Seven-day working: the bigger picture
The government wants to see a "seven-day NHS" - while doctors argue such a plan would affect services over the rest of the week. In this week's Scrubbing Up, Nigel Edwards of the Nuffield Trust argues the issue is even more complex.
Health Secretary Jeremy Hunt has spent the summer at war.
He wants to remove senior hospital doctors' right to opt out of doing planned procedures in NHS hospitals at the weekend, citing the aim of a "seven day NHS" that can provide safe care every day.
Their trade union, the British Medical Association (BMA), strongly disagrees - and as you might have seen on Facebook and Twitter, many doctors are annoyed by the suggestion that they get the weekend off.
Several studies over the years have suggested that the odds of dying if admitted during the weekend are greater than if admitted on some weekdays.
If that reflects lower standards of care then it needs to be tackled, although it isn't clear that the focus on senior hospital doctors is the answer.
Some evidence does show that consultants matter, but one recent study on stroke patients found that weekend mortality was linked to the number of registered nurses per bed, not the frequency with which senior doctors made their rounds.
But of course the government's agenda of seven-day working goes much wider than the issue of the consultant contract.
Appointments on the weekend for hard-pressed commuters. Fully staffed hospitals backing A&E departments every day, and discharging people back home whenever is most suitable.
Isn't it what makes sense in the modern world? Isn't it what we would all want?
A price to pay
Opinion polls confirm that the public like the idea of seven-day services. But they also have a serious concern: what will it cost?
They are right to be cautious.
The Healthcare Financial Management Association, whose members look after NHS hospital budgets, held a forum recently on costs and savings from seven-day working.
Looking across eight hospital trusts, they found it usually cost 1.5% to 2% of all the money they received for patient care.
For most trusts, the main driver of costs was the need to employ a larger total number of doctors to fill all shifts safely.
Across the whole NHS, that would mean several hundred million pounds or more.
There are some ways seven-day working could lead to savings.
In some cases, trusts could use fewer medical machines and buildings by using what they have for more days each week.
But to make these savings from using fewer facilities quickly enough to offset costs, you'd have to start selling or closing sites that were no longer being used.
You don't need to consult an opinion poll to know how people tend to feel about that when their hospital is on the chopping block.
Running on empty
Anyone would want equal access every day to their local NHS services. But the health service is in a world of tough trade-offs.
It is already failing to carry out its current commitments within its budget. The number of patients admitted to hospitals has risen by about a fifth since 2010, and this trend is continuing.
Hospitals are now meeting key waiting times targets after struggling last year, which means they are keeping up with the number of referrals from GPs.
But they are often achieving this by relying on running up deficits - spending public money they do not have.
And meanwhile, the health service still finds itself unable to afford many new treatments, even when they are quite cost-effective.
For example, the health service has struggled to fund Sofosbuvir, a new drug with a high cure rate for Hepatitis C.
Academics at Manchester University actually used the strict methods by which the watchdog NICE (National Institute for health and Clinical Excellence) tests new medicines, to see whether the NHS would fund seven-day working if it was a new drug.
They found that the answer was probably no. It wouldn't be thought cost-effective.
So what else could we spend that money on?
This proposal for seven-day working comes after many years of doctors and managers increasingly thinking about how patients might receive more care outside hospital, where possible in their own homes.
The easiest way to do this is to find more reliable and faster ways to safely send them back from hospital.
What limits this, in part, is the strength of community services that look after patients outside hospital, like district nurses.
Hospitals won't and shouldn't send people back without knowing they can be cared for elsewhere if they need it. NHS England's Five Year Forward View will also rely on more capacity in the community.
'Getting the basics right'
But our research suggests that the GPs at the heart of out-of-hospital services have missed out on the extra money hospitals have enjoyed over the past few years.
So shouldn't we think of funding out of hospital services as a priority - as much as focusing yet again on hospitals, and making sure they can offer appointments over longer hours?
While investing in community care would cost money, if it reduced time in hospital it could also bring significant savings.
Focusing on individual conditions shows what else we might be able to achieve with a similarly expensive national programme.
Sepsis is when an infection causes dangerous reactions in peoples' blood. It can worsen very fast if not identified and dealt with, and kills 37,000 people each year.
Many of these deaths are avoidable. There have been long-standing problems with guidelines and procedures not being followed, busy clinicians not spotting when sepsis sets in, and patients not receiving help in time.
NHS England and the government periodically order NHS trusts to focus on the problem - but what more could be achieved by a national initiative backed by even a fraction of the money that seven-day working would cost?
NHS policy is largely made by middle-aged, middle-class men and women who commute long distances into London and Leeds.
For them, not being able to get a hospital appointment at the weekend can feel like one of the biggest problems with the health service.
More typical patients might be more concerned that the NHS gets the basics right. Some areas already trialling extended appointment hours in primary care have been surprised to find that patients - at least at first - just didn't turn up.
Patients should be able to expect safe, efficient and effective services regardless of the day of the week they are admitted.
The government's ambition for seven day working is a bold vision. They, and the NHS are ultimately right to aspire to seven-day working.
But as with everything in today's NHS, it can only come after some tough decisions. Depending on the extent of the services on offer, implementing seven day services would come at a definite cost in financial terms.
Without extra NHS funding, it may come at a cost in local hospital sites. And the public should also ask whether they are willing to pay the invisible cost - the things that can't be done because of the time and money spent sorting out seven day working.