The Ethical Imperative to Move to a Seven-Day Care Model
Whilst the nature of human illness is not determined by time of day or day of week, we currently structure health service delivery around a five-day delivery model. At least one country is endeavouring to develop a systems-based approach to planning a transition from five- to seven-day healthcare delivery models, and some services are independently instituting program reorganization to achieve these ends as research, amongst other things, highlights increased mortality and morbidity for weekend and after-hours admissions to hospitals. In this article, we argue that this issue does not merely raise instrumental concerns but also opens up a normative ethical dimension, recognizing that clinical ethical dilemmas are impacted on and created by systems of care. Using health policy ethics, we critically examine whether our health services, as currently structured, are at odds with ethical obligations for patient care and broader collective goals associated with the provision of publicly funded health services. We conclude by arguing that a critical health policy ethics perspective applying relevant ethical values and principles needs to be included when considering whether and how to transition from five-day to seven-day models for health delivery.
KeywordsHealthcare reform Delivery of healthcare Healthcare ethics Ethics, institutional
Despite the nature of human illness not being determined by time of day or day of week, we currently structure health service delivery through a five-day delivery model. At least one country is endeavouring to develop a systems-based approach to planning a transition from five- to seven-day healthcare delivery models (NHS Health Improvement Agency 2012; British Medical Association 2013) and some services are independently instituting program reorganisation to achieve these ends (NHS Health Improvement Agency 2012). Reconsidering current delivery models has become a priority after research has, amongst other things, highlighted increased mortality and morbidity for weekend admissions to hospitals (Academy of Medical Royal Colleges 2012; de Cordova et al. 2012, Handel et al. 2012; Freemantle et al. 2012). It is difficult at an instrumental level, however, to change something as fundamental as a delivery model when it is and has been a sectoral norm, around which funding models, staffing practices, and policy and practice are based.
In this article, we argue that the issue of whether health systems should transition from five- to seven-day models of care delivery does not merely raise instrumental concerns but also raises a normative ethical dimension, recognizing that clinical ethical dilemmas are embedded within systems of care. Accordingly, this paper aims to use health policy ethics to critically examine whether health services, as currently structured, are at odds with ethical obligations for patient care and broader collective goals associated with the provision of publicly funded health services. This approach does not emphasize professional norms or the moral motivations of healthcare professionals but rather looks to the level of policy as a catalyst for systems change (Sharpe 2003). First we discuss the limitations of the five-day delivery model, particularly in regards to research that indicates that this model can impact upon mortality and morbidity. We then canvas some core ethical arguments that we believe support a transition to a seven-day-service delivery model focusing on ethical obligations around quality and safety, access, and stewardship and system governance. The primary focus of this paper is to examine the ethical arguments suggesting the desirability of a transition from a five- to seven-day-service model. We recognize that similar arguments also can be made in respect of a 24/7 model of care addressing issues in relation to the provision of after-hours care on a weekday, although this is not the primary focus of this paper.
The Five-Day Delivery Model
The five-day delivery model sees healthcare systems arrange the majority of services, apart from emergency care, critical care, and acute wards, differently at the weekends. In most services based on a five-day delivery model, weekend healthcare delivery is characterized by lower staff numbers, lack of service provision, or difficulty in undertaking some activities, for example weekend discharges. The five-day delivery model is maintained on the basis of custom and practice (a five-day working week being uncritically accepted as a given), financial resource allocation, and staff availability, both for primary care and for emergency and elective admissions to hospitals. Delivery models are also shaped by funding paradigms that may drive a wedge between better integration of care across the continuum of a patient’s journey and stifle collaboration on integrating IT and communication flows to improve continuity of care across the length of stay (Duckett and Willcox 2011).
The five-day delivery model was established in the absence of consumer engagement in the design of service delivery, as historically methods of care delivery were a matter of negotiation between clinicians and governments or other agencies that funded, managed, or provided services. Consumer engagement in health-service management is evolving but is still at an early stage of maturation. National accreditation bodies are mandating that consumer engagement should no longer be an aspirational endeavour, but one that health services must comply with in the expectation it forms an integral part of the quality cycle for patient care into the future.
There is also a growing body of evidence that weekend (and also after-hours admissions) result in increased case-mix-adjusted thirty-day-mortality rates based on population studies (Academy of Medical Royal Colleges 2012). The effect appears stronger at the weekend than after hours during the working week (de Cordova et al. 2012). Within a five-day model, elective and emergency admissions, across multiple pathologies, have been implicated in an all-of-National-Health-Service-based study as being at increased risk of death, with confirmatory data from the United States suggesting this is a systemic effect (Freemantle et al. 2012; Handel et al. 2012). Increased patient length of stay (de Cordova et al. 2012) and subsequent waiting times to ward admission for emergency department patients also has the effect of increasing short-term mortality for those patients so delayed (Guttmann et al. 2011).
In addition to the mortality risk, patient privacy and confidentiality in overcrowded clinical areas is affected, pain and anxiety can be prolonged, and the ability for clinicians to enact their professional duties suffers, all of which carries moral weight (Moskop et al. 2009). It is postulated that the weekend effect described above results from poorer quality of care rather than patients being inherently sicker on the weekend (NHS Health Improvement Agency 2012). Early research investigating elective admissions at the weekend demonstrated that the mortality effect is even more pronounced in this group than for emergency admissions, which supports the relationship (at least at this early stage) (Mohammed et al. 2012).
The reduced intensity of weekend medical care is important because subsequent increased efforts later in a patient’s admission may not be able to compensate for any adverse events in the earlier phase of care for those patients admitted, but not reviewed by a consultant, at the weekend (Redelmeier and Bell 2007). This is a numerical- and expertise-based phenomenon and extends to the provision of diagnostic testing (Lee et al. 2005), interventions (Kostis et al. 2007), access to consultant-level care (Royal College of Physicians 2012), medication-error prevention (The Regulation and Quality Improvement Authority 2013), and adequate leadership over the weekend (Cavallazzi et al. 2010).
We argue in subsequent sections of this paper that the five-day care delivery system is a feature of the inequity that exists for a range of demographic, geographic, and condition-specific reasons (Bennett 2013). The end result is a fragmented, highly scheduled system organized around clinicians not patients (Dugdale 2012). The idea that systems and processes are arranged around what clinicians do (or want to do) and not what patients need challenges healthcare systems to focus on patients and to transition to a seven-day-care model to optimize outcomes for patients.
Ethical Arguments to Support Transitioning to a Seven-day Delivery Model
Sharpe has noted that some health issues require examination in a manner whereby patient populations at the aggregate are the normative focus (Sharpe 2003). We suggest that policies and practices relating to models of care delivery are one such health issue. As Kenny and Giacomini (2005) have noted, public policy is an inescapably moral enterprise and affects patient populations. Kenny and Giacomini (2005) further argued for the necessity for an expanded set of principles and virtues, in addition to the (traditional) bioethical principles, as a basis for health policy analysis. This broader characterisation of the ethical concerns required to undertake a comprehensive ethical analysis of health policy recognizes that clinical ethical dilemmas are embedded within systems of care and these systems of care require ethical attention as well. While the ethical principles applied in the clinical context remain relevant in this broader sphere, they contend that further and more expansive values must be considered to create a more holistic ethical structure with which to approach healthcare policy analysis. These values include: examining the ethical dimensions of efficiency and productivity; addressing the relationship between citizens and the state through such principles as fair processes, accountability and transparency; and focusing on ethical principles such as sustainability, stewardship, and social justice.
It must be acknowledged that the assumption underlying the analysis that follows is that governments and other actors who have governance responsibilities for publicly funded and/or provided health systems and for service management have certain responsibilities to the public. For the purposes of this analysis, we have loosely grouped these responsibilities as being in respect of quality and safety, access, systems governance, and stewardship.
Quality and Safety
It almost goes without saying that the moral motivation for a move towards seven-day models of service delivery are the ethical principles of beneficence and non-maleficence, derived from the positive obligation to protect people from harm and the negative obligation to not cause harm. As discussed above, there is evidence to support the contention that current five-day models of service delivery are causing harm to patients. The omission to provide care and treatment of an appropriate standard outside of the core business hours dictated by the five-day delivery model is a compelling moral argument for a shift to a seven-day delivery model. After all, the right care, in the right place, at the right time is central to the patient centred view of healthcare (Bennett 2013). In a five-day delivery model, the ability to perform procedures and diagnostic testing after hours are all impacted by consultant paucity and junior medical officer propensity. The Regulation and Quality Improvement Authority (RQIA) of Northern Ireland undertook a three-year review which assessed the safe delivery of care outside of 8 a.m. to 6 p.m. Monday to Friday. This review noted that under a five-day model nights and weekends are characterized by a junior-medical-staffing model, including doctors in training, with off-site-consultant coverage (The Regulation and Quality Improvement Authority 2013), with obvious implications, as discussed above, for clinical care.
Patient-centred care has been defined as an “approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families” (Institute for Patient- and Family-Centered Care [IPFCC] 2015, ¶1 under “What is patient- and family-centered health care?”). The nature of human illness or injury, as discussed previously, is not determined by time of day or day of week. Some have noted that by getting sick or injured and so demanding treatment or care patients determine the work of clinicians (Dugdale 2012) and to some extent this is correct. However, the lack or inconsistency of service provision outside normal business hours Monday to Friday implies that the needs of patients are not totally driving the provision of care. The five-day delivery model is also arguably not responsive to the “time use preferences of patients” versus “the internal time demands of the health system” (Dugdale 2012, 193). Patients and/or their families may prefer an outpatient appointment or a needs assessment to be undertaken on a weekend; however, that need cannot be met under the current system for the delivery of public health services, as it is supply driven and organized around the governance norms of the organizations that provide care (Porter and Lee 2013). A commitment to patient-centred and responsive care, as well as to the principle of consumer engagement, would indicate that a review of the organizational systems and processes within which care is provided is warranted.
Whilst the rights of individuals to healthcare are generally not explicit, nor enforceable under law, those countries with schemes that provide universal access to healthcare implicitly support that right and recognize a moral right of their citizens to the receipt of healthcare services of an appropriate quality, even if not to health per se (Daniels 1998). As much as receiving appropriate healthcare in general is a positive right (Kerridge, Lowe, and Stewart 2013), non-evidence based practice or practice that is not properly informed or aligned with patient preferences is arguably inappropriate. The lack of control over physical environment and private information for emergency department patients is an example (Moskop et al. 2009). A further example is outpatients having little flexibility as to the timing of their appointments. There are also identified service gaps when areas such as specialist community rehabilitation and post-discharge teams are not attended to at the weekend, causing further disruption to acute healthcare delivery (Bennett 2013; Kerridge, Lowe, and Stewart 2013). Poor coordination of care due to these types of differences in levels of service provision can result in fragmented and hence poor quality care for patients.
To attain the right to healthcare of an appropriate quality, attention may need to be focused on quality improvement methodologies. This would ensure that deliberate patient-centred actions, in the context of process improvement, are adequately measured and guided by outcome data that includes patient-experience elements (Lynn et al. 2007), as well as reliance on an evidence base about what models of service delivery may result in better outcomes for patients. Currently, quality is inferred from easily measured and “economistic” indicators that may not be important to patients, but are conveniently available to decision makers (Braithwaite, Healy, and Dwan 2005). A three-tiered approach is described by Porter and includes indicators for health status, nature of the care cycle, and sustainability of health services (Porter 2010). Tier one relates health status to survival but extends this to include degree-of-health and quality-of-life measures. Tier two, arguably the most important when considering seven-day services, relates to the time to recovery and considers disutility of care and treatment process delays such as diagnostic error, ineffective care, treatment-related discomfort, and complications (Porter and Lee 2013); all of which challenge the ethical principles of patient-centred care, beneficence/non-maleficence, and efficiency of care delivery. A transition to a seven-day model may allow these important quality indicators to be improved. Tier three indicators focus on downstream benefits for patients, including that the healthcare delivered is sustainable and not marred by recurrence or the long-term consequences of therapy (Porter and Lee 2013), but may not directly relate to the seven-day issue. In addition to focusing on the quality improvement indicators discussed above, engaging consumers in decisions about the structure and design of health services delivery may also improve service quality in terms of consumer satisfaction.
The ethical principle of justice can be broadly characterized as a concern with equity, equality, and fairness (social justice) (National Health and Medical Research Centre [NHMRC] 1999; Kenny and Giacomini 2005). In considering what model of service delivery should be used, we are making a decision about how to allocate the “good” of healthcare, and there have been many interpretations of distributive justice from a variety of philosophical and bioethical traditions. Underlying system-wide strategies and healthcare priorities will influence the moral assumptions made about distributive fairness in any given healthcare system and vice versa (Daniels 1998). Consumer engagement could also assist to bring a social justice perspective to such allocative decisions (Kerridge, Lowe, and Stewart 2013).
Concerns about equity or equality of access would suggest that we, as much as possible, equally distribute access to healthcare amongst the population, or as Daniels, Kennedy, and Kawachi put it, “[t]he fair design of a health system should give some weight to meeting actual medical needs” (2000, 24). In this context, this would suggest that there is unequal distribution if patients admitted to hospital on the weekend get reduced access to services compared to those admitted at, for example, midday on a Wednesday, given that the level of need experienced by those patients is the same. But it is important to note that universal access to core healthcare benefits need not mean that every potentially useful service should be accessible seven days a week (Levine et al. 2007). Inequality in service delivery becomes a matter of pressing ethical concern when inequalities become inequities.
When is a health inequality between two groups inequitable? Kawachi, Subramanian, and Almeida-Filho define these terms: “health inequality is the generic term used to designate differences, variations, and disparities in the health achievements of individuals and groups,” while “health inequity refers to those inequalities in health that are deemed to be unfair or stemming from some form of injustice” (2002, 647, emphasis original). Dahlgren and Whitehead (1992) have argued that health inequalities count as inequities when they are avoidable, unnecessary, and unfair. In this context, one could say that the inequality of service delivery is avoidable (as there is another form of care delivery—the seven-day model), unnecessary (there seems no reason other than traditional work organisation why services are organized in particular ways), and unfair (the nature of human illness is not determined by time of day or day of week so why should your ability to access health services of an appropriate quality be determined by the day on which you become ill or injured). Applying this aforementioned test, the five-day model of care is inequitable and should be remedied. Whitehead and Dahlgren’s test, however, has been critiqued for not being linked to broader theories of justice and not addressing pragmatic issues about how to address the balance between equity and aggregative concerns (Norheim and Asada 2009).
Every person or group should have equal health except when: (a) health equality is only possible by making someone less healthy, or (b) technological limitations exist to further health improvements. In other words, the weak principle of health equality suggests that health inequalities that are amenable to positive human interventions are unacceptable (Norheim and Asada 2009, 6–7).
In this case, the health inequality in question, the five-day delivery model which results in patients receiving different levels of care depending on the period of the day or week they get sick, will be amenable to positive human intervention. The positive human intervention in question would be to transition to a well-designed seven-day delivery model.
A remaining question in Norheim and Asada’s test is a utilitarian one, whether the intervention in question may reduce overall aggregate utility, that is, might it make other people unhealthier (Norheim and Asada 2009)? Central to utilitarianism is a concern to maximize utility. Could spreading resources across seven days instead of five result in a reduction in aggregate utility? While the persons who receive care on a Saturday may get a better care experience under a seven-day model, could a person receiving care on a Wednesday get a lesser care experience as resources are now no longer concentrated on weekdays? Or might a move to a seven-day delivery model reduce the quality of care provided to all patients? If so, then this may suggest maintenance of the current five-day model. However, the assumption of policymakers in England is that reshaping services may improve or at least not lessen the quality of services if properly managed and resourced (NHS Improvement Agency 2012).
As Kenny and Giacomini note, “[w]hen many people—as well as societal constructs such as institutions and economies—are affected in many ways by every decision, the moral quandaries arise not in the question of whether to harm or benefit but how to harm and benefit: whom, how much, how certainly, in what ways, and so forth” (Kenny and Giacomini 2005, 254, emphasis original). Some would suggest that a strong moral obligation exists even when there is a loss of overall utility if a preventable harm is avoided or lessened as it may be in this instance. Equality of opportunity should exist in healthcare over and above the maintenance of normal functioning for an individual patient (Kerridge, Lowe, and Stewart 2013; Moskop et al. 2009).
Systems Governance and Stewardship
In the Australian context, under the Medicare principles, governments commit to make improvements in efficiency, effectiveness, and quality in relation to the healthcare system (Kerridge, Lowe, and Stewart 2013). In other words, governments commit to good stewardship of the healthcare system. This is not solely an Australian phenomenon, as other governments in countries with universal public-funded systems are also committed to stewardship vis-à-vis their health systems. It might be more difficult, however, to make an argument that stewardship is an overarching value in relation to health systems that are not based on a universal access premise and which may claim that another overarching value governs systems operation. In the United States, for example, competition appears to be prioritized in respect of the management of the health system. For those nations where stewardship is a priority in respect of health system management, striking the balance between current resource use and preserving access in the future (or sustainability) lies at the core of the notion of stewardship (Reiser 1994), as does good financial management.
The ethical principle of stewardship encompasses arguments about efficiency and effectiveness. Efficiency has an ethical dimension as well as an economic one. A just healthcare policy should also ensure an efficient use of scarce resources, although the reverse may not necessarily be true (National Health and Medical Research Council 1999). Efficiency in resource use is an ethical imperative as the state has finite resources that should be used effectively to maximize benefit to its citizens. If fiscal resources are used effectively, additional funds may be available through complementary disinvestment strategies, whether in health or in other areas; if they are used inefficiently, there may be reduced access to services for patients.
Strongly associated with efficiency are considerations of effectiveness and the relative importance of competing effective treatments. In considering a move from a five- to seven-day delivery system, questions regarding the provision of a narrow range of critical care services that benefit a few versus a wider range of less acute services that benefit a greater number need to be debated. Institutional standards appear to be able to mitigate the risk of out-of-hours condition-specific mortality when resourced, but at a system level the implications for widespread upscaling of weekend resourcing in the hospital and primary care sector will need to be assessed against the ethical principles set out in this paper and clearly targeted within local contexts to be financially viable (Handel et al. 2012).
Healthcare limited to a delivery paradigm based on a five-day working week may also raise efficiency and effectiveness issues in relation to infrastructure. The built infrastructure has been designed to meet peak demand, and as such mismatch between peak capacity and peak demand creates waste (Lee et al. 2005). One argument runs that it is cheaper and more efficient to enhance weekend services and construct new senior staffing schedules to spread usage across a seven-day week than it is to continually add to built infrastructure that is only used to capacity five days a week (Bell and Redelmeier 2005). The efficiency argument is creating tension between healthcare purchasing agencies focusing on inefficient use of resources due to lower weekend usage, and health service providers that point to a decline in actual inpatient beds per capita. Activity-based funding, for all its critics, does allow health services to monitor their efficiency gains according to cost per Weighted Activity Unit (WAU). Those health services operating efficiently can raise strong arguments to reopen beds and operating theatres that were closed as part of system-wide disinvestment, ahead of future infrastructure development to meet rising demand. The conflicting arguments in relation to greater bed numbers versus more efficient use of existing beds has become so polarized that enhancing weekend services using existing infrastructure may be the only short-term solution, especially given the lead times to planning new built capacity.
There may also be an issue in terms of human resources. There may be issues in respect of the adequacy of clinician coverage for an extended model due to the fact that budgets do not stretch to unlimited additional adequately trained full-time medical equivalents (setting aside issues of availability). This may be addressed, however, through taking the opportunity to review care structures and move towards multidisciplinary models of service provision (NHS Improvement Agency 2012; The Regulation and Quality Improvement Authority 2013). The ethical principle of stewardship would suggest that arguments in relation to efficiency and effectiveness need to be critically considered to support the most effective use of resources to ensure the short- and long-term sustainability of the system.
At the level of system governance, healthcare is a complex interaction between patients, clinicians, government, insurers, and regulators. Clinicians at the coalface see where the system is working for patients and where it is failing them. They are also acting as stewards for a system that feels, to them at least, to be insufficiently ethical and transparent in its construction—all the while advocating for the patient within that system (Levine et al. 2007). Seeing how patients access care within the clinic, in the emergency department, or on an inpatient ward gives cause for them to pragmatically evaluate the ethical and legal ramifications of their routine work. Clinicians have become somewhat sceptical of approaches to care devised by health bureaucrats far removed from direct patient care (Wolf 1994). Nevertheless, when clinicians are made accountable for cost-related decisions, in addition to any clinical determination, they are acting as stewards of the system. As such, arguably they may have a broader professional and ethical responsibility, not just to an individual patient but to all patients, to the health system, and to the community more generally, to ensure, to the extent that they are able to, that resources are used effectively at the micro, meso, and macro levels. While much attention is focused on a clinician’s responsibility to his or her patient, some, especially amongst some professional groups, acknowledge that clinicians cannot divorce themselves from the broader context within which they practise and that decisions made in respect of one patient have consequences, perhaps negative impacts, for other patients (Medical Council of New Zealand, 2008; Australian Medical Association 2010; General Medical Council 2012; Ubel and Jagsi 2014) and also for the community more generally. This is particularly critical for clinicians who also have managerial responsibilities, who have responsibilities at the organizational and/or health-systems level which give rise to an ethical obligation to individual patients as well as more broadly. In addition to the arguments around the effective stewardship of finite resources, we have earlier argued that there are cogent arguments from a safety and quality and access-related perspective to support the move to a seven-day delivery system for healthcare which all support the role of clinicians in critically considering the current design of health delivery. We have argued in this section of the paper that using resources in a wasteful manner is not only uneconomical but unethical, making peer review, benchmarking, and performance reporting important quality-accountability mechanisms for clinicians (Levine et al. 2007). At a system level, however, pragmatic feedback via legislated clinician-engagement mechanisms (Queensland Government 2011) assists in formulating the forward looking vision of healthcare delivery for patients, rather than just accepting things for how they are (Wolf 1994), as may greater consumer engagement. The introduction of ethical analysis within systems of healthcare when developing health policy, via the translation of specific clinical experience to include broader populations or communities, is important for the system as it evolves (Kenny and Giacomini 2005).
So assuming we accept the ethical arguments supporting a transition to seven-day service, a significant stewardship challenge, both at the instrumental and ethical levels, will be to balance the demands on clinicians and others such as administrative and support staff. There is an ethical concern not to treat them as means to some end but rather to respect them as an end in themselves. Clinicians and others’ willingness to work after hours and at weekends is challenged by the notion that many clinicians choose specialties for the very reason that they have not traditionally been viewed as encompassing shift work. The same is true of allied health professionals and administrators, who do not routinely work after hours or weekends (Bell and Redelmeier 2005). Irrespective of this, the views and concerns of clinicians and other staff about work schedules, compensation, and the impacts of schedules on their well-being need to be both heard and addressed. Achieving an appropriate balance between meeting the needs and expectations of patients for flexible service delivery, the autonomy of clinicians to work when and how they want and to have working arrangements that do not unduly compromise their own well-being, and the need for services that are safe and of an appropriate quality across the board may be difficult and time-consuming, but it is a discussion that should be progressed.
Also important to recognize is that our health systems have to be many things to many people in the pluralist societies in which we live. It is important to understand the professional cultures within the health system, recognizing there may be disparate perspectives on what to do, how to do it, and varying code of ethics and practice standards. Consensus cannot always be reached because of the idea that clinicians are not necessarily a “community of moral friends” as much as they are a “society of moral strangers” (Kerridge, Lowe, and Stewart 2013). Cultural medical inter-specialty, nursing and allied health professions inter-professional differences and the viewpoints of health service managers can make obtaining a consistency of ethical thought in practice challenging, especially when schedules and hours of coverage of the respective services differ and there is perceived inequity. This is largely because the theoretical ethics of individuals and professions prioritize the means (deontology), the ends (consequentialism), the character of the moral agent making the decision (virtue ethics) or the outcomes and context of similar patients (casuistry) differently (Kenny and Giacomini 2005). The clinical community is bound by various written and unwritten codes of professional ethics and conduct that are descriptive in nature, and by extension provide an incentive for moral alignment (Kenny and Giacomini 2005). Much of this is reflected in the models of care and the historical basis for providing coverage. Legitimate clinical redesign initiatives are occurring in some jurisdictions to address inefficient legacy delivery approaches (NHS Health Improvement 2012). Creating an interdependency of purpose between health services, managers, and clinicians will create value for patients (Porter and Lee 2013).
The minimum framework in which to achieve collegiate and respectful inter-professional functioning is through interactions that remain patient focused. Seeking the acceptance for a transfer of care permits maximal benefit for patients, because drawn out referral processes that are overly “permission” based are time consuming and have the potential to cause a loss of patient focus (Kerridge, Lowe, and Stewart 2013). This normative approach to decision making requires that issues are raised and an exchange of views occurs so that the final disposition for the patient is the same as “what ought to have been done,” in an optimal circumstance (Kenny and Giacomini 2005). Within contemporary healthcare systems, much clinical interaction is dependent upon transfer of information, handovers of care, and acceptance of patients into hospital and back into the community or between community providers. The shortage of an appropriate bed or services can influence these discussions in an adverse way because uneven distribution of resources across the working week, accompanied by reduced access to specialist opinion, diagnostics, and interventions can create tensions and surface moral differences which create potential concerns for patient safety and continuity of care, and may actually prolong hospitalization (Academy of Medical Royal Colleges 2012; Lee et al. 2005).
The current five-day model for service delivery raises significant questions about service flexibility and safety and quality, as well as raising equity issues in respect of access. In this article we have made a case that ethical considerations, in addition to instrumental concerns, suggest a transition to seven-day delivery models should, at the very least, be carefully considered by all actors in the multilevel process that governs the health system. Those who govern the publicly funded/provided health system have, we have argued, particular responsibilities or obligations to the public. We have argued that a central concern of governments must be to ensure that services are provided that are, as much as possible, safe and of an appropriate quality. The evidence indicates that the current five-day model of service delivery may be causing increased mortality and morbidity and may not be meeting the clinical or social needs of patients. We also argue that a central concern must be to address inequalities in service provision between those receiving care during business hours Monday to Friday and those receiving care and treatment at other times. We suggest that these inequalities amount to inequities that must be addressed. Finally, we argued that government’s stewardship responsibilities suggest that they should be concerned about the quality, efficiency, and effectiveness associated with delivery models and that a transition to a seven-day model of care may address some key quality, effectiveness, and perhaps efficiency concerns.
We acknowledge that a fundamental shift in the model through which health services are provided will be difficult and there are a number of instrumental barriers to making this transition which include financial constraints, the availability of staff, organization by specialty, conflicting public/private clinician commitments, cost accounting processes driven by expenses as opposed to actual costs, patient populations spread across multiple institutions that may not have the critical mass of patients to be truly efficient, and siloed information technology systems (Porter 2013). Our current model for service delivery has been in place for at least a hundred years, however, and a re-evaluation is long overdue. The ethical argument supporting the transition to a seven-day model of care may assist us to put some of these difficulties in context as being not insurmountable, help galvanize support for the transition from all those involved in whatever way in service delivery, and achieve a significant and important change that has the potential to improve the care provided across the aggregate of patients.
We thank Associate Professor Christy Simpson for her helpful comments on this paper.
Compliance with ethical standards
The authors have none to declare.
- Academy of Medical Royal Colleges. 2012. Seven day consultant present care. London: Academy of Medical Royal Colleges.Google Scholar
- Australian Medical Association. 2010. Doctors’ engagement in the management of hospitals. https://ama.com.au/position-statement/doctors%E2%80%99-engagement-management-hospitals-2010. Accessed February 6, 2016.
- Braithwaite, J., J. Healy, and K. Dwan. 2005. The governance of health safety and quality: A discussion paper. Canberra: Commonwealth of Australia.Google Scholar
- British Medical Association. 2013. BMA position paper: 7-day services. http://bma.org.uk/-/media/files/pdfs/working%20for%20change/shaping%20healthcare/bma%20position%20paper%20seven%20day%20services.pdf. Accessed December 15, 2015.
- Dahlgren, G., and M. Whitehead. 1992. Policies and strategies to promote equity in health. Copenhagen: WHO Regional Office for Europe.Google Scholar
- Daniels, N. 1998. Is there a right to healthcare, and if so, what does it encompass? In A companion to bioethics, edited by H. Kuhse and P. Singer, 316–325. Oxford: Blackwell.Google Scholar
- Daniels, N., B. Kennedy, and I. Kawachi. 2000. Justice is good for our health. In Is inequality bad for our health?, edited by J. Cohen and J. Rogers, 3–33. Boston: Beacon Press.Google Scholar
- Duckett, S., and S. Willcox. 2011. The Australian health care system, 4th ed. South Melbourne, VIC: Oxford University Press.Google Scholar
- Dugdale, P. 2012. Governance challenges for primary healthcare. In Health workforce governance, edited by S. Short and F. McDonald, 183–201. Surrey: Ashgate Publishing Limited.Google Scholar
- General Medical Council. 2012. Leadership and management for all doctors. http://www.gmc-uk.org/guidance/ethical_guidance/management_for_doctors.asp. Accessed December 15, 2015.
- Guttmann, A., M.J. Schull, M.J. Vermeulen, and T.A. Stukel. 2011. Association between waiting times and short term mortality and hospital admission after departure from emergency department: Population based cohort study from Ontario, Canada. British Medical Journal 342: d2983. doi:10.1136/bmj.d2983.
- Institute for Patient- and Family-Centered Care. 2015. Frequently asked questions. http://www.ipfcc.org/faq.html. Accessed December 15, 2015.
- Kerridge, I., M. Lowe, and C. Stewart. 2013. Ethics and law for the health professions, 4th ed. Annandale, NSW: Federation Press.Google Scholar
- Medical Council of New Zealand. 2008. Statement of safe practice in an environment of resource limitation. https://www.mcnz.org.nz/assets/News-and-Publications/Statements/Safe-practice-in-an-environment-of-resource-limitation.pdf. Accessed December 15, 2015.
- Mohammed, M.A., K.S. Sidhu, G. Rudge, and A.J. Stevens. 2012. Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: A retrospective database study of National Health Service hospitals in England. BMC Health Services Research 12: 87. doi:10.1186/1472-6963-12-87.CrossRefPubMedPubMedCentralGoogle Scholar
- National Health and Medical Research Centre. 1999. Ethical considerations relating to health care resource allocation decisions. https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e24.pdf. Accessed December 15, 2015.
- National Health Service Health Improvement Agency. 2012. Equality for all: Delivering safe care—seven days a week. http://www.nhsiq.nhs.uk/media/2336450/equality_for_all_-_delivering_care_seven_days_a_week_july2013.pdf. Accessed December 15, 2015.
- Norheim, O., and Y. Asada. 2009. The ideal of equal health revisited: Definitions and measures of inequity in health should be better integrated with theories of distributive justice. International Journal for Equity in Health 8: 40. doi:10.1186/1475-9276-8-40.CrossRefPubMedPubMedCentralGoogle Scholar
- Queensland Government. 2011. Health and Hospitals Network Bill 2011: Explanatory notes. http://www.legislation.qld.gov.au/Bills/53PDF/2011/HealthHospNB11Exp.pdf. Accessed February 6 2016.
- Porter, M., and T. Lee. 2013. The strategy that will fix healthcare. Harvard Business Review 2013(October): 1–19.Google Scholar
- Royal College of Physicians. 2012. An evaluation of consultant led input into medical admissions management in England: Hospital service patterns versus clinical outcomes in England. http://webcache.googleusercontent.com/search?q=cache:VfhEQbSFDx4J:www.aomrc.org.uk/doc_view/9450-the-benefits-of-consultant-delivered-care+&cd=2&hl=en&ct=clnk&gl=au. Accessed December 25, 2015.
- Sharpe, V. 2003. Promoting patient safety: An ethical basis for policy deliberation. The Hastings Center Report 33(5): S1–S20.Google Scholar
- The Regulation and Quality Improvement Authority. 2013. The Regulation and Quality Improvement Authority review of hospitals at nights and weekends. http://www.rqia.org.uk/cms_resources/Report%20on%20the%20Review%20of%20Hospitals%20at%20Nights%20and%20Weekends%20Published%2003%20July%2013.pdf. Accessed December 15, 2015.
- Wolf, S.M. 1994. Shifting paradigms in bioethics and health law: The rise of a new pragmatism. American Journal of Law & Medicine 20(4): 395–415.Google Scholar