We have just passed the highest risk month of August when the novice house officers take over and their consultants are on holiday. Weekends are another issue, and the figures are shocking… But the problem is due to undercapacity and poor manpower planning over many political terms of office. It is not due to Doctors themselves, but the organisation that the majority are no longer engaged with..
The case for improving hospital care at weekends in England is “simply unassailable”, medical chiefs say, as new figures on deaths are published.
NHS England medical director Sir Bruce Keogh called for action as research by him and others linked the “weekend effect” to 11,000 excess deaths.
It is not clear exactly how many of these could have been avoided.
But the study in the British Medical Journal said the findings raised “challenging questions” about weekends.
The study has been published as the government is trying to push ahead with its policy of extending the services available seven days a week.
The research – carried out by seven leading doctors and statisticians, including Sir Bruce – looked at hospital records during 2013-14.
It follows on from similar research published three years ago.
During the year studied, 15.9m patients were admitted to hospital and just over 290,000 – 1.8% – of them died within 30 days.
But when the data was broken down by day of admission a clear “weekend effect” was identified.
An admission on Fridays led to a 2% increased risk of death, on Saturdays it was 10%, on Sundays 15% and Mondays 5%, the study said.
Combined, this equated to 11,000 excess deaths over the course of the year.
Researchers adjusted the data to take into account factors such as the age of patients and their levels of illness – patients admitted at weekends tend to be sicker because non-emergency work, such as knee and hip operations, tend not be done, while community services are less available.
But they said it was impossible to know whether this process had managed to take into account these factors entirely and so it would be “misleading” to conclude all these excess deaths could have been avoided.
Is this death rate worse than previously thought?
No. It reinforces what has been said before. In July, when Health Secretary Jeremy Hunt set out his intentions on seven-day working in hospitals he talked about 6,000 deaths.
That was based on the previous study by these authors, which was published in 2012.
The higher risk of death at weekends was almost exactly the same in the two studies – 16% on Sundays last time compared with 15% in the latest one and 11% on Saturdays compared with 10%.
The reason why the absolute number is different is because the 6,000 figure was just based on Saturday and Sunday while this one includes Friday and Monday. What is more, the total number of admissions and deaths is increasing, partly because of the ageing population.
But this report does contradict the health secretary in one respect. He talked about the deaths being avoidable, while the researchers say you cannot be so categorical.
Nonetheless, Sir Bruce said he believed it presented a compelling case for action.
“Doctors up and down the country routinely go the extra mile, well beyond any contractual duty, to save and improve lives. But the idea that patients are being harmed because of the way we organise our services is quite simply beyond what any of us can regard as acceptable.
“The moral and social case for action is simply unassailable and there is widespread clinical consensus about that. Change always brings practical difficulties that must be tackled but we cannot duck the facts.”
While emergency care from A&E units to life-saving surgery is available at weekends, staffing levels are much lower and access to key tests is more difficult than it is during the week.
Ministers have identified the opt-out consultants have in their contract meaning they do not have to do non-emergency work at weekends as a key barrier to improving care.
They have given the British Medical Association a deadline of next Friday to agree to talks about removing it – or they will impose the change on new doctors.
BMA leader Dr Mark Porter said: “Given the current funding squeeze on NHS Trusts, the only way for many hospitals to increase the number of doctors over the weekend would be to reduce the number providing care during the week.
“If the government really want to deliver more seven-day services then they need to show patients, the public and NHS staff their plan for how this will be delivered at a time of enormous financial strain on the NHS and when existing services and staff are under extreme pressure.”
Chris Ham, chief executive of the King’s Fund think tank, said there was a need to be “cautious” about the causes behind the excess deaths, but he admitted it would give “further impetus”.
Health Secretary Jeremy Hunt said the findings should act as a “wake-up call”.
At times, the seven-day debate can seem like a Punch and Judy show. One minute Health Secretary Jeremy Hunt is accusing hospital doctors of being part of a Monday to Friday culture.
The next, medics are saying “oh no we’re not” and taking to Twitter and Facebook to demonstrate how they are toiling away while much of the rest of the country has its feet up at the weekend.
So who is right? In their own ways, both are. As anyone present in a hospital on a Friday evening can testify, there is a clear sense of a change of pace. Machines are turned off, staff slip away and patients settle down as the hurly, burly of the week gives way to the weekend.
In one respect there is nothing wrong with this. Much of the non-emergency side of a hospital’s work (knee and hip replacements for example) stops or at the very least slows at weekends. But this is not really the issue.
Nor is there any real suggestion – despite the rhetoric being used – that there is no activity taking place all. After all, there are parts of the hospital where there is little let up no matter what day it is.
Any member of an A&E department will tell you Friday night is one of the worst shifts as patient numbers are swollen by those who are worse for wear after a heavy night drinking. And, of course, anyone needing immediate life-saving treatment will get it. Quickly.
Instead, what is at the heart of the seven-day debate is the care that lies in between these two. It is generally being referred to as urgent care.
That term covers a range of services from tests such as MRI and CT scans to specialist procedures like urgent radiotherapy, complex dialysis and endoscopies. In many places, getting access to these at the weekend is difficult.
While they don’t all need a consultant to carry them out, they do often need consultant input and oversight. And this is where the problem lies.
As the system is currently set up, consultant cover drops significantly at weekends. A recent Freedom of Information request by the Daily Telegraph found in general medicine it fell five-fold.
The result of this is that the consultants in work are stretched more thinly and junior doctors have to do more.
That means these vital tests and procedures sometimes cannot take place until Monday comes. The suspicion among experts is that this is one of the reasons why, as the study published by the British Medical Journal on Sunday suggests, patient care may be being hampered.
Another area of concern is the loss of regular review and quick assessment by specialist consultants to ensure those being admitted get the right treatment from the start. There are on-call rotas so junior doctors can always refer up, but this does not always happen.
As in any job, there is a reluctance to be seen to bother “the boss” too much or – as one doctor put it to me recently – “you don’t want to be seen as a wimp for calling the consultant all the time”.
But none of this means that the genuine anger and upset of doctors should be dismissed.
It shouldn’t need saying, but up-and-down the country there are thousands of consultants – and other staff for that matter – going above-and-beyond the call of duty – as this film of Tan Arulampalam demonstrates.
He is a colorectal and general surgeon and is regularly “on call” at weekends. However, he usually finds himself working a full day and only goes home at night to sleep.
The notion of opting out of weekend work (as the consultant contract allows in certain circumstances) is alien to doctors like him.
It’s also worth noting that things have begun to change. Increasingly the most forward-thinking hospitals – with the full co-operation of their senior doctors – have already started ensuring there is more seven-day working available.
But this costs money. It is estimated that seven-day working costs hospitals between 1.5% to 2% of their budget, because consultants tend to be paid more for agreeing to weekend work but also because hospitals need to employ more support staff such as radiographers to cover.
At a time when many trusts are running up deficits, that is money that is going to be difficult to find.
The question now is how far and how quickly the seven-day push continues. In the next few weeks we should find out if ministers and doctors can reach agreement on the consultant contract and then later in the autumn the government will set out its spending plans in more detail. It is likely to be a crucial period.