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Views And Reviews Acute Perspective

David Oliver: Consultant contracts and seven day services

BMJ 2016; 354 doi: (Published 12 August 2016) Cite this as: BMJ 2016;354:i4357
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

It’s a year since England’s health secretary, Jeremy Hunt, gave a speech linking his government’s promise of “truly seven day” NHS services with changes to contracts for the junior doctors and consultants supposed to enable this.1

He has suggested that a need for more “senior decision makers” (consultants) at evenings and weekends justified changes to trainees’ contracts. Meanwhile, however, the consultant contract has been on the back burner.2

As the NHS’s medical director, Bruce Keogh, has stated, Hunt further conflated issues by suggesting that contract changes were essential for delivering seven day services.3 More confusion ensued about whether seven day services should include only acute unscheduled care or elective and outpatient care too.4 5

We need realism. Broke commissioners of services from broke hospitals can’t pay for more elective activity. Hospitals busy trying to limit demand can hardly trade their way into workforce expansion. NHS Improvement has called for honesty on this.6

Meanwhile, at the sharp end of acute care, we already have seven day services. In emergency departments and in acute medical, intensive care, and coronary care units you’d be hard pressed to tell what day it was. Consultants are aware that deeper hospital wards aren’t staffed the same on a Sunday evening as on a Monday morning, although the National Audit Office has shown that arrangements for daily senior review are the norm, not the exception suggested by political spin, and that most newly admitted patients are seen by a consultant on the same or next day.7 8

True seven day working would require major increases in workforce and morale. There are no such expansion plans

Most acute consultants have worked evenings and weekends their whole careers. They don’t opt out of doing so contractually and are often paid small uplifts for spending long hours physically at the hospital when they do weekends on call.

Well before Hunt, Keogh had passionately argued the case for weekends more closely resembling weekdays in hospital, as had the Academy of Medical Royal Colleges.9 A Royal College of Physicians survey found that 70% of consultants favoured seven day acute services.10 Many consultants would love to work in a dream system with enough staff across all professions, services, and care settings to deliver against the 15 standards for seven day services set out by NHS England—but not at the cost of burnout.9

And this is the crux: true seven day working would require major increases in workforce and morale. There are no such expansion plans, and we face current and future recruitment and rota gaps throughout acute specialties.11

Wrightington, Wigan, and Leigh Trust has shifted to more seven day acute services, but getting there cost £2.1m for 34 extra staff.12 Let’s stop pretending that a contract change for just one staff group in isolation can deliver comprehensive seven day services.



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