14 May 2012
Calls for hospitals to offer the same services on a Saturday as they do on a Wednesday have sparked much debate among doctors leaders.
NHS medical director Professor Sir Bruce Keogh wants 24/7 healthcare in order to meet the needs of patients in our ‘increasingly consumer-based society’.
BMA consultants committee chair Mark Porter says that flexibility is key, and not every department would need a consultant present at all times.
Sir Bruce’s proposals have been labelled terrifically expensive and unaffordable at a time when services are already being cut.
Different at the weekend
A study, led by Sir Bruce and published in the Journal of the Royal Society of Medicine in February, looked at 14.2 million admissions to NHS hospitals.
It found that patients admitted on a Saturday or Sunday were at greater risk of dying within 30 days. However, researchers found that patients were more likely to die mid-week than at weekends. They say that no assumptions should be drawn about staffing levels or the availability of senior staff.
CC surgical specialties subcommittee deputy chair Stephen Blair questions the evidence base for round-the-clock hospital services.
Wirral consultant vascular surgeon Mr Blair says people admitted at weekends could not wait until Monday and were therefore sicker to start with.
He says: ‘If you were to get the same capacity running on a Saturday and Sunday that would be a 40 per cent increase.
‘More capacity would need bigger hospitals, more doctors and more nurses.
‘The whole thing becomes completely unmanageable with the EWTD [European Working Time Directive].’
One argument in favour of increased consultant presence out of hours is that it would improve supervision of junior doctors who cover services.
BMA junior doctors committee chair Tom Dolphin says junior doctors often feel very stretched when working weekends and would welcome increased support from seniors.
But he says this should not be at the expense of proper training opportunities during normal working hours.
Dr Dolphin says: ‘We don’t know for sure why there is an association between being admitted at the weekend and higher mortality; it may be about supervision and staffing, or it might be that people are less likely to present for care at the weekend unless they are really sick.
‘Switching to a 24/7 service in the NHS could improve access for patients to specialist input and diagnostics, and improve the doctor-patient ratio at weekends, which is quite low at the moment.’
However, Dr Dolphin adds that increased opening hours of some services would impact on staffing levels during the week, as doctors were already working right up against or even over the EWTD.
Some trusts are already improving the emergency services and maternity cover offered overnight and at weekends.
CC obstetrics and gynaecology subcommittee chair Alan Russell has long had an interest in 24/7 consultant working.
The consultant in obs and gynae says the two maternity units at his trust, Pennine Acute Hospitals NHS Trust, provide 102-hour consultant cover a week, compared with just 40 hours three years ago.
He cautions that the change could not happen overnight. While his trust is working towards providing 168-hour cover, the traditional on-call system is still used at weekends.
Dr Russell says: ‘Certainly for the frontline services, why should it be different at 3am than 3pm? Not dermatology, but for emergency, obstetrics, emergency paediatric medicine, general surgery and general medicine.
‘There is some evidence now that you do get better outcomes and everything is cheaper because consultants tend to ask for fewer investigations and strike the heart of the problem rather quicker.’
Dr Russell says the rota system brought in to boost consultant cover at the Fairfield General Hospital in Bury provides family-friendly shift work. He says: ‘It is actually ideal for consultants with young families. They never have to work another night, and get every weekend off to spend with the kids.’
Merseyside consultant obstetrician Bode Williams cautioned that a one-size-fits-all approach might not be the best solution owing to variations in activity levels and case mixes across the country.
Dr Williams adds: ‘Better information about the benefits and costs of a consultant-led, seven-day maternity service is needed. Also, the impact on the other consultant clinical duties — such as outpatient-clinic, operating-theatre and managerial duties — should be assessed.’
The extra senior cover at Dr Russell’s trust is provided by additional resident consultants, who work a rota system on week nights.
He says: ‘My experience has been that the profession tends not to be keen on this at first.
‘By 24/7 working they will assume that this is on top of what they do rather than designing a completely new system.’
Commenting on Sir Bruce’s proposals, Dr Russell adds: ‘I think he is going too far too quickly … With some of the cutbacks we are seeing on important things, such as surgery being delayed, we are a long way from that [24/7] service.’
Coventry and Warwickshire consultant in EM (emergency medicine) Mehmood Chaudhry says the benefits of enhanced consultant cover are ‘beyond doubt’ in all acute specialties.
He says that at his trust, University Hospitals Coventry and Warwickshire NHS Trust, consultants are present in EM departments for 16 to 18 hours every day, including on bank holidays and at weekends.
Mr Chaudhry says benefits include improved safety and quality of care, enhanced supervision of junior doctors, an early and definitive management plan for patients, and the prevention of unnecessary hospital admissions.
He adds: ‘I feel this is only possible in large emergency departments, with adequate staffing and back-up.’
Shortage of consultants
Norfolk emergency consultant Chris Lloyd, who is also Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust clinical lead for EM, says better cover over the entire week was essential to improving the quality of care in hospitals.
However, he says there is a shortage of consultants and middle-grade staff in EM, making an increase in consultant-delivered services not sustainable.
County Down consultant anaesthetist Peter Maguire, a former chair of the BMA council EWTD working party, says: ‘Introducing seven-day-a-week working in the way that Professor Keogh suggests is going to be terrifically expensive.
‘It’s not only the need to have doctors [present], but [also] the support services — radiographers for X-rays and social workers.’
He is in favour of seven-day working, but adds: ‘We are going to have to review what services are available in what hospital settings. It may well mean there will be fewer hospitals providing emergency services, and those that do will have senior staff working longer hours.