(10 years, 3 months ago)
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Lord Ribeiro
To ask Her Majesty’s Government what assessment they have made of the implications of introducing seven-day working in the National Health Service.
Lord Ribeiro (Con)
My Lords, in opening this debate I must first record my interests in the register and my chairmanship of the Independent Reconfiguration Panel. I support the introduction of a seven-day service, promoted by Sir Bruce Keogh, medical director of the NHS, but I believe that it should focus on emergency and urgent care, which is currently poorly provided at weekends. The move to a seven-day service has the support of the Medical Royal Colleges, NHS Confederation, NHS Employers and the BMA, but why is it necessary?
When I was a consultant, I often provided an emergency service at weekends, initially every four weekends and then every eight as staffing numbers increased. That was a requirement to go into the hospital to deal with emergencies when they occurred, rather than a commitment to be there all day as I would be during the week. What has changed is, of course, the increasing number of elderly patients with comorbidities requiring care and the findings of the Francis report that patients felt vulnerable at weekends when,
“staff absences and shortages are more noticeable”.
A report commissioned by NHS London in 2011 found that increasing cover by consultants in acute medical and surgical units at weekends could prevent 500 deaths a year in London. Further evidence in the Journal of the Royal Society of Medicine in 2012, analysing 14.2 million admissions in NHS hospitals in England in 2009-10, found that patients admitted on Sundays were 16% more likely to die than those admitted on Wednesdays, and 11% more likely to die if admitted on Saturdays. The Dr Foster Hospital Guide in 2012 reported similar findings, confirming that a higher level of senior medical staff at the weekend is associated with lower mortality. The case for change in respect of emergency admissions has been made and now something must be done.
Despite a reduction of acute beds by a third in the past 25 years, the number of unplanned admissions of those over 65 continues to rise, with some 2 million admissions a year. Length of stay is also important: for those under the age of 65, the average length of stay is three days but for over 65s it rises to nine days and for those over 85 it is 11 days. To prevent unplanned admissions we need more consultants because consultants make the decisions. They are able to decide whether patients can be sent home or need to be admitted. Junior doctors often lack the confidence to do that. We also need the infrastructure and systems in general practice and social care to allow those patients to be treated nearer their home. That must also be available at weekends.
My noble friend the Minister will no doubt point out that “seven-day working”, as this debate is titled, is not the same as a seven-day service. I agree but the public need to be clear what sort of service they receive. When we promise them the same service at weekends as in the week, they will assume that that implies seven-day working. That means that there will need to be a massive expansion of consultant numbers. I have recently heard the figure of 1,800 quoted as likely. Do we actually have enough qualified trainees to fill those posts—and trainees of the right calibre? Over what timescale do we expect to have this expansion? If the service is to be both for elective procedures, including routine operations, and emergencies, then a bigger challenge is funding and the staffing of theatres, X-ray rooms, and pathology and scientific laboratories—all of which must be supplied if we are to provide the same service at weekends as we do during the week.
We should not promise what we cannot deliver. The seven days a week forum report commissioned by Sir Bruce Keogh, which the Library kindly sent round as a briefing document for those involved in this debate, identifies 10 clinical standards that are evidence based. Three of them incorporate standards developed by the Academy of Medical Royal Colleges, whose committee on this was chaired by the president of the Royal College of Surgeons—so I have a slight inside track on what was developed. The standards cover the patient’s experience through to the transfer to the community. They focus mainly on the management of emergency admissions. Of the 10 standards, eight revolve around hospital care. They recognise that a one-size-fits-all solution cannot be applied in this situation and that what will work best is usually based around local solutions. But there is an emphasis on emergency care that does match the rhetoric of providing care for all at the weekend.
The NHS Confederation and NHS Employers recognised that we already work seven days a week, but it is how we do that work that is in question. Changing to a seven-day service could be liberating for many staff. I heard one lady consultant on southern TV last week say how much she enjoyed working at weekends. I think she worked at Southampton General. One reason she enjoyed working at weekends was that it provided a better work-life balance for her family. We should grasp the opportunity that this offers to use our workforce more flexibly. With the increasing feminisation of the workforce, remembering that more than 60% of our medical school intake is female, it is important that we take families, children and women into account when we design our workforce of the future. It is also important that many women with children would find working at weekends helpful because it would mean that their partners were there to look after the family and home while they were away working. I am not against that but will put forward some arguments as to why we should deal with the emergency problems first.
We also need to be much more creative about how we utilise some of our older, senior staff. I say that advisedly as I retired at 64 and was doing emergency admissions until the age of 60. How I could have done that between 60 and 64 I do not know; I feel for my colleagues who still do. Between the ages of 55 and 60, you could take most senior doctors off the emergency on-call rota and have them there providing mentorship for more junior consultant colleagues, and perhaps undertaking elective work at weekends if that could be managed.
Much could be done to achieve seven-day care but I am daunted by the cost of implementing both an emergency and elective service at weekends. The seven-day services improvement programme, which I believe was due to start in January this year, is focused in its first year on emergency care and the provision of enhanced recovery pathways and diagnostic and support services. The programme freely admits that its big challenge is how to actually develop those diagnostic and support services. I wonder where it will focus its attention in the next two years of the three-year programme it has set out. In addition, what are the likely costs of staffing a seven-day service in both primary and secondary care? The figures of £3 billion, from the Department of Health, and £32 billion, from the BMA, have been quoted as the cost of introducing seven-day care right across the piece in primary, secondary and social care.
From my experience of service reconfiguration, the public want high-quality care, but are wary of change, particularly if it affects their local hospital. We have seen the benefits of such service change, particularly here in London. Stroke services, acute heart condition services and trauma care concentrated in fewer centres have already delivered improved outcomes, so we have the evidence. A new project in Northumbria to produce a specialist emergency care hospital, which is due to open in 2015 at a cost of £200 million, is an example of a local solution to rural problems. Local solutions driven by clinicians and co-designed with the public can lead to centres of excellence.
It is important that we focus our attention on delivering an emergency service. If we base this on the 22 trauma centre networks that were designed by Profession Keith Willett and Sir Bruce Keogh, the success of the centres will trickle down to the spoke hospitals which are linked to them. By aiming for this low-hanging fruit, we can demonstrate success to the public, and the effectiveness can be translated to elective care. However, I do not think we are yet in a position where we can provide care at the weekend in the way we go shopping at Tesco and Sainsbury’s. Please do not forget the European working time directive, which applies to junior doctors and equally to consultants, because the SiMAP and Jaeger agreements are still there and they will require compensatory rest for consultants who work at weekends.
I have identified barriers to change. I am not a naysayer, but I have concerns about staff and cost implications, particularly with an austerity budget designed to reduce our deficit, GP contracts—will they be asked to work nights and weekends again?—the ability of social services to cope with seven-day working and whether payment by results can be adjusted to take account of the increased emergency work. I support the proposals for a seven-day service, but I have misgivings about implementation and the costs involved. I hope the Minister will be able to reassure me.
Baroness Jolly (LD)
My Lords, I remind noble Lords that this is a time-limited debate and, with the exception of the Minister, speeches are restricted to four minutes. When four is on the clock, time is up.
Lord Warner (Lab)
My Lords, I congratulate the noble Lord, Lord Ribeiro, on securing this platform to enable us to discuss this very important issue. I declare my interest as an adviser to Synlab, a German pathology company.
There is not much to disagree about in principle on the idea of seven-day working in healthcare with such a large number of emergency admissions to hospital. The evidence is pretty clear that we need the most senior doctors working later in the day and at weekends in those places dealing with emergency conditions. The noble Lord, Lord Ribeiro, told us the scale of those admissions each year. The interesting thing is that the Academy of Medical Royal Colleges has made clear that patients with these conditions need on-site consultant inspection at least once every 24 hours. Those admitted on Friday may not be seen by a consultant until Monday. That is clearly a dangerous practice. I would be very interested to know whether the Minister accepts that in hospitals which have A&E departments they would expect there to be seven-days-a-week consultant cover to enable a person to be seen by an on-site consultant at least once every 24 hours. Is that now government policy or just an aspiration set by the Academy of Medical Royal Colleges?
We know all about the difficult practical issues of implementing this kind of policy. We have also heard from the noble Lord, Lord Ribeiro, the different financial estimates for doing this. It is very interesting that the BMA’s estimate of £32 billion for seven-day working overall is roughly the same size as NHS England’s estimate of a £30 billion funding gap by the end of this decade on present plans for the NHS. There is some symmetry and agreement around about £30 billion; it is just a question of whether it applies to the gap or the funding increase you would need for this kind of policy.
I do not disagree with anything the noble Lord, Lord Ribeiro, said, but I want to focus on the point he made about money. Before I do that, I pay tribute to the work he has been doing in his capacity as chairman of the Independent Reconfiguration Panel. The trouble with that work is that he has to wait for what is served up to him. He is not allowed to take the initiative. We know many of the failing health economies. The NHS Trust Development Authority was set up to deal with many of these bodies. We have a situation where we are thinking of dreaming up a highly desirable change in patients’ access to consultant cover on urgent admission to hospital when we know full well that we have a very large number of almost insolvent trusts carrying out A&E admissions day in, day out. They are propped up by handouts from other bits of the NHS. This is the reality that the NHS faces daily. I suggest that we can implement this policy only if we grasp the nettle of reconfiguring services rapidly and consolidate more of these specialist services on a single site.
Baroness Brinton (LD)
My Lords, I, too, thank the noble Lord, Lord Ribeiro, for securing this key debate. It is shocking that your chances of receiving prompt treatment and, indeed, of surviving are worse if you are admitted to hospital over a weekend or on a bank holiday. The 2011 Freemantle report provided the evidence that more than 500 deaths could be prevented in London each year purely by increasing consultant cover in acute medical and surgical units.
The good news is that there are early adopters and pathfinders who are demonstrating that it can be done. I hope your Lordships’ House will indulge me with a personal anecdote. I was very unwell over Christmas and had the good fortune to be admitted to the acute admissions unit at Watford General Hospital. The unit was set up in 2009 to help reduce pressures on A&E and the main hospital. The £12 million 120-bed unit shares the building with A&E but all referrals have to come from a GP and the maximum length of stay is 72 hours, although stays are usually much shorter. Consultants are on duty 24 hours a day and see patients as they are admitted so care is tailored very quickly. The AAU and A&E share their own MRI scanner, X-ray and ultrasound unit, a catheterisation unit for angioplasty, blood testing facilities and pharmacy. My experience of the care was outstanding: tests, scans, monitoring and observation and treatment were all prompt, and I felt that the entire clinical team worked smoothly as one unit. I know that I am not alone in my praise for the unit.
Seventy-two hours seems to be about the right length of time. I have seen reports of other acute units where the time is only 36 hours. Recently a Leeds hospital reported that there is still pressure on the main wards from this shorter timescale.
The briefing from the Royal College of Surgeons states:
“Seven day services may also reduce pressure and stress on doctors. For example, consultants can spend much of Monday morning dealing with weekend admissions that are waiting for review or discharge”.
However, this does not affect just doctors: radiologists and many other clinical support staff are similarly affected by the Monday morning catch-up that impacts on an already busy week. Can the Minister assure the House that the NHS will provide robust modelling and review structures using the examples of early adopters to ensure that seven-day working is introduced carefully and effectively?
There needs to be a realistic timetable and a full understanding of the workforce issues—not just consultants or contracts and payments, but also appropriate staffing levels right through the NHS. It therefore seems sensible to move ahead on urgent and emergency care first and then reassess for wider clinical services, rather than rushing ahead with elective care at the start.
Many people are concerned about the costs of adopting a seven-day working system. With careful modelling—and with units such as the one I described earlier—in addition to inevitable new costs, we will find that there are some cost savings. Overall, the biggest change will be in culture and attitude. The NHS heart is willing. We all need to use our heads and energy to make it happen.
Baroness Masham of Ilton (CB)
My Lords, I thank the noble Lord, Lord Ribeiro, for asking this question. I am sure all noble Lords speaking today want to see improvements in the NHS.
A few years ago, I attended an open day at the Harrogate hospital trust. When we were shown the MRI scanner and other equipment, one of my group asked, “Would it not be desirable and beneficial to keep everything running seven days a week?”. The radiologist said, rather forlornly, “There are only one and a half of us”. The public would be very pleased to see a seven-day service in the NHS, but this would need more trained staff right through the system, and a culture of co-operation and communication. There should be an eradication of bullying and fear among managers and all staff. There should be a duty of candour and transparency, and dedicated teams looking after patients. Patients need continuity of care. They are so dismayed when their operations are cancelled at the last minute. Is there too much pressure on our existing National Health Service? General practice is facing a growing crisis as it struggles to provide the care needed for an increasing patient population.
I agree with the forum’s ambitions but, first, it is surely important to improve the safety of patients and the training of staff, so that they become experts in diagnosis and treatment. So much money is wasted on compensation and there is so much heartbreak for the nearest and dearest—and for the patients, if they live—when something goes wrong. Before the much hoped for seven-day working there should be improvements for what we already have in the NHS. For example, hospital A&E costs for stand-in doctors have increased by millions over three years. Blood donors are turned away by clinics because of late-running sessions and sick staff. If they feel their gift is not respected and they are not well treated, they will not turn up next time. I have an interest, as blood transfusions saved my life. Volunteers play an important part in the NHS, and they should be appreciated. There are huge variations in how GP surgeries provide a service to patients across the country.
I for one appreciate our health service, but we need to keep it safe and sustainable, and it has to grow with the increasing demands. Carrots are better than sticks. How can we keep our good doctors in a competitive world? How can we make nurses put patients first, giving them TLC? Without commitment and enthusiasm, it will be difficult to keep the NHS in full sail for seven days a week. Does the Minister agree that safety of patients at weekends should be addressed now?
Lord Parekh (Lab)
My Lords, I thank the noble Lord, Lord Ribeiro, for securing this debate and introducing it so well. A case for seven-day working in the NHS seems so overwhelming that I am surprised that it has taken us so long to raise it. I can think of half a dozen powerful reasons why seven-day working is an absolute must. As the noble Lord, Lord Ribeiro, has said, it reduces mortality, which can rise by as much as 16% for patients admitted over the weekend. In law—although I have not had the time to get this tested—it would amount to indirect discrimination to suggest that people who are admitted over the weekend receive less satisfactory treatment and invite death earlier than in other cases. That would constitute a case of indirect discrimination.
If we have seven-day working, it will amount to better use of diagnostic machines, laboratory equipment and operating theatres. It will also decrease the patient’s length of stay in hospital and thereby not only reduce pressure on hospitals but increase GDP because people will come out of hospital earlier and be able to work more days. The amount of patient satisfaction would also be considerable. For all these reasons, a case for seven-day working seems compelling.
I add an extra reason to assist the Minister in his negotiations with doctors who might resist this, but it is not the comparison with retail traders opening on a Sunday, as that is not a good analogy. We ask that our hospitals be open over the weekends, and that consultants and others be available, because these are issues of human lives. Where human lives are concerned, you cannot make a distinction between a weekend and a weekday.
Given that the case is so overwhelming, what are the objections? I hear three objections from many doctor friends who I am privileged to know. First, I am told it will impose extra burdens on consultants and senior clinical staff. The answer to that is, first, it need not be so because the workload can be properly distributed. Secondly, the same doctors who talk about the extra burden have absolutely no difficulty attending private clinics and private hospitals where they perform operations over the weekend. That is an argument of self-interest, which does not wash with me.
The second argument is that it will increase the cost. It could, and we have had figures bandied about. To that, my answer is: first, if you have better rota and shift planning, you need not employ a large number of extra consultants or senior clinical staff. You will also reduce the patient’s length of stay in hospital, which would mean a considerable saving. Hospitals under the same trust should be able to share clinical staff, so it does not necessarily mean each hospital having its own extra consultant. Equipment could be more effectively shared—that would mean a considerable saving—and, of course, there will be a reduction in the current payments for unusual hours that are paid to doctors. For all these reasons, I think that the objections based on cost can be addressed.
There is a third objection that many of my friends have made, which is that it could be hard on women. The noble Lord, Lord Ribeiro, said that many women consultants and others might welcome working over the weekend; but there are also many others who would find it difficult to work over the weekend and might resent being compelled to work in exactly the same way as their male colleagues would. There again, talking to consultant friends, I am told there is an answer: better rota and shift planning so that women need not necessarily be involved over the weekend. I suggest that there are enough reasons to go ahead, full steam, with this project.
Baroness Barker (LD)
My Lords, in 2003, the noble Lord, Lord Hunt of Kings Heath, the Minister and I were deep in the depths of the delayed discharges Bill. During our discussions, the journal Nursing Older People published clear evidence that if older people were discharged on a Friday, they were more likely to be readmitted to an acute hospital, or to die.
Let us flick forward to July 2013, when Sir Bruce Keogh concluded, in his review of 14 Trusts for NHS England, that,
“performance … was much worse … for their emergency patients, with admissions at the weekend and at night particularly problematic. General medicine, critical care and geriatric medicine were treatment areas with higher than expected mortality rates”.
In its 2013 report, Dr Foster stated that the mortality rate for patients who had routine surgery is 24% higher if the operation is performed just before the weekend and that the number of patients who return to hospital after being admitted at the weekend is 3.9% higher, so 10 years on it is the same story.
A lot has happened in that decade. Technology has improved and kit is marvellous these days. Data have become much more copious and available. Patients have become better informed and empowered. The pressure on resources was changed out of all recognition during the Labour Government, when lots more resources went into the NHS, but the rising tide of demand continued on ahead. It is the same story over a decade. One thing that we can conclude is that this is not about resources. That is not the answer to these issues.
This is therefore an interesting question for the Government to think about now that we are in a period of austerity. How do we address what we know to be long-standing and systemic issues? First, in order to have a seven-day-a-week NHS, we have to have better integrated social care and improved access to low-level social support. We know that 50% of the users of the NHS in future will be older people with long-term comorbidities, particularly dementia. The bulk of their care will not come from consultants; it will come from their families and friends. What is important is supporting their families and friends to look after them in the community.
Secondly, GPs have a critical role in determining access to the NHS. I think we can by now conclude that the GP contract negotiated by the previous Government was not the roaring success that it was made out to be at the time. GPs have a critical role in managing care pathways and access and we now need to go back and say to them, particularly since their response to Sir Bruce Keogh was simply to talk about resources, that there needs to be a change in their role in managing that point between all-out A&E access and long-term care.
Finally, we need to be absolutely clear with the British public that having a full seven-days-a-week service is not going to be realised in the short term. The general public will have to understand which parts of the health service they can expect to be available seven days a week and which they should not. The British public are very proud of the NHS and are, by and large, responsible. They want to make the best and most sparing use of it they can. Let us not deceive or mislead them into being wasteful and thinking that they are going to have everything all the time.
Viscount Bridgeman (Con)
My Lords, the whole House will be grateful to my noble friend Lord Ribeiro for securing this debate. He produced devastating statistics from Sir Bruce Keogh and NHS London but this debate surely cannot be complete without revisiting the working time directive. I have one or two further telling facts from my noble friend’s own royal college. For example, 86% of surgical trainees working to a working time directive-compliant rota have seen their work-life balance deteriorate. A survey published by Pulse of 500 junior doctors on the impact of the working time directive reported that 65% of respondents felt that it is having a detrimental effect on their training and 75% felt that there is now insufficient cover on the wards.
Further analysis by the royal college says that the number of hours available to surgical trainees for training and experience in compliance with the working time directive has been significantly reduced. Every month, 280,000 surgical training hours are lost to that directive and the doctors beginning their surgical training today will have 3,000 fewer hours to learn throughout their training, which is the equivalent of 128 whole days. This is but a snapshot of the telling statistics showing the handicap which the working time directive is imposing not only on patients today but on the precious investment in young medical talent for the future.
My message to my noble friend the Minister is to ask what pressure can be brought on the Commission to improve the working of the directive, which, let us not forget, has at its core wholly admirable aims. The Commission does listen. The United Kingdom, led by the Department of Health, has over the past two years taken the lead in inducing the Commission to modify the free movement directive which has hitherto prohibited the regulatory bodies in healthcare, such as the GMC and the Nursing and Midwifery Council, from testing health workers from the EEA for English-language competence before registration, potentially releasing healthcare workers on to the market with less than adequate English. That is a disaster for patient safety waiting to happen. The Commission has now listened and taken measures to modify the directive to ensure that language competency is established before a certificate of fitness to practise can be issued.
I use that as an example where the issue was patient safety. Let us be in no doubt that in the case we are debating it is simply that again, whether it is in the inadequate training of doctors to which I referred or the lack of continuity which was provided under the old structure of the firm, whose demise was one of the principal casualties of the directive. The introduction of the shift system also plays against continuity. Can my noble friend give an assurance that his department will build on his earlier successes with the Commission and give a high priority to securing a modification to the working time directive?
I finish with an instance which I assure your Lordships is not simply hearsay. I know of doctors who need to get work experience in another country within the European Union. Both the time and money available are limited and, to get the best value out of their secondments, they have quite simply chosen to go to member states where the working time directive is openly disregarded. By the way, these are not newer accession states but old, western members of the Union with highly sophisticated health services. This country has a history of abiding by the law and I leave my noble friend the Minister, and all your Lordships, to draw their own conclusions.
Baroness Manzoor (LD)
My Lords, I, too, thank the noble Lord, Lord Ribeiro, for securing this debate. As other noble Lords have stated, the variation in outcomes and patient experience for patients admitted as emergencies at the weekend is evidenced in higher readmission rates, higher mortality rates, poorer patient experience and an increased length of hospital stays, while the availability of diagnostics such as imaging can be 40% lower. These facts are, on the whole, not in dispute so it is not my intention to mention the many excellent surveys and reports which evidence them. However, it would be remiss of me not to restate the importance of the report commissioned by NHS London in 2011, which concluded that increasing consultant cover in acute medical and surgical units at the weekends could prevent more than 500 deaths a year in London alone. The evidence clearly demonstrates the need for the NHS to take action.
Like other noble Lords, I applaud Sir Bruce Keogh’s report and its conclusions, except that it is rather disappointing that it took nearly a year to produce. I would like to hear what the Government are doing to ensure that the pace of change is rapid and that the report’s implementation programme is given greater priority. Quite rightly, there is much emphasis by the Government and NHS England on clinical outcomes and reducing inequalities in care, but NHS England will not deliver on its mandate should the current status of health services prevail at weekends.
While the £3.8 billion Better Care Fund which the Government have made available, pooled with local government, is also welcome, NHS England has yet to demonstrate how clinical commissioning groups are addressing the need for services at weekends and what support CCGs are giving to local authorities which support patients being discharged from hospitals and prevent unnecessary admission to hospitals, particularly as CCGs spend three-quarters of the £98 billion NHS budget. Indeed, I find it difficult to understand how the regulator, the Care Quality Commission, could have judged any hospital to be outstanding when such inequalities in care and service have existed in the NHS and been evidenced as such for at least the past 12 years. Perhaps the Minister can reassure the House that regulators will not be awarding outstanding status until a hospital is deemed to have improved its record of safety and patient care for patients at the weekend.
NHS England should also demonstrate how, as the commissioner of primary services, it is ensuring that it addresses and improves the variable quality offered by general practitioners. Although an optimist, I remain concerned by the slow pace of change. On the current evidence, NHS England cannot deliver on its mandate, and Public Health England will fail to close the inequality gap in social provision for some of the most vulnerable in our society, such as the elderly and people who need access to mental health services at the weekend. This is mainly because there is an absence or limited availability of consistent support services such as diagnostics, and a lack of community and primary care services which, if available, could prevent some unnecessary admissions and support the timely discharge of patients. It remains, as has been said, difficult to get routine blood tests, X-rays, MRI scans, pharmacy, physiotherapy and social services at weekends. Of course, I have already mentioned the variable out-of-hours primary care.
Sir Bruce is quite right when he advocates a whole-system approach to improve the current, unacceptable standards being offered in the NHS at the weekends. However, although I do not support yet another reorganisation of the NHS, with tight finance restraints, the Government may need to think further about simplifying the current and complex NHS system. They will also need to consider how budgets are shared and pooled between organisations, including with local authorities, and who will lead on this. The NHS is a great institution, and it is our duty to make it fit for the 21st century.
Lord Hunt of Kings Heath (Lab)
My Lords, I, too, am grateful to the noble Lord, Lord Ribeiro, for instituting this debate. It is clear that all noble Lords who have spoken are broadly in favour of moving to what we are calling a seven-day week for the NHS. However, there is a range of views about whether it is deliverable. I hope that the noble Earl will be able to address some of the substantive points that have been put to him.
The argument for seven-day working to its full extent is of course persuasive. Noble Lords have talked about the high mortality rate at weekends, the variable staffing levels, the absence of senior decision-makers and a lack of consistent specialist services, such as diagnostics. It is also clear that capital is not used by the NHS to the extent that one would desire if very expensive machines are left idle for quite a part of the week.
However, there are three major questions about whether this is workable which I will put to the noble Earl. First, is the rest of the health and social care system able to match the seven-day working of the health service? It seems that the major pressure problem facing the NHS is frail, older people who probably should not have been admitted, but have been because either nursing homes or social care provision was not sufficient. Once they are admitted to hospital, it often becomes difficult to enable them to be discharged quickly because of an absence of community infrastructure. If we are going to have full seven-day working within acute hospitals, it is essential that GPs and social and community services also embrace seven-day working.
I do not know to what extent the Bruce Keogh work has really reflected that. It will have to be tackled. We cannot carry on any longer with GPs who are inaccessible and unable to do what is necessary to help people who have been discharged into the community. The same goes for social services, which still seem to shut down over bank holidays and the Christmas period. This simply is not going to work unless the whole of the system is working to the same tune.
Secondly, there are mixed views on resources. My noble friend Lord Parekh thought that the cost of this could be contained. I must say that I rather share the view of my noble friend Lord Warner and the noble Lord, Lord Ribeiro, that this is in fact going to be massively expensive. The noble Lord, Lord Ribeiro, talked about the necessary massive expansion of consultants. That must be true because we do not want seven-day working that involves staffing up at the weekends and reducing staffing during the week. I suspect that mortality rates would go up during the week because you would not have the necessary cover. I am afraid that some of the plans of acute hospitals are indeed to squeeze staffing during the week. That is a crazy way to go about it. I am very concerned that, in time, we will see a rise in mortality rates during the week. I do not think that this has been fully considered by those who say that we can do this simply by a better ordering of the way in which things are done. I refer the noble Earl to the Institute of Fiscal Studies report published today, about the resource challenges facing the NHS, and ask him how this is to be afforded.
Finally, does the noble Earl think that, as a result, the noble Lord, Lord Ribeiro, will be even more engaged in dealing with reconfiguration issues? Does the noble Earl agree that the implications of this are that we have to have radical reconfiguration of services? Will Ministers support that? Equally, will they tell Monitor and the competition authorities to back off from instituting competition procedures if this reconfiguration is necessary to make this work?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I congratulate my noble friend Lord Ribeiro on securing a debate on this important issue. I know that as a former consultant surgeon and former president of the Royal College of Surgeons this is a subject in which he takes a great deal of interest. I also take this opportunity to pay tribute to the work done on seven-day services by NHS England, the NHS Services Seven Days a Week forum, the Academy of Royal Medical Colleges and the Royal College of Surgeons, among others.
The historical five-day service model offered in many NHS hospitals no longer meets justifiable patient and public expectations of a safe, efficient, effective and responsive service. I very much echo the comments of the noble Lord, Lord Parekh, in that context. Over the past 10 years, a growing body of national and international evidence has emerged that links poor outcomes, including a higher risk of death, to patients admitted to hospital at the weekend, around the world. It is impractical and inefficient to continue to operate a five-day approach when our illnesses and conditions do not limit themselves to office hours. Patients are entitled to receive the same standard of care regardless of the day of the week.
As the largest and most comprehensive health service in the world, the NHS is well positioned to solve the issue of poorer outcomes and reduced levels of service provision at the weekend. That is why NHS England has set out a vision for the NHS which is of a service more closely organised around the lives of the public it serves. To develop this vision, NHS England established the NHS Services Seven Days a Week forum in February last year to consider how NHS services can be improved to provide a more responsive and patient-centred service across the seven-day week.
The forum’s work has been met with nothing but positive feedback and support from the public and patients, the Academy of Medical Royal Colleges and the British Medical Association, among other organisations. The immediate focus for improvement activity will be addressing the need for high-quality urgent and emergency care services, seven days a week. NHS England is also looking to make similar improvements across primary and community health services and social care, and the forum will report in autumn this year, setting out proposals for the creation of a fully integrated service. NHS England’s ambition is for seven-day services to be fully implemented in England by the end of 2016-17.
I recognise that we cannot talk about the idea of seven-day services without giving full consideration to questions of staffing and finance; many noble Lords have raised those issues. NHS providers and their commissioners already face difficult choices when deciding where to invest their resources in order to maximise the outcomes for patients and value for taxpayers. Early indications are that seven-day services have the potential to be part of the solution. However, more information is needed. NHS England is therefore conducting research which will provide a helpful indication of the likely costs providers and commissioners face when considering how to redesign their services to provide comprehensive seven-day care. In addition, to answer my noble friend Lady Brinton, NHS England intends to commission financial and system modelling and analysis of the implications of its strategy for achieving seven-day service provision in the NHS.
My noble friend Lord Ribeiro rightly highlighted the workforce implications of having a consistent, high-quality service seven days a week. The department, alongside NHS England, Health Education England, NHS Employers and a number of strategic partners, is considering that very issue. Its analysis is considering issues such as junior doctors feeling unsupported during weekend working and the resulting need to ensure that education contracts include appropriate seven-day senior supervision; and numbers of diagnostic and scientific staff, with NHS England intending to undertake a thorough assessment of the different roles needed in diagnostic and scientific services to support an extended service.
Of course, many commissioners and providers will need support to address the challenges presented by seven-day services. To that end, NHS Improving Quality has just introduced a new, large-scale transformation change programme, set up in collaboration with all healthcare commissioners and providers, to support the spread of seven-day services over a three-year period.
I realise that the move towards seven-day care will not be easy, but there are encouraging examples of pioneering NHS organisations that have moved to make healthcare services more accessible seven days a week to avoid compromising safety and patient experience. For example, Sheffield Teaching Hospitals NHS Foundation Trust has adopted seven-day service provision, improving patient flow of frail and older people through the emergency pathway. Bed occupancy for emergency care for older patients has now reduced by more than 60 beds. Other examples in my brief include Salisbury District Hospital and the Lancashire Intermediate Support Team, both of which have produced impressive results.
We know that across the country, more hospitals, primary and community care organisations and social care services are working together to break the link between poorer outcomes for patients and the reduced level of service provision at the weekend. We also know that patients and the public want us to act now to make seven-day services a reality in all parts of our NHS.
A number of noble Lords, including my noble friend Lord Ribeiro and the noble Lords, Lord Parekh and Lord Hunt of Kings Heath, raised the issue of cost. Interestingly, there is already evidence that seven-day services can be implemented in a way that does not increase the overall cost of healthcare. The average cost of implementation at trusts pioneering the service was 1.5% to 2% of their total income. Costs vary according to local service models, but research shows that they can be reduced by reconfiguring services and by trusts working collaboratively. Seven-day services at the front end—that is to say, A&E departments—could also pay for themselves by reducing admissions and lengths of stay.
Seven-day services would not work under a one size fits all model—a point made by my noble friend Lord Ribeiro. Local solutions need to be found and pioneering NHS providers and commissioners are already working to develop them.
In answer to the noble Baroness, Lady Masham, on the issue of safety at weekends, we expect all NHS services to be able to meet patients’ needs as they arise. To do this, trusts should adopt the clinical standards developed by the seven-day services forum to drive up clinical outcomes and improve patient experience at weekends.
My noble friend Lady Manzoor referred to the CQC. The CQC and the Chief Inspector of Hospitals are considering how implementation of the clinical standards could best be assessed by the CQC and how this might be reflected in its forthcoming ratings and the judgments it makes when it inspects.
As I said, workforce is a major issue. The noble Baroness, Lady Masham, was right to raise that point. There are over 12,200 more clinical staff in the NHS than there were before the election, thanks to the money we have invested in the service and to the reforms we have carried out. Nevertheless, there is an issue about motivating staff to work at weekends, as the noble Baroness rightly said. We understand that contractual levers and incentives are required to drive change. NHS England and a number of key strategic partners are already looking into this. However, in many cases seven-day services have reportedly already had a positive impact on individuals’ work-life balance, offering greater certainty in planning ahead and flexibility in time off. In addition, the medical royal colleges are all in support of seven-day services. Building seven-day service provision into recruitment, job planning and appraisal processes will help create a sense of common purpose to underpin organisational delivery.
A number of noble Lords, including my noble friends Lord Ribeiro and Lady Barker, referred to the role of GPs. To address that important role in the mix of services the NHS provides, we recently announced the setting up of a £50 million fund to support innovative GP practices in improving services, and in particular access for their patients, including seven-day week access and evening opening hours and the testing of a variety of services including Skype, e-mail and phone consultations.
However, as the noble Lord, Lord Hunt of Kings Heath, emphasised—as did my noble friend Lady Barker—community services and social care are absolutely integral to this as well, particularly when it comes to the care of the frail elderly. Social care and the NHS are priorities for the Government and we know that there is interdependency between the two systems. However, providing more resources is not enough on its own. We have provided more resources from the Department of Health but we need to do more. NHS England is currently working with the Local Government Association to create a health and social care system that is truly seamless so that people receive the right care at the right time and in the right place. The Seven Days a Week forum will report on that work in the autumn, setting out proposals for a fully integrated service.
The Better Care Fund is a key enabler for change, as my noble friend Lady Manzoor pointed out. As part of the process for accessing funding, clinical commissioning groups and local authorities will have to demonstrate, as part of agreed local plans, that they are addressing a number of national conditions, including seven-day services in health and social care.
The noble Lord, Lord Warner, asked whether the Government would expect A&E departments to have weekend consultant cover. We recognise that the consultant contract is a key enabler of seven-day services. In October last year the Government mandated NHS Employers to enter into formal negotiations with the BMA to deliver joint proposals for consultant contract reform, including changes that will support seven-day services.
My noble friend Lord Bridgeman focused on the working time directive. He may know that we asked the president of the Royal College of Surgeons, Professor Norman Williams, to chair an independent task force to look at the implementation of the working time directive, and the impact of the directive on the delivery of patient care and the training of the next generation of doctors. The independent review will provide its report during March 2014. Professor Williams is working with stakeholders from the Royal College of Surgeons, NHS organisations, the BMA, National Voices and others, and we ourselves are working with the task force to ensure that it has appropriate legal and analytical support.
There is a compelling case for healthcare services to be accessible seven days a week. To echo the noble Lord, Lord Parekh, if we were starting the NHS from scratch I very much doubt whether we would design a part-time system. We would surely create a seven-day service to better meet patients’ needs. Seven-day service provision is about equitable access, care and treatment, regardless of the day of the week. It is a cause for some pride that the NHS will be the global pioneer in providing equality of access to consistent, high-quality healthcare seven days a week.
Lord Hunt of Kings Heath
My Lords, before the noble Earl sits down, I was remiss in not declaring my interests at the start as chair of a foundation trust, president of GS1 and a consultant trainer with Cumberlege Connections. I know that we all know that, but I have to do it every time.