NHS: Seven-day Working

Baroness Jolly Excerpts

Thursday 6th February 2014 Lords Chamber

[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.