#ImAtWorkJeremy: weathering the (tweet) storm over seven day services

29 July 2015

Two weeks ago, the Health Secretary, Jeremy Hunt, outlined his 25 year vision for the NHS. Central to that vision was the Government’s commitment to create a seven day health service, eradicating the “weekend effect” in English hospitals. Patients, he explained, are 15 per cent more likely to die if they are admitted to hospital on a Sunday compared to a Wednesday. Hunt set out plans to renegotiate the existing consultant contract which includes a weekend opt out clause, in what was dubbed a “war” on the BMA.

This triggered an angry reaction from some health service staff. The hashtag #ImAtWorkJeremy became a twitter sensation as doctors posted pictures of themselves in work the following weekend. This response, and some coverage of the speech, implied Hunt had accused NHS staff of slacking. Yet, he was clear that “every weekend swathes of doctors go in to the hospital to see their patients, driven by professionalism and goodwill”. To that extent, the tweeters were refuting an accusation Hunt never made.

Doctors’ objections also overlooked a well evidenced truth: hospital patients receive unequal care based on the day they turn up. While many doctors are at work over the weekend, they are not there in the same numbers and not consistently across the country. Sir Bruce Keogh, Medical Director at NHS England, writing in the Sunday Times, described this simply as “not sustainable”. Appearing before the Health Select Committee last week, Keogh outlined the damaging consequences for patient safety. Patients, he explained, have a 10 per cent higher mortality on Saturday compared to Wednesday, 15 per cent higher mortality on Sunday. Monday and Friday, affected by the bunching of work, also see raised mortality rates of 2 and 5 per cent respectively. The ultimate consequence of this, according to Keogh, is approximately 10,000 excess deaths a year.

To understand why, we must look to workforce deployment. Currently hospital staff time is concentrated Monday to Friday, 7am to 7pm. Preliminary findings from the High-Intensity Specialist-Led Acute Care project (HiSLAC) help to illustrate the problem. They surveyed 115 acute trusts in England, comparing consultant staffing on Wednesday and Sunday, and found that more than three times as many specialists attended acutely ill patients on a Wednesday than a Sunday. Moreover, there were “half the number of specialist hours per 10 emergency admissions on a Sunday compared to Wednesday”.

The Government is right to want to eradicate these variations in provision. Workforce reform will be critical. The consultant contract allows doctors to opt out of non-emergency weekend work. This hampers care continuity and raises costs for Trusts which must pay “unsocial hours” rates, of up to £200 per hour, to consultants who exercise the opt out. As Hunt has made clear, the new regime will not mean “asking any doctor to work longer hours”. But it will mean changing terms and conditions, working patterns and attitudes of NHS staff.

Workforce reform is always politically difficult. The experience of the last Parliament, and reaction to Hunt’s speech, demonstrates the inevitable resistance. Some NHS providers, however, have already innovated to deliver six or seven day services. Northumbria Foundation Trust, for example, has been working seven days a week since 2004. By introducing seven day contracts for consultants they have cut unnecessary admissions and improved patient flow. They have done so with full staff support. The Government should take heart from their example.

Leo Ewbank, Researcher, Reform

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