards, to review patients and to manage them appropriately, again off putting as this costs money. More importantly we need to pressurise social services to come up to the mark and work efficently and promptly to discharge patients at the other end. This is what causes backlogs of ambulances outside departments at weekends, this is what cripples our hospitals and this is what endangers patients. Vulnerable people are kept in hospital longer due to delays in packages of care, develop Nosocomial infections and then sucumb to a preventable cause of death.
I would also question how we would work 7 days a week. Many hospitals cannot recruit enough doctors now, so how do they aim to recruit enough to fill a normal working day, every day?
Competing interests: Chairperson of the BMA Welsh JDC A medical registrar likely to be heavily impacted by changes to 7 day working
I cannot vote yes to the question posed because I do not believe it is possible for the NHS to work at weekends exactly as it does on weekdays but I am sympathetic to attempts to provide more and better services at weekends. A considerable number of problems would need to be overcome to make this possible.
Foremost in my mind is the provision of training to young surgeons. The amount of contact time I have with my trainees is already sub-optimal, largely as a result of the European Working Time Directive. My trainees miss a quarter of the operating lists, clinics and ward rounds where training might take place because of rota commitments (and miss more because of various types of leave). If I were to work on Saturdays and/or Sundays and have compensatory days off on week days, it would be essential that my trainees should do the same. This might be intolerable for young surgeons with young families.
I am also concerned about continuity of care. Cover arrangements in hospitals at weekends are constructed on the assumption that only the consultant led team on duty will be around. This presents some problems but is arguably better than a system under which various consultant teams are absent on various days in the week when cover arrangements are not robust. My own stage in life and career is such that I would be willing to consider working at weekends and having time off in the week - my No vote does not indicate a Luddite attitude - but I would only accept it if it were also acceptable to trainees and adequate continuity of care could be guaranteed. I am not convinced that these requirements could be met.
Competing interests: I am a consultant surgeon and might be affected by changes in working practices for NHS hospital doctors
I read with great interest “Should the NHS work at weekends as it does in the week? No” and “can the NHS be run like a supermarket” elsewhere, and I was asked similar questions before. And I completely agree with the author that it may be good but not a model that NHS can afford at the present situation without private initiative. We need to assess our affordability, availability of human resources, to run 24/7 service. As the author rightly pointed out we are not commercially profit driven service. We are public service people and we do with passion. In supermarket you get things because you pay for it and in NHS you don’t pay. People might point out it taxpayers money. If only patients are very clever and if certainly know what they want and they can like self-cater service self-treat, walk-in do their own tests, treatments and self-care for themselves probably this model may work. But are we in that situation really. And if that is the case actually we don’t need these many people and hospitals at all. Elsewhere it is published about 80% patients don’t understand or retain about the advice given in spite of written information. Elsewhere they have to send text reminders to be compliant with the advice or treatment given.
I am sure there are occasions ambulances were called for paper cut injuries, or called in the middle of night for an on-going problem for few months, and wanted answers or solutions instantly. Wanted to be seen but won’t wait for results of the investigations arranged. Has anyone walked into a supermarket in the odd hours trying to speak to someone for advice and do you really expect you will get someone sane to give instant answer. What are the odds of it? And we talk about 24/7 consultant cover in hospitals particularly ED and other acute specialities. But these services need support from other services like transport, social services, and diagnostics. The perks of seniority are the social hours. Can we afford to lose our senior and trained people? Because they can’t and are not ready to adopt these changes.
More importantly the staff in supermarket are trained for few days to few weeks depending upon the skills they are needed for. Unlike medical professionals who are trained for few years. If we have to work like a supermarket the main problem will be keeping up the morale of staff. Keeping up the skills and retention of skilled staff within NHS is a big task. Already NHS is facing big difficulties in staff recruitment. We are already being pressurised by target culture. Though it has done a lot of good, we can’t risk of losing more staff. We might need to write more letters to Santa to train us about the time management, resource management and keeping everyone happy.
Yes it may be a good model to provide service 24/7 like a supermarket in patient perspective but it is not economically viable for NHS or for the staff’s morale, at least for now. It is inevitable, happening slowly and we need to face it one day.
Dr Rajesh Vasiraju MBBS; MRCS; MCEM.
Cambridge.
Competing interests: No competing interests
Re: Should the NHS work at weekends as it does in the week? No
The answer is clearly no until we become more efficient in the weekday work.
a) Theatre efficiency is abysmal. More time is wasted waiting for the patient to be fetched. An audit of theatre efficiency will be an eye opener.
b) What about supportive staff? Nurses, ODPs, nurse practitioners, biomedical scientists, transfusion practitioners, physios, occupational therapists and last but not the least secretaries are willing to work?? its a clear NO
c) Getting a simple non-invasive investigation like trans thoracic echo over the weekend is a herculean task.
d) Laboratories - pathology, histology, microbiology are willing to work??
e) Compromise of the quality time for trainees who get only weekends to take decisions on their own and seek help if not sure.
Competing interests: No competing interests