Can the NHS become a 7-day service for all?
I
n his first major speech since winning the 2015 general election, Prime Minister David Cameron has unveiled his plans for the introduction of a comprehensive 7-day NHS (Prime Minister’s Office et al, 2015). Although much of the election was fought on the battle field of the NHS, with much speculation by opposing political parties that the NHS was not safe in the hands of a Conservative government, this new initiative is designed to show critics that, despite claims that his government would dismantle the NHS, David Cameron will actually increase spending on the service by an extra £8 billion a year by 2020. The NHS is fiercely defended by all political parties with a mantra of free health care for everyone, wherever they are and whenever they need it. But what lies behind the rhetoric?
Background The NHS has been under continuing and relentless strain in recent years, and much of it is blamed on the changes to the GP contract in the 1990s, leading to a radical decline in outof-hours services. This placed the system of 24hour care by GPs under considerable pressure (Hallam, 1994). In an attempt to address these shortcomings in service provision, the then Conservative government introduced a range of measures to give the public access to out-ofhours medical care. This included the launch of NHS Direct and other telephone management strategies, with Lattimer et al (1998) showing that nurses were able to effectively and safely give telephone consultation to patients in outof-hours primary care situations. However, these strategies failed to stem the demand for out-of-hours care, especially over weekends. In desperation, many patients resorted to using emergency departments in district general hospitals for medical attention. This trend has now been exacerbated by the burden of health care for the increasing numbers of older people requiring medical attention and those with long-term conditions. Few would argue that the current models of care delivery were not designed for the health challenges of today, and
706
tomorrow. The changing patterns of disease and the rising expectations of the public are fuelling demand for fundamental changes to the way the NHS works. In particular, care provision for patients beyond the hospital will need to be strengthened. Much of this is predicated on creating more GP positions and more surgeries in the community, but Donnelly (2015a) reported that one in three posts for trainee GPs across the country has not been filled, with the Royal College of General Practitioners indicating that more than 500 practices are under threat of closure. Donnelly attributes this situation to the reality that many GPs are now close to retirement age and this is compounded by too few younger trainees willing to enter the profession (Donnelly, 2015a).
Introducing 7-day working In 2013, Bruce Keogh, the Medical Director of the NHS in England, highlighted that the expectations of customers in most industries has led to service provision being built around their convenience, resulting in 7-day service provision being available—with the exception being health care (Keogh, 2013a). Keogh seeks to address the real problems facing the NHS, where, sadly, illness, trauma, heart attacks, mental-health crises and strokes do not limit themselves to office hours. So why does the NHS? Keogh highlighted that there is compelling evidence that 5-day NHS working causes increased mortality rates with an 11% increase in death rates among patients admitted on a Saturday, and a 16% increase among those admitted on a Sunday (Freemantle et al, 2012). This is why he made provision of 7-day services across the NHS his number one priority and leads a forum to make 7-day NHS provision a reality to address some of these unmet need issues, both in hospitals and in the community (NHS England, 2013). Although clinical studies have reported higher mortality for patients admitted on weekends, it is not clear if this ‘weekend effect’ is affected by skill mix and staffing
ratios at weekends (Keogh, 2013b). Bray et al (2014) have shown, for example, that mortality outcomes for patients suffering stroke at weekends are associated with the intensity of weekend staffing by registered nurses, but not 7-day week attention by stroke specialist physicians. Despite this finding, Peter Carter, Chief Executive and General Secretary of the Royal College of Nursing (RCN), acknowledged that there are significant levels of evidence to show that the way parts of the NHS operate at the weekend simply has to change (RCN, 2013). Introducing 24/7 working is, however, not embraced by all, and the British Medical Association (BMA) has accused the Government of not explaining how this additional care delivery emphasis will be achievable while there is a shortage of doctors, especially GPs and emergency care physicians (BMA, 2015). Similarly, Mason (2013) reported that doctors believe that the plans to roll out 7-day services across the NHS will compromise resources and threaten the quality of care delivery during the week, thus posing a danger to patient safety. Mason has also reported that GPs are not happy with the Prime Minister’s vision of GPs offering advice over the internet and opening surgeries for longer hours, 7 days a week, to help ease the pressure on struggling hospital emergency departments (Mason, 2013). Although the nursing profession has traditionally embraced 7-day working, and for most clinical nurses there is nothing novel about working across the 24/7 cycle, some are opposed to the Prime Minister’s initiative. Members of the trade union Unison are concerned that the plans for a 7-day NHS may result in healthcare workers losing their extra remuneration for working unsocial hours. Delegates at Unison’s annual healthcare conference in 2015 voted to ballot for industrial action if any future government tries to remove the unsocial hours payments that are traditionally linked to standard salary packages (Donnelly, 2015b).
© 2015 MA Healthcare Ltd
Alan Glasper, emeritus professor at the University of Southampton, discusses the launch of a new campaign by the Prime Minister in which he pledges his Government’s commitment to providing free health care for all, wherever and whenever they need it
British Journal of Nursing, 2015, Vol 24, No 13
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY Sir Bruce Keogh has acknowledged those that oppose his aspirations for the NHS by emphasising that it is necessary to move beyond the debate about 7-day working, where the emphasis is on the people delivering the service, but to relate to the concept of a 7-day service that concentrates on patients. NHS England is therefore committed to offering a more patientfocused service. Part of this commitment will be fulfilled by moving towards routine NHS services being made available 7-days a week. In December 2012, the policy Everyone counts: planning for patients 2013/14 sets out the initial step towards identifying how there might be better access to services 7 days a week. Keogh set up the 7-day services forum which is focusing on making 7-day working more than just a vision, and is the backdrop to the Prime Minister’s campaign for the 7-day NHS moving from aspiration to reality. The forum has developed ten evidence-based clinical standards to end current variations in outcomes for patients admitted to NHS hospitals at the weekend. Keogh wants these to be fully adopted by 2016–17 (Keogh, 2013c). The standards specify, for example, that all hospital inpatients have access to diagnostic services, and that support services in hospital and primary, community and mental health settings are available 7 days per week. The healthcare regulator, the CQC, will be empowered to monitor the implementation of these standards (Keogh, 2013c).
© 2015 MA Healthcare Ltd
The Prime Minister’s vision In his speech (Prime Minister’s Office et al, 2015), David Cameron gave his personal commitment, and that of his Minister for Health, to a number of core principles. David Cameron believes that the NHS should unite and bind all people to the same achievable goal of making the NHS the best health service in the world. In addition to increasing funding he is seeking to raise staffing levels. He is open to third-sector organisations being given the opportunity to work with the NHS to deliver services. He does, however, fully appreciate that there are pressures on the NHS, not least being felt by emergency departments, and rising numbers of people needing dementia care. He believes his government will put quality, safety and compassion back at the heart of the NHS. The prime minister wants to meet the huge challenges facing contemporary health care and he wants the NHS to harness the opportunities presented by the advance of science and technology to support people living longer and coping with more complex health conditions. Importantly, David Cameron values the committed work ethic of NHS doctors and
British Journal of Nursing, 2015, Vol 24, No 13
nurses and he understands the pressures they face every day and night. He also acknowledges the worries and concerns people have about the future of the NHS. At the heart of the plan is a focus on healthy living to address some of the morbidities in society such as obesity. Crucially, in this plan, he is committed to multidisciplinary working where the sum of the NHS workforce is greater than the sum of its parts, with electronic health records available giving patients a real say over how they are cared for and who cares for them. He also envisages faster access to new drugs and treatments with a renewed focus on mental health. The Prime Minister is aware that one in four people in the UK has a mental health condition and he believes that these people should get access to more timely and supportive help. He has pledged his government will go further in enabling full transparency about the quality of mental health services in every part of the country. To achieve this he intends to publish audit information on how good mental health services are, so that any deficiencies in service provision can be identified to drive up standards. The Prime Minister is confident about his vision—of a modern NHS offering services 7 days of the week, whenever and wherever it is needed. In his view, this begins with a transformation of primary care and supporting GP surgeries to open from 8 am until 8 pm, 7 days a week. He wants primary care to be re-engineered with an emphasis on prevention and holistically treating the whole person. It is the implementation of modern communication technology into primary care that will, for example, allow patients to use an app to book appointments for before or after work and order a repeat prescription online. The Prime Minister wants, by the end of this financial year, 18 million patients to have access to a GP at mornings, evenings and weekends, and by the end of the current parliament that everyone will have an NHS that provides 7-day services in all areas, including hospitals.
Conclusion The Prime Minister is open about the scale of the challenge in making his vision a reality, but believes he has the whole nation behind his aspiration to become the first country in the world to deliver a truly 7-day health service. Ham et al (2014) insist the overriding priority must be to achieve closer integration of care where the services are safe, effective, responsive, caring and well-led, underpinned by an overarching need BJN to ‘first do no harm’. Bray BD, Ayis S, Campbell J et al (2014) Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Med 11(8): e1001705 British Medical Association (2015) Doctor shortages overshadow seven-day services pledge. http://tinyurl.com/ qcgye2n (accessed 26 June 2015) Donnelly L (2015a) One in 3 trainee GP posts are empty, amid warnings of crisis shortage. The Telegraph (online). 6 April. http://tinyurl.com/mkzrth9 (accessed 26 June 2015) Donnelly L (2015b) NHS union votes to ballot to strike if ‘7 day NHS’ means pay cuts. http://tinyurl.com/o7q4g2v (accepted 26 June 2015) Freemantle N, Richardson M, Wood J et al (2012) Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 105(2): 74–84 Ham C , Dixon A, Brooke B (2014) Transforming the delivery of health and social care. The King’s Fund. http:// tinyurl.com/cshydnp (accessed 26 June 2015) Hallam L (1994) Primary medical care outside normal working hours: review of published work. BMJ 308(6923): 249–53 Keogh B (2013a) Should the NHS work at weekends as it does in the week? Yes. BMJ 346: f621 Keogh B (2013b) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. http://tinyurl.com/ph9e267 (accessed 30 June 2015) Keogh B (2013c) NHS services seven days a week. http:// tinyurl.com/pv6mrb4 (accessed 29 June 2015) Lattimer V, George S, Thompson F et al (1998) Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial.The South Wiltshire Out of Hours Project (SWOOP) Group. BMJ 317(7165): 1054–9 Mason R (2013) GP surgeries to open seven days a week, says David Cameron.The Guardian (online). http://tinyurl. com/ojb9kcp (accessed 26 June 2015) NHS Commissioning Board (2013) Everyone counts: planning for patients 2013/14. http://tinyurl.com/phobxpq (accessed 26 June 2015) NHS England (2013a) NHS England’s Sir Bruce Keogh sets out plan to drive seven-day services across the NHS. http://tinyurl.com/nzyz6fd (accessed 26 June 2015) Prime Minister’s Office, Department of Health, Cameron D (2015) PM on plans for a seven-day NHS (speech). 18 May. http://tinyurl.com/ma47xu5 (accessed 26 June 2015) Royal College of Nursing (2013) RCN response to Sir Bruce Keogh’s plans for 7 day working in the NHS. http:// tinyurl.com/pshq7my (accessed 26 June 2015)
KEY POINTS n In his first major speech since winning the 2015 general election, Prime Minister David Cameron has unveiled his plans for the introduction of a comprehensive 7-day NHS n There is evidence that 5-day NHS working causes increased mortality rates for some groups of patients admitted over weekends n One in three posts for trainee GPs across the country has not been filled, with the Royal College of General Practitioners indicating that more than 500 practices are under threat of closure n Some are worried that a 7-day NHS may result in health professionals losing their extra remuneration for working unsocial hours
707
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
I
n his first major speech since winning the 2015 general election, Prime Minister David Cameron has unveiled his plans for the introduction of a comprehensive 7-day NHS (Prime Minister’s Office et al, 2015). Although much of the election was fought on the battle field of the NHS, with much speculation by opposing political parties that the NHS was not safe in the hands of a Conservative government, this new initiative is designed to show critics that, despite claims that his government would dismantle the NHS, David Cameron will actually increase spending on the service by an extra £8 billion a year by 2020. The NHS is fiercely defended by all political parties with a mantra of free health care for everyone, wherever they are and whenever they need it. But what lies behind the rhetoric?
Background The NHS has been under continuing and relentless strain in recent years, and much of it is blamed on the changes to the GP contract in the 1990s, leading to a radical decline in outof-hours services. This placed the system of 24hour care by GPs under considerable pressure (Hallam, 1994). In an attempt to address these shortcomings in service provision, the then Conservative government introduced a range of measures to give the public access to out-ofhours medical care. This included the launch of NHS Direct and other telephone management strategies, with Lattimer et al (1998) showing that nurses were able to effectively and safely give telephone consultation to patients in outof-hours primary care situations. However, these strategies failed to stem the demand for out-of-hours care, especially over weekends. In desperation, many patients resorted to using emergency departments in district general hospitals for medical attention. This trend has now been exacerbated by the burden of health care for the increasing numbers of older people requiring medical attention and those with long-term conditions. Few would argue that the current models of care delivery were not designed for the health challenges of today, and
706
tomorrow. The changing patterns of disease and the rising expectations of the public are fuelling demand for fundamental changes to the way the NHS works. In particular, care provision for patients beyond the hospital will need to be strengthened. Much of this is predicated on creating more GP positions and more surgeries in the community, but Donnelly (2015a) reported that one in three posts for trainee GPs across the country has not been filled, with the Royal College of General Practitioners indicating that more than 500 practices are under threat of closure. Donnelly attributes this situation to the reality that many GPs are now close to retirement age and this is compounded by too few younger trainees willing to enter the profession (Donnelly, 2015a).
Introducing 7-day working In 2013, Bruce Keogh, the Medical Director of the NHS in England, highlighted that the expectations of customers in most industries has led to service provision being built around their convenience, resulting in 7-day service provision being available—with the exception being health care (Keogh, 2013a). Keogh seeks to address the real problems facing the NHS, where, sadly, illness, trauma, heart attacks, mental-health crises and strokes do not limit themselves to office hours. So why does the NHS? Keogh highlighted that there is compelling evidence that 5-day NHS working causes increased mortality rates with an 11% increase in death rates among patients admitted on a Saturday, and a 16% increase among those admitted on a Sunday (Freemantle et al, 2012). This is why he made provision of 7-day services across the NHS his number one priority and leads a forum to make 7-day NHS provision a reality to address some of these unmet need issues, both in hospitals and in the community (NHS England, 2013). Although clinical studies have reported higher mortality for patients admitted on weekends, it is not clear if this ‘weekend effect’ is affected by skill mix and staffing
ratios at weekends (Keogh, 2013b). Bray et al (2014) have shown, for example, that mortality outcomes for patients suffering stroke at weekends are associated with the intensity of weekend staffing by registered nurses, but not 7-day week attention by stroke specialist physicians. Despite this finding, Peter Carter, Chief Executive and General Secretary of the Royal College of Nursing (RCN), acknowledged that there are significant levels of evidence to show that the way parts of the NHS operate at the weekend simply has to change (RCN, 2013). Introducing 24/7 working is, however, not embraced by all, and the British Medical Association (BMA) has accused the Government of not explaining how this additional care delivery emphasis will be achievable while there is a shortage of doctors, especially GPs and emergency care physicians (BMA, 2015). Similarly, Mason (2013) reported that doctors believe that the plans to roll out 7-day services across the NHS will compromise resources and threaten the quality of care delivery during the week, thus posing a danger to patient safety. Mason has also reported that GPs are not happy with the Prime Minister’s vision of GPs offering advice over the internet and opening surgeries for longer hours, 7 days a week, to help ease the pressure on struggling hospital emergency departments (Mason, 2013). Although the nursing profession has traditionally embraced 7-day working, and for most clinical nurses there is nothing novel about working across the 24/7 cycle, some are opposed to the Prime Minister’s initiative. Members of the trade union Unison are concerned that the plans for a 7-day NHS may result in healthcare workers losing their extra remuneration for working unsocial hours. Delegates at Unison’s annual healthcare conference in 2015 voted to ballot for industrial action if any future government tries to remove the unsocial hours payments that are traditionally linked to standard salary packages (Donnelly, 2015b).
© 2015 MA Healthcare Ltd
Alan Glasper, emeritus professor at the University of Southampton, discusses the launch of a new campaign by the Prime Minister in which he pledges his Government’s commitment to providing free health care for all, wherever and whenever they need it
British Journal of Nursing, 2015, Vol 24, No 13
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY Sir Bruce Keogh has acknowledged those that oppose his aspirations for the NHS by emphasising that it is necessary to move beyond the debate about 7-day working, where the emphasis is on the people delivering the service, but to relate to the concept of a 7-day service that concentrates on patients. NHS England is therefore committed to offering a more patientfocused service. Part of this commitment will be fulfilled by moving towards routine NHS services being made available 7-days a week. In December 2012, the policy Everyone counts: planning for patients 2013/14 sets out the initial step towards identifying how there might be better access to services 7 days a week. Keogh set up the 7-day services forum which is focusing on making 7-day working more than just a vision, and is the backdrop to the Prime Minister’s campaign for the 7-day NHS moving from aspiration to reality. The forum has developed ten evidence-based clinical standards to end current variations in outcomes for patients admitted to NHS hospitals at the weekend. Keogh wants these to be fully adopted by 2016–17 (Keogh, 2013c). The standards specify, for example, that all hospital inpatients have access to diagnostic services, and that support services in hospital and primary, community and mental health settings are available 7 days per week. The healthcare regulator, the CQC, will be empowered to monitor the implementation of these standards (Keogh, 2013c).
© 2015 MA Healthcare Ltd
The Prime Minister’s vision In his speech (Prime Minister’s Office et al, 2015), David Cameron gave his personal commitment, and that of his Minister for Health, to a number of core principles. David Cameron believes that the NHS should unite and bind all people to the same achievable goal of making the NHS the best health service in the world. In addition to increasing funding he is seeking to raise staffing levels. He is open to third-sector organisations being given the opportunity to work with the NHS to deliver services. He does, however, fully appreciate that there are pressures on the NHS, not least being felt by emergency departments, and rising numbers of people needing dementia care. He believes his government will put quality, safety and compassion back at the heart of the NHS. The prime minister wants to meet the huge challenges facing contemporary health care and he wants the NHS to harness the opportunities presented by the advance of science and technology to support people living longer and coping with more complex health conditions. Importantly, David Cameron values the committed work ethic of NHS doctors and
British Journal of Nursing, 2015, Vol 24, No 13
nurses and he understands the pressures they face every day and night. He also acknowledges the worries and concerns people have about the future of the NHS. At the heart of the plan is a focus on healthy living to address some of the morbidities in society such as obesity. Crucially, in this plan, he is committed to multidisciplinary working where the sum of the NHS workforce is greater than the sum of its parts, with electronic health records available giving patients a real say over how they are cared for and who cares for them. He also envisages faster access to new drugs and treatments with a renewed focus on mental health. The Prime Minister is aware that one in four people in the UK has a mental health condition and he believes that these people should get access to more timely and supportive help. He has pledged his government will go further in enabling full transparency about the quality of mental health services in every part of the country. To achieve this he intends to publish audit information on how good mental health services are, so that any deficiencies in service provision can be identified to drive up standards. The Prime Minister is confident about his vision—of a modern NHS offering services 7 days of the week, whenever and wherever it is needed. In his view, this begins with a transformation of primary care and supporting GP surgeries to open from 8 am until 8 pm, 7 days a week. He wants primary care to be re-engineered with an emphasis on prevention and holistically treating the whole person. It is the implementation of modern communication technology into primary care that will, for example, allow patients to use an app to book appointments for before or after work and order a repeat prescription online. The Prime Minister wants, by the end of this financial year, 18 million patients to have access to a GP at mornings, evenings and weekends, and by the end of the current parliament that everyone will have an NHS that provides 7-day services in all areas, including hospitals.
Conclusion The Prime Minister is open about the scale of the challenge in making his vision a reality, but believes he has the whole nation behind his aspiration to become the first country in the world to deliver a truly 7-day health service. Ham et al (2014) insist the overriding priority must be to achieve closer integration of care where the services are safe, effective, responsive, caring and well-led, underpinned by an overarching need BJN to ‘first do no harm’. Bray BD, Ayis S, Campbell J et al (2014) Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Med 11(8): e1001705 British Medical Association (2015) Doctor shortages overshadow seven-day services pledge. http://tinyurl.com/ qcgye2n (accessed 26 June 2015) Donnelly L (2015a) One in 3 trainee GP posts are empty, amid warnings of crisis shortage. The Telegraph (online). 6 April. http://tinyurl.com/mkzrth9 (accessed 26 June 2015) Donnelly L (2015b) NHS union votes to ballot to strike if ‘7 day NHS’ means pay cuts. http://tinyurl.com/o7q4g2v (accepted 26 June 2015) Freemantle N, Richardson M, Wood J et al (2012) Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 105(2): 74–84 Ham C , Dixon A, Brooke B (2014) Transforming the delivery of health and social care. The King’s Fund. http:// tinyurl.com/cshydnp (accessed 26 June 2015) Hallam L (1994) Primary medical care outside normal working hours: review of published work. BMJ 308(6923): 249–53 Keogh B (2013a) Should the NHS work at weekends as it does in the week? Yes. BMJ 346: f621 Keogh B (2013b) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. http://tinyurl.com/ph9e267 (accessed 30 June 2015) Keogh B (2013c) NHS services seven days a week. http:// tinyurl.com/pv6mrb4 (accessed 29 June 2015) Lattimer V, George S, Thompson F et al (1998) Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial.The South Wiltshire Out of Hours Project (SWOOP) Group. BMJ 317(7165): 1054–9 Mason R (2013) GP surgeries to open seven days a week, says David Cameron.The Guardian (online). http://tinyurl. com/ojb9kcp (accessed 26 June 2015) NHS Commissioning Board (2013) Everyone counts: planning for patients 2013/14. http://tinyurl.com/phobxpq (accessed 26 June 2015) NHS England (2013a) NHS England’s Sir Bruce Keogh sets out plan to drive seven-day services across the NHS. http://tinyurl.com/nzyz6fd (accessed 26 June 2015) Prime Minister’s Office, Department of Health, Cameron D (2015) PM on plans for a seven-day NHS (speech). 18 May. http://tinyurl.com/ma47xu5 (accessed 26 June 2015) Royal College of Nursing (2013) RCN response to Sir Bruce Keogh’s plans for 7 day working in the NHS. http:// tinyurl.com/pshq7my (accessed 26 June 2015)
KEY POINTS n In his first major speech since winning the 2015 general election, Prime Minister David Cameron has unveiled his plans for the introduction of a comprehensive 7-day NHS n There is evidence that 5-day NHS working causes increased mortality rates for some groups of patients admitted over weekends n One in three posts for trainee GPs across the country has not been filled, with the Royal College of General Practitioners indicating that more than 500 practices are under threat of closure n Some are worried that a 7-day NHS may result in health professionals losing their extra remuneration for working unsocial hours
707
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
