Everyone can help make the NHS run 24 hours

Just as ill health does not respect the working week, neither does it respect circadian rhythm, it seems.

The phrase “seven-day services” reflects the existing focus on patient outcomes at the weekend, underpinned by well reported data.

‘The expectations of the public have been shaped by our responsive, 24-hour internet, demand-led age’

But perhaps 24-hour services would be more apt, since new research from a team of NHS analysts shows a dramatic difference in the impact of the time of day a patient is admitted. Those admitted at 9am-10am are discharged on average three days earlier than those patients admitted at 9pm.

The usual warnings apply: such analysis reveals correlation not causation. But the researchers’ conclusion that access to consultants is likely to be a major factor is a logical one. It is also likely that those admitted in the evening are more unwell. Which perhaps explains the gap in length of stay: the most poorly people are admitted at a time when there are the fewest consultants and senior staff on hand.

Well worn arguments

In short, it seems clear that outcomes for patients are worse at “off peak” times. This raises a clear case for the need to redesign acute care cover (and arguably all cover) to balance both day/night and weekday/weekend times in a way that better reflects patient needs and flows.

This insight from the new analysis strengthens the case for round-the-clock services. Few dispute that such a change would be good for patients and the public. It is clear that it would lead to improved outcomes and greater convenience for patients.

The stumbling blocks are financial and cultural. Does it necessarily need to lead to greater workforce costs? How can clinicians be won over? Will it ultimately lead to some savings?

The workforce and cost arguments are well worn. There will be some additional cost, especially to start with, but how much depends on many variables, at least some of which can be managed through system design. The focus has to be to find a way to get the design right and the winning over of those whose working patterns will be affected.

Public expectation

All groups have a responsibility to engage constructively to find the much needed solutions. The expectations of the public have been shaped by our responsive, 24-hour internet, demand-led age, and it is clear they expect the NHS to find a solution that delivers universal access and outcomes at all times.

‘Community care is not necessarily cheaper. Savings are only cashable if the hospital can shed its costs or attract additional work’

This will also involve thinking about sustainability. For example, it is clear that the work that junior doctors do out of current core hours is crucial for building their experience, yet it is known that those times when fewer experienced staff are on hand yield poorer outcomes for patients (and higher use, and therefore cost, for diagnostic services). This highlights the need to rethink the way that junior doctors are supported to become the experienced hands of the future in a way that is most effective in the present.

Meanwhile, there is the issue of savings. Effective planning, although difficult to achieve, can help to reduce temporary staff costs, and if the average length of stay was reduced then the cost per patient would undoubtedly fall.

However, assumptions must, as ever, be treated carefully. It has been known for some time that about 50 per cent of patients in acute beds can often be cared for in other settings and it is often argued that using community services would lead to savings. Done right, multidisciplinary community care can undoubtedly offer a better service for some patients.

But as Nigel Edwards argues, community care is not necessarily cheaper. Even when community services are targeted at those who will benefit most, savings are only cashable if the hospital can shed its costs or attract additional work.

In reality, it is often the latter.