In a recent press statement, David Cameron reiterated the Conservative party’s manifesto promise that people would be able to see a GP and receive hospital care seven days a week by 2020. At face value, these promises seem laudable, yet they have not been greeted with unalloyed enthusiasm, but rather criticism and objection, particularly from the medical profession.
Easier access to GPs
The attraction of GP surgeries being open for longer during the day and open at weekends is that it will be more convenient for “hardworking families” to see their GP. Extending out-of-hours provision of GP care may also help to relieve pressure on the hospital sector, although it’s not clear if primary care appointments reduce A&E attendances or push them up.
The government can’t force GPs to open their surgeries in the evening or on weekends, but it is hoping enough will volunteer to do so. GPs’ response, though, has been underwhelming. Given the profession’s acknowledged recruitment and retention problems, most GPs are struggling to cope with their existing workload.
It’s not even clear how much demand there is for a seven-day GP service. Eighteen areas have been piloting the scheme, but some have already scaled back their opening hours because demand has been less than expected. Clearly, the case for prioritising this policy needs to be strengthened.
Better quality hospital care
The seven-day debate for hospital care is driven by evidence that suggests that people admitted to hospital on weekends are more likely to die than those admitted during the week. A recent study found that 11,000 more people die each year if admitted over the extended weekend, from Friday to Monday, compared with those admitted on midweek days. This holds true even after accounting for the fact that people admitted at the weekend tend to be sicker. While this suggests poorer care over the weekend, there is little agreement about what to do about it.
Thousands of doctors complained in a letter sent to the parliamentary commissioner for standards that the secretary of state for health, Jeremy Hunt, misrepresented the research. He claimed that the problem stems from senior consultants being unavailable at weekends. Consequently seven-day services have taken centre-stage in current contract negotiations with the medical profession. The government hopes to remove the option for doctors to opt-out of providing non-emergency care at weekends, a deal that they secured as part of the 2004 contract negotiations. This has not gone down well.
The government’s position has met with three criticisms. The first is one of misrepresentation, giving the impression that the NHS has been running a five-day service when, of course, it has always operated 24 hours, seven-days a week. The #ImInWorkJeremy twitter campaign is a response to this misrepresentation.
It took until September 8 2015 for the government to offer a precise definition of what it meant by a seven-day service, the under-secretary for health Ben Gummer stating that: “A seven day hospital service would mean that, by 2020, all patients admitted to hospital at the weekend will get the urgent and emergency treatment they need; and those who are already receiving treatment and care will get it to the same high standards at weekends as during the week.”
The British Medical Association was quick to point out that this definition merely reflects current practice, so appears an inadequate description of the government’s plans.
Gummer may have been better referring to a report published by NHS Improving Quality in November 2013. This sets out five incremental levels of seven-day service, from level zero (no weekend or out-of-hours service), up to level three (seven-day services involving several departments working together) and level four (seven-day provision integrated across health and social care settings). The report also describes 14 examples of seven-day services that were already up and running, seven of which were level three and a couple that were level four. The report recognises that, rather than a blanket policy, seven-day services need to be targeted and tailored to specific people and circumstances in order to realise greatest benefit.
The second criticism concerns the best way to address the problem of higher weekend mortality. Responding to the BMJ article Jeremy Hunt “repeatedly told MPs and the public that these excess deaths were due to poor staffing at weekend.” The article itself identifies no specific cause for excess weekend deaths and also states that to assume that all the excess deaths “are avoidable would be rash and misleading”. Addressing the issue will require a more nuanced response than just appointing doctors, but also ensuring seven-day access to a range of diagnostic, assessment and treatment services.
The third criticism is about the cost of moving to seven-day services. Cost estimates derived from “eight volunteer trusts … with an interest in seven-day services” found that overall savings generated did not cover additional costs. Nationwide, the cost of implementing seven-day services in hospital is estimated to be £1.07bn-£1.43bn a year, even supposing that it would be possible to recruit staff with the necessary skills. Opening GP surgeries seven-days a week might cost a further £1 billion a year. This money is to come from the “£10 billion of additional investment” promised over the course of this parliament. But that money was part-payment to meet the growing demands on the NHS, requiring an extra £30 billion, the shortfall to come from £22 billion of efficiency savings. The implication is that implementing seven-day arrangements will entail sacrifices elsewhere, the net effect perhaps producing more harm than good.
It’s time to take stock
There should be proper assessment of the demand for out-of-hours GP services, and whether satisfying this demand is the most cost-effective way of improving primary care. Similarly, we need to identify what causes hospital mortality to vary by admission day and devise tailored strategies to tackle these causes. Even if the government wishes merely to pick a fight with the medical profession, its proposals will need a better defence.