How to design seven-day care for tomorrow’s consultants

In recent weeks and months, mounting evidence has highlighted the inadequacy of evening and weekend care and a seven-day NHS has seemed increasingly possible. So far, contributions from the medical community have come mainly from senior clinicians, with consultant contract negotiation the most likely forum from which any change will emerge.

‘For junior doctors especially, being asked to manage a patient on a weekend who has had no formal plan written since Friday morning can be overwhelming’

However, it is critical that junior doctors and trainees have a voice in the discussions. It is they who have the most current experience of on-calls and for whom seven day care could mean unsociable hours for significantly longer than initially imagined.

In light of this, it is time to consider how seven-day care can deliver benefits for clinician and patient alike. More support from seniors, more flexible working hours and greater opportunity to work as part of a team are some of the ways this can be achieved.

For junior doctors especially, being asked to manage a patient on a weekend who has had no formal plan written since Friday morning while covering several wards of patients they have never met can be overwhelming. In this context, it is challenging to deliver a high standard of care but also difficult for young doctors to learn as effectively as they could do.

Opportunities for collaboration

Opportunities for doctors to collaborate with consultants on management plans with a minimum regularity, for example daily ward rounds which are already the norm in some hospitals, would improve the educational value of out of hours work as well as patient safety. Another way both can be improved is through ensuring there are enough staff for doctors to manage the same patients during and between shifts, which currently does not always happen. In this way, continuity of care and the opportunity for doctors to learn through seeing the outcomes of their management decisions are improved.

Following Modernising Medical Careers, career pathways have become more rigid than ever. Yet at the same time, more women are entering medical training than ever before and more doctors are pursuing dual qualification or unusual combinations of specialty interests.

‘Thoughtfully designed seven day rotas could deliver more flexible working hours’

Thoughtfully designed seven day rotas could deliver more flexible working hours, bringing the opportunity to care for children or pursue other interests such as research or policy on week days and earlier on in training. It would be a missed opportunity for any major change to doctors’ working patterns not to incorporate such goals.  

Elevated weekend mortality rates and the experience of working an on-call shift cannot be improved through increased consultant cover alone. If consultants are to  spend more time on the wards, and for out of hours services and patient care be truly improved, then radiology, social services, pharmacy and other healthcare professionals must come with them. There are many reasons to anticipate that this will improve patient outcomes but another benefit is helping doctors to feel more like they are working as part of a team. The current model of a skeleton staff with reduced resources has made out of hours shifts lonely and more stressful than they need to be.

Less stressful on-calls would mean qualifying consultants would not feel the need to defend a quality of life only just obtained and juniors would feel better about working out of hours for longer. In addition, intelligent service design combined with the increased efficiency of using more trained staff means seven-day care should be achievable at little increase in out of hours work for individuals. Not least because, as many have pointed out, the NHS cannot afford a seven-day service built simply on increased hours for all.

The debate on seven-day working needs to focus around three key themes:

• maximising support and learning;
• flexible rotas and flexible careers; and
• extending the on call team to reflect service needs.

Current discussion around seven day working too often falls into the trap of pitching patient care against doctors’ quality of life. Both are important but they are also interrelated. Much of the stress of any shift comes from the fear of not doing the best for patients. More flexible hours, more resources and more support from seniors are just some of the ways seven-day care can improve patient outcomes but also the experience and educational value of going on-call. In this way, working a Saturday and Sunday would feel, though not the same, much closer to working any other day of the week.

Vita Sinclair is a final year medical student at King’s College London