NHS weekend working: the inside story

Junior Doctors Contract March London - 19. Image: Garry Knight (shared under Creative Commons License)

Let me give you a bit of personal history.  Apart from writing, I have been a freelance management consultant these past 23 years, the vast majority of which have been spent working at senior levels in and with NHS organisations, notably Acute Trusts (hospitals), but also commissioners, regulators, community providers and the Department of Health themselves.  That I’ve continued to work with these bodies tells you that there is a deepening crisis, mainly through the ignorance of our political masters and the fact that the clinical community are not being allowed to do their job.  Allow me to explain.

In short if this extended exposure to our much-loved healthcare system has taught me anything, it is that governments of all persuasions are the problem, not the solution.  The best thing any government can do for the service is to stop meddling and allow the professionals, by which I include executive, management, admin, clinical staff, associated healthcare professionals, clinical technicians and all the other staff on whose goodwill the treatment of patients depends, to deliver the results that matter – more effective care pathways to make people well or to manage their transfer to ongoing care in the community.

The impact is simple:  patients are no longer the priority of the NHS; the top priority is contracts and financial management

Among 27 major changes, the previous Labour government instituted a vast array of performance standards, many of which distorted patient service and focuses on the wrong things (this being my area of expertise.)  That government also picked up the PFI programme commenced during the John Major government and used it to construct many new hospital facilities without adding to the national debt… at a huge cost to the revenue budgets of the hospitals concerned, such that some had no hope in hell of breaking even.  

The recent Tory/Lib Dem coalition promised us no further top-down reorganisations, yet within weeks of the 2010 election wheeled out the biggest top-down reorganisation of the lot, one that was in no manifesto and which, frankly, destroyed the service as people have come to know and cherish it these past 68 years. That the 2012 Health and Social Care Act (which, incidentally, did precisely nothing to help the integration between health and social care, such that delayed transfers of care caused by shortage of community beds is greater than ever) was an unmitigated disaster is revealed by the fact that the government is quietly inching away from the internal market it created, one in which NHS bodies were prevented from tendering for contracts.  Up to that point, most Trusts broke even and hit most performance targets most years, but for the ones that would probably fail anyway.  In other words, good management and clinical governance were rewarded; after that point all Trusts were punished, regardless.  

_87619927_strike5The impact is simple:  patients are no longer the priority of the NHS; the top priority is contracts and financial management.  Executives are concerned with how to manage the vast deficits created by this ham-fisted piece of legislation.  NHS England, the body now responsible for allocating funds does so with considerable strings attached – typically by issuing templates for Trusts to complete to demonstrate where money will be spent and the impact of every additional pound of funding.  NHS Trusts had a net deficit of £843m in 2014-15, £91m deficit in 2013-14 contrast to a £592m surplus in 2012-13; NHS Trusts predicted total overspend for 2015-16 is now about £2.5 billion.  I could talk about PbR contracts, tariff structures that mean Trusts must provide services that will always lose money, Agenda for Change and many more aspects of financial mismanagement from the government down, but those can wait for another day.

Where did we lose track of what our healthcare provider is all about?  Why did it become such a political football?  The two are interlinked, none more so than in the current controversy about junior doctors and 7-day working.  Before I do, please remember one plain fact: almost all Trusts are radically short-staffed in many key areas.  These will include senior and junior clinicians in several hard-pressed specialties, radiologists and radiographers with specialised skills, endoscopists (which is why gastroenterologists often double-up to ensure their patients have the gastroscopies they need), histopathologists, nurses and pretty much every clinical profession is short-handed at some areas – typically where patients are most in need.  

Even worse, Trusts can rarely recruit the right people to these roles, especially in rural areas.  Trusts do attempt to recruit overseas to fill gaps, which is why we have a great number of roles filled by people who are needed in their own countries, but with immigration laws being tightened, any healthcare staff earning less than £35k pa will be deported, as soon as the legislation takes effect.  Where will we get our professionals then?  Furthermore, thanks to national pay scales and contracts, no Trust can improve on salaries or make ex-gratia payments to attract staff, which is one reason why vacancies are filled from bank and agency staff at huge cost (eg. locum doctors.)  It’s not the fault of Trusts – it is out of their control.

Weekend working: to begin with, don’t let anyone tell you Acute Trusts don’t work 7 days already, because they do.  A&E operates 24×7 on almost all sites; emergency surgery happens when it’s required. Diagnostic tests continue for emergencies, inpatients, cancer patients and electives, particularly to reduce queues, using internal and subcontracted private facilities (how often have you seen a mobile MRI unit parked in the car park at a hospital?)  Elective surgical lists are also scheduled as Trusts attempt to reduce backlogs and treat patients within the national 18 week target.  The best bit is that many of the staff who come in on weekends not only don’t do so at inflated weekend rates – often they do it for love of the job and from caring for patients, with minimal or zero recompense for their time; a good proportion of those staff who do weekend are certainly not well-paid by any stretch.  

Where did we lose track of what our healthcare provider is all about?  Why did it become such a political football?

It’s true that some consultants use the weekends for their private lists, but a substantial number still put NHS patients first.  As for “junior” doctors (house officers, SHOs, junior and senior registrars, which therefore includes some very experienced practitioners, a good number of whom will have reached their mid-40s and acquired partners and families without achieving consultant grades), it’s very common for the staff shortage to result in their having to work back-to-back shifts and therefore to be on duty for 72 hours at a time, a practice that is nominally illegal and was formally abolished when the Working Time Directive became law in England and Wales.  

The effect of the Secretary of State, Jeremy Hunt’s imposed contracts would be that the same number of doctors would be spread in shifts across 7 days rather than 5 as a contractual requirement rather than by goodwill.  For those cases where payments are offered, those would vanish in the new world – as would the goodwill that held the system together, because once you are expected to work whatever shifts are thrown at you, which typically might mean little or no sleep, let alone days off convenient to family life, you aren’t going to put yourself out – you are going to go home and rest all you can.  Small wonder then that junior doctors are so incensed – but the reality is that with not enough doctors to pad out the gaps in the schedule, restrictions on the use of locums and backlogs increasing due to sheer volume of demand, even more doctors will be forced to work all week with no break.  As the placards say, tired doctors are not safe.

For the amount this will save, it is barely worth the aggravation – it is simply the implementation of control to demonstrate the power of the Health Secretary.  Worse, the likelihood is that the rate of attrition by doctors leaving for health services where they can earn more for a guaranteed working week, already at appalling levels, will go through the roof.  The sad fact is that this is almost certainly what Jeremy Hunt wanted: an NHS which cannot serve the needs of its patients, and therefore must be supplemented by forms of private health insurance.  I suspect Nye Bevan is spinning in his grave.



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