Now that we have had confirmation from Mr Hunt himself that seven-day NHS refers to urgent and emergency care, I wonder what impact that will have on my chosen speciality; A+E. Whilst it is fair to say that many healthcare professionals already work a seven-day pattern in the case of emergencies, there are undoubtedly less resources available on a Saturday and Sunday compared to a weekday. Perhaps we will see a shift in emphasis towards emergency care from the NHS, and a scale back on elective work.
A+E is the link bridge from primary to secondary care and it is fair to accuse it of being a reflection of the overall functioning of a vast healthcare system. Sadly, crowding currently plagues A+E; patients queue in corridors, ambulance staff wait to handover and professionals get burnt due to unsustainable intensity. It is also important to note that crowding shows no regard for which day of the week it is.
This month the RCEM produced a how-to guide for tackling the crowding crisis during winter. The underlying causation is broken down into three categories - input, throughput and output. More importantly, it is a politically charged and opportunely timed document. As it lays out the focus areas to reduce the burden on emergency services it effectively serves as a blueprint for a seven-day NHS.
Naturally, input would seem uncontrollable given the nature of the speciality. However, for healthcare planning purposes it is essentially a banker given the repetitive annual swell of A+E attendances. People survive longer with more complex illnesses thus are increasingly dependent upon healthcare provision. But the mantra with which every healthcare professional lives by (prevention is better than cure) has a major role to play via public health and primary care. We know from pilot studies that weekend GP care has scant uptake, but will widespread normality of 24-hour, 7-day availability incur a decline in terms of attendances? I personally believe rerouting that finance into general public health would result in a quicker and more cost-effective yield.
Of the three modifiable factors, throughput was the least targeted. Escalation played a key role with increased vigilance for crowding amongst hospital hierarchy. This is essentially meaningless, as by the time you have crowding, the system has already failed. Locally agreed targets for investigations gained a mention too, but these have long been in place since we have seen a yearly squeeze with subsequent elevation in pressure.
Within output the elephant reared it's trunk. The four-hour target has essentially been acknowledged as a useful evil. The pressure and financial impact deemed acceptable for efficiency and a catalyst for change as it is an objective marker of performance. An interesting point in output was that of capacity levels. This could be interpreted as an indirect slight given the multitude of hospital closures that has lead to an overall decrease in number of beds. Also flirted with, but not mentioned explicitly, was increased social care availability. Effective discharge on weekends and bank holidays was the terminology used to combat the so-called bed blockers.
In a sense it seems natural that emergency medics are leading the light on this. The current fire fighting the speciality has descended into has become ungratifying. With widespread improvements upon the system as a whole, A+E can return to being a sought after speciality with clinicians being allowed to offer world-leading care. By subtlety highlighting the key areas for development, that of primary care, social care and capacity, it should help focus the channels for change.