The Government is committed to delivering seven day services to make sure that patients get the same high quality, safe care on a Saturday and Sunday as they do on a week day.

1. The definition of ‘committed’ from google “the state or quality of being dedicated to a cause, activity”. This would suggest a sustained ‘dedication’ to a cause.

2. However, the NHS has seen a fall in funding year on year as % GDP –  9.7 in 2009 (inflatedly high due to the economic recession), to 9.1 in 2013. [1]  The absolute spending per capita has also fallen; from a high of $3916 per head of population in 2007 to $3598 in 2013. This is the lowest bar Italy of the G7 countries (Japan, Canada, US, Italy, France, Germany, and the UK) as well as lower than most of Western Europe and New Zealand.

3. From the data, see below, into ‘safe’ weekend care, this mostly applies to emergency care – therefore ‘safe’ should focus on funding A&E and GP. Dozens of A&Es have been downgraded or closed [3] and 169 GP practices are either contemplating or planning closure in 2014/15 [4].

Many people do not realise that if you are admitted to hospital on a weekend, you have a 16% greater chance of dying. 

1. The reason they don’t realise this is because it’s not true.  The narrative from the government is : “if are you admitted at the weekend, there is a 16% chance that you wil die in hospital, and this is due to a lack of care from professional who would otherwise be there if it wasn’t a pesky Sunday”. The government also hasn’t officially attributed this figure to any research: however the figure is lifted from here.

2. Here are two analyses of said paper- juniordoctorblog and abrainiablog. The actual narrative is more complex, but to summarise it probably goes “Research shows emergency patients admitted on a Sunday are 16% more likely to die in the next thirty days as patients on a Wednesday, a third within three days, during the week, and a third after discharge, after weeks in hospital. Additionally, patients, in hospital, are 8% less likely to die on a Sunday than a Wednesday. This probably reflects the fact patients have to be more unwell to present to A&E on a Sunday than a Wednesday, but it is very unclear the reason why.” What is very clear however is that the bump in mortality applies primarily to emergency admissions.

The Government wants to change this

1. Which will be extremely hard to do if you fail to understand what ‘this’ actually represents.

so that everyone can be confident that they will receive the same level of care whatever day of the week they are admitted to an NHS hospital.

2. But we know, to improve safety, we must improve emergency admissions. That is in no way the same as ‘the same level of care’ which encompasses the whole weekday non-emergency NHS activity. If you have a resource finite environment you prioritise to increase the best outcome- limiting mortality over morbidity over inconvenience. This is a fundamental principle of healthcare.

3. The ‘same level of care‘ targeted in the contracts is, by definition, non-emergency care. Firstly, the data linked to increased 16% in deaths in weekend admissions is entirely emergency admissions, which are already covered. Secondly, a recent FOI request found, so far, of 4101 consultants NONE have opted out. (Explicit thanks to Kiara Vincent who filed all of these requests [7]). Here is a table.

UPDATED 28/7/15: I will just reiterate that. Not a single consultant has been found to be opting out of non-emergency care. NOT ONE. NADA. NIL. NO ONE. The previous single Pennine doctor, found to be opting out initially, turns out had opted out of the European Working Time Directive to help with ‘service demands and provision’. This means they worked longer than a 48 hour week, i.e extra hours for the benefit of the hospital. [16] (Thanks to Dr Hugh Harvey for the follow-up excellent piece of FOI).

5. ‘Same level of care‘ does not mean ‘consultant presence’- it should mean the same doctors, porters, nurses, OT, physiotherapists, radiographers, MRI and CT access, biochemistry and microbiology access. The system can’t afford this on current funding- regardless how much doctors are forced to work for how much that will not change.

NHS consultants already provide an outstanding service and show great dedication to ensuring patients get the best outcomes.

1) Yes they do. In fact here are the WHO outcomes for the NHS compared with the rest of the world. Here they are in 2010 through to 2013. No change- despite the levelled ‘failings’ of the NHS the actual numbers are not changing.

But the Government has a duty to make sure the system is set up in a way which makes it as easy as possible for hospitals to organise their resources to maximise patient safety across every day of the week.

1) It doesn’t technically have a duty to provide a comprehensive NHS anymore [8] as of the 2012 Health and Care Social Act.

2) Organisation of resource- already the system is stretched, during the week or weekend. Admissions are increasing [9] from 11.9 million in 1998 to 18.2 million in 2013 and many hospitals are in debt due to PFI [10] deals that no one has offered to renegotiate. What would increase patient safety is redeployment of resources to increase ancillary staff, to fund A&E and staff it, and to the renegotiation of PFI deals to end their crippling interest**.

3) Additionally under new immigration rules [11] will mean the culling of about 3500 NHS nurses, which has not only financial implications but the loss of experience from the utter bedrock of the NHS will be catastrophic- so there are much bigger problems than seven-day non-emergency convenient services.

To understand more about the possible issues for staff contracts,

1. Read ‘to make a political show of backing our own aggressive undermining policies toward the medical profession’.

last year the government asked the independent pay review bodies for NHS staff – The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) and the NHS Pay Review Body (NHSPRB) for their observations and recommendations about how the reform of employment contracts could help support the delivery of seven day services in England.

The reports were published this month. They identified that a major barrier to seven day services is a decade old contractual right in the consultants’ contract negotiated by their union representatives in 2003 that allows senior doctors to refuse to work non-emergency work in the evenings, at nights and at weekends.

1) So here the Government [UPDATED]: MUST HAVE LOST THEIR MINDS if that is a ‘major barrier’ to seven day services. I.E the evidence is clear, not a single consultant so far has opted out, therefore this is utterly malicious rubbish.

What constitutes non-emergency care? For example: Hip replacement, dermatology opinion, shoulder physiotherapy. Do you want to get an eye test at 2am? Probably not. But you might want to at 9am on Saturday? So would I- except thats a cost to pay for convenience, not safety. ***

No junior doctor, nurse or other clinical group has any such right.

1. Except they do- junior doctors would not be expected to see non-emergency patients out of hours ‘on call’- they would be properly sent to GPs or ambulatory care units. What goes on in hospitals depends how you define ‘non-emergency’. If you take emergency to mean new admissions, unwell patients and complex patients requiring daily review these are standard on call duties. But, non-emergency work over the weekend, for example doing blood tests that take weeks to get a result (e.g genetic sequencing) or seeing a patient with acne, pull time away from emergency patients unnecessarily. We can’t ‘opt-out’, but that doesn’t mean that we are providing a 24-7 non-emergency service and only consultants are missing – this is a gross misrepresentation. And additionally no consultant IS opting out.

Other senior public sector professionals who work in services required to keep the public safe, such as police officers, firemen and prison governors, do not have this opt out either.

1. Following along- suddenly non-emergency opt out= safety. If there is any non-emergency police or fire work that our colleagues are doing at weekends and nights, please let us know.

Whilst the vast majority of consultants work tirelessly for their patients,

1. Correction- they all do.

the opt out allows individuals to charge employers hugely expensive payments which are much higher than national contract rates (up to £200 an hour).

2. UPDATED: The evidence is clear, whoever wrote this is actually referring to agency doctors covering staff shortages NOT any single doctor reaping the rewards of imaginary opt-outs. (Which, let me labour the point, DOES NOT EXIST).

The average earnings for a hospital consultant are already in the top 2% in the country at £118,000, and these inflated payments can make it difficult for hospitals to provide the weekend cover they know patients need.

1. Average UK earnings for consultants- this is not clear, the top salary after 19 years of being in post is £101,451 – I struggle to find how the average is 118K. Here is the pay scale: [12]  Who else is in the top 2%? [13]  In a list that includes brokers, chief executives, financial managers, sales directors and PR directors only two other professions are comparable: pilots and air traffic controllers. No job in that list requires AT LEAST 14 years of training (6 years of medical school and 8-10 years of postgraduate training) and holds the responsibility for life and death. And don’t forget the cost of indemnity to handle that responsibility.

2. Inflated payments that make it difficult; what also makes hospital finances difficult are PFI deals, and locum costs for overstretched departments like A&E when other hospitals have closed.

3. We, as a profession, know the patients need ‘weekend cover’ for emergencies– which is already in place. This should be better funded.
The report endorsed the removal of the opt out, as well as broadly supporting other changes to the consultant contract that would ensure the right level of cover is available every day of the week; not just Monday to Friday.

1. The DDRB has rubber stamped the government and is not independant at all. It also recommended a pay rise- which the government completely ignored. ****

Under the new plans, doctors will still continue to receive a significantly higher rate for working unsocial hours

and there will be a contractual limit (not an expectation) of working a maximum of 13 weekends a year.

1. The redefinition will actually mean an effective pay cut, possibly in the realms of many thousands of pounds. [14]

By the end of the Parliament, the Government hopes that the majority of consultants, in line with existing practice for nurses, midwives and junior doctors, will be on reformed contracts,

1. As above, this will mean a pay cut and longer hours and no benefit to patients other than convenience, but likely an overall  much worse service, in the context of an already besieged emergency system.

working across seven days, to deliver a better service to patients.

2. Note now the aim is service and not safety.

Hospitals like Salford Royal and Northumbria that have instituted seven day services have already seen improvements in patient care and staff morale.

1. These improvements [15] are all in the emergency areas and acute wards, no non-emergency work at all.

These new plans will mean that doctors working in some of the toughest areas in the NHS, such as A&E and obstetrics, will at last be properly rewarded and there will be faster pay progression for all consultants early on in their career.

1. Despite closing or downgrading 66 A&Es and maternity units already.

Under the new proposals, the highest performing consultants could be able to receive up to £30,000 a year in bonus payments, on top of their base salary. Of course, improving weekend care requires more than just ensuring greater consultant presence.

1) Really? First time this is mentioned.

That’s why the government is also addressing issues such as access to weekend diagnostic services, provision of out of hospital care to facilitate weekend discharges, and adequate staffing cover amongst other clinical groups,.

2) Really, where?

But NHS leaders and the independent pay review bodies are clear that increasing the presence of senior clinical decision makers at weekends is vital, and that the consultant opt out remains a barrier to organising broader support services and staff rotas.

3) [UPDATED] 28/7/15: I’ll just reiterate: WHAT BARRIER? THERE ARE NO OPT OUTS. IT LITERALLY TOOK ABOUT 3 PEOPLE 2 HOURS TO FIND THIS OUT. MAYBE SPEND A BIT LONGER ON NATIONAL HEALTH POLICY THAN A TEATIME. *****

The Government feels it is under an obligation to the public to do all it can to make NHS care at the weekend as safe as during the week through the delivery of seven day services this Parliament and that is what it will continue to do.

1) And back to ‘safety’.

PHEW.

This is an infogram to summarise the governments reasoning for seven day care.

While the real thinking is;

1) How can we make the NHS more into a ‘consumer’ friendly service, despite the fact that we know the funding will not cover such a change, and simultaneously demoralise doctors and staff to the point that both patients and staff will look to ‘private’ reform as a crisis solution.

It doesn’t get a lot of media coverage but here is some interesting information on the Health Secretary, the Right Honourable Jeremy Hunt.

1) He co-authored a book called ‘Direct Democracy’ which explicitly idealises the dismantling of the NHS and how to do it

2) In 2012 he was stepped down from the position of Culture secretary following accusations of corruption over the BSkyB deal- putting private interests first over public benefit.

3) He has no medical or scientific qualifications whatsoever- he has a 1st class degree in Philosophy, Politics and Economics from Oxford.

4) His background is business, but he did try to make it as English Language Teacher. I wish he’d stuck with it.

5) It is a instant dismissal offence in the NHS to break patient confidentiality. A picture from Mr Hunts visit to an NHS hospital showed the names of several patients for surgery. The DoH found the picture, shared to 70,000 people, was an ‘innocent mistake’. Still no one has apologised to the named patients on the list, telling the whole world about their medical histories without their consent.

And this is the man charged with looking after the NHS.

#weneedtotalkaboutJeremy

And then sign this;

https://petition.parliament.uk/petitions/104334

**Yes, most of these PFIs came from the last Labour government. There are few heroes in this story.

***Perhaps a more reasonable solution would be to create a statutory medical appointment payment- this would pay a small fee for missed work to companies where patients are away attending non-urgent appointments.

****The DDRB is also destroying the junior doctor contract- altering it to make unsociable hours extend to 7am-10pm at Monday to Saturday. 9pm on a Saturday for your in-growing toenail removal?

*****I am a little sad I had to remove the phrase “Nuclear Powered Super Doctor”, so I’ve archived it here for posterity.

[1] http://data.worldbank.org/indicator/SH.XPD.PCAP/countries

[2] http://www.hscic.gov.uk/searchcatalogue?productid=17192&q=title%3a%22Hospital+Episode+Statistics%2c+Admitted+patient+care+-+England%22&sort=Relevance&size=10&page=1#top

[3] http://www.telegraph.co.uk/news/health/news/11184912/The-list-of-66-AandE-and-maternity-units-being-hit-by-cuts.html

[4]  http://www.pulsetoday.co.uk/home/stop-practice-closures/nuclear-option-rise-in-practices-seeking-to-close-or-merge/20009336.article#.VbUfQIfCdUQ

[5] http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters

[7] https://www.whatdotheyknow.com/user/kiara_vincent

[8] http://www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_20120007_en.pdf

[9] http://www.hscic.gov.uk/hes

[10] http://www.independent.co.uk/money/loans-credit/crippling-pfi-deals-leave-britain-222bn-in-debt-10170214.html

[11] https://www.rcn.org.uk/newsevents/news/article/uk/rcn-report-shows-immigration-rules-will-cause-chaos-and-cost-the-nhs-millions

[12] http://bma.org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/consultants-england

[13] http://www.thisismoney.co.uk/money/news/article-2868911/Best-paid-UK-jobs-2014-Compare-pay-national-average.html

[14]http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Post%20report%20DDRB%20guidance.pdf

[15] http://www.nhsiq.nhs.uk/media/2396737/consultant_led_northumbria.pdf

[16] https://www.whatdotheyknow.com/request/reason_for_consultant_opt_out#incoming-685389