Seven day working in the NHS. Good or bad?
For several months we have been hearing the
government arguing that the NHS should provide a 'seven day service'. Initially
this was in order that working people could see doctors without taking time off
work, and more recently the argument has been about poorer quality of care at
the weekend. To many people it seems a
no brainier. If Tesco can be open on Sundays, why should the NHS not provide a
full service? According to this idea, it would prevent the "excess
deaths" among patients admitted at the weekend, and furthermore make use
of expensive capital resources better.
Of course let me start by saying that all truly
emergency services i.e. CT scans, anaesthetists, labs, emergency operating
theatres should always be available at any time of day or night. Generally,
this is the case in the NHS (although oddly this tends not to be true in
Private Hospitals), and the few cases where it is not need to be addressed.
Very few (around 1%) consultants have opted out of on call responsibility, and
all NHS doctors will have done a lot of unsocial hours during their careers in
order to meet the needs of emergency patients.
But making all NHS services available at
weekends for routine work, would be unlikely to achieve any of the gains that
are claimed, and would do a lot of harm in ways that are pretty obvious but
have received little attention.
Taking the claims first, the 16% excess deaths
in patients admitted at weekends ignores the obvious fact that this is
comparing apples and pears. For example, most hospices (not part of the NHS
remember) do not have enough staff to admit patients at weekends, so when a
patient with a terminal illness gets suddenly worse at weekends, they tend to
be admitted to hospitals where they are likely to die. Many similar examples
can be quoted. The statistics are complex and odd, and defy simplistic analysis. For example the day with the
biggest death rate is Wednesday, and Monday is also a relatively risky day
to be admitted.
As far as the utilisation of capital resources
is concerned, in general expensive kit like MRI scanners is rarely idle. The
wage bill is approximately 90% of the cost of the NHS. So the potential for
improvement from more efficient utilisation of capital resources is tiny, and
it certainly does not need wholesale reorganisation to achieve it.
The harms of changing working patterns have
actually already been demonstrated by the introduction of the European Working
Time Directive for Junior Hospital Doctors in 2009. Doctors who formerly worked
in small teams with other doctors that they knew well, doing a lot of hours
some of which were not fully occupied, found themselves working fewer hours much
more intensively. But the small teams
were amalgamated into much larger units in which relationships were much harder
to create and maintain. The apprenticeship model in which a specialist would
take a real interest in training his juniors, partly because he himself stood
to gain thereby, was severely damaged. The quality of training was harmed as
was morale and the quality of care.
Specialists do still work in teams with personal
secretaries and ward and theatre staff, and there is still a lot of liaison
between colleagues, which of course happens during normal office hours. If the
NHS really became a 7day service these relationships and the effective teamwork
they lead to would be harmed.
The other huge problem that would arise would be
a worsening of continuity of care. Patients already complain bitterly of changing
staff and decisions being frequently altered. This would inevitably worsen with
an adverse effect on quality of care.
As far as GPs are concerned we have relevant
experience already. As part of the Blair reforms lots of 'walk in centres' were
developed which routinely saw patients on Sundays and evenings, at considerable
cost, which is why they have mostly been closed. Our experience was that almost
all the patients that were seen were told to 'go and see your own doctor'. The
duplication of effort was huge. The challenge fund proposals which involve one
practice in each area opening on Sunday's etc. would inevitably lead to the
same waste and duplication. In fact, few of our patients have to take time off
work to see us. Most of our patients are not working for obvious reasons. Some
of the pilot schemes have paid doctors overtime rates to sit and twiddle their
thumbs for lack of demand.
The weird thing about the whole debate is that
patients have consistently expressed satisfaction rates of around 80% with GP
opening times – even though few GP’s are even open on a Saturday morning, (which we could probably cope
with without much difficulty).
Noone has
even bothered doing a poll asking people if they want their hernia operated at
the weekend, but the results would be predictable.
So, why is this even on the agenda? The answer
we are given is that it was on the Manifesto of the Political party which got
37% of the votes from 66% of the people registered to vote. So just under a
quarter of voters voted for that party. How many read manifestos is uncertain
but as they have around 30,000 words the number cannot be high. How many of the
conservative voters were aware of the manifesto aim is equally obscure.
This democratic mandate seems to trump all
logical argument, when as in this case it suits the minister. If this really is
what democracy means ?
To quote HL Mencken “To
every complex problem there is a solution that is simple, elegant, and
completely wrong.”
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