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Time to end that Monday feeling

Posted on 21 January 2013 by Patrick Cadigan  7 comments

‘I am relieved on Monday that nothing catastrophic has happened at the weekend…’

Most members of the public would be shocked by this quote from a consultant physician working in a busy district general hospital. The RCP (Royal College of Physicians) recorded it while gathering evidence for our Hospitals on the Edge? document , and it powerfully underlines the need to move to a consistent seven-day working pattern for acute services.

Physicians, on the other hand, would not be surprised at all, and recognise this as a fair description of how care varies when traditional working patterns continue.

The RCP made its first statement on seven-day services in 2010. Since then, the Academy of Medical Royal Colleges and NHS medical director professor Sir Bruce Keogh have also called for equality of care ‘out of hours’. 

Some of these calls have been for the provision of more elective services at the weekend, on the ‘John Lewis is open on Sundays’ model. But if choices have to be made, the priority is clear.

We must first correct the fatal disparity in acute service provision that has led to increases in mortality at weekends, and to do that we might need to reconfigure.

One of the problems with reconfiguration is the term itself, which seems to have become inextricably linked to a scenario of closure due to cuts. We need to find a word that captures the concept of change for clinical benefit, and which recognises that this is not just about buildings but involves many areas of the way we provide services. (‘Transformation’ is a candidate, but other suggestions would be gratefully received.)

To achieve high-quality, seven-day acute services, we will need to reconfigure in a number of ways that are unrelated to buildings and locations.

There will certainly need to be a cultural change about the weekend being a time for rest. New contracts and terms and conditions might have to be devised, and new flexible ways of working involving skill shifting might have to be considered. Smaller units will struggle to fully populate rotas, and will need to consider network and telemedicine arrangements. And all of this is likely to be difficult practically and politically.

But we should surely support change that will benefit patients, even if it is politically difficult. Loyalty to local institutions is admirable and understandable, and has financed many CT scanners but should not be allowed to trump high-quality care.

Professional bodies, hospital trusts and politicians will all need to show courageous leadership if positive change is to occur. The RCP’s current contribution is the Future Hospital Commission, which has been asked to review the way that the skills of physicians are deployed in hospital and the community.

Patrick Cadigan is Royal College of Physicians registrar

Posted in:  Reconfiguration

Tags:  consultant contract reconfiguration work patterns working arrangements royal college of physicians of london

Comments

  • Dr S Boardman

    22 January 2013

    There is a myth that mortality is highest at the weekends...its patients admitted at the weekend who are at greater risk of dying ( usually mid week). The RCP has never investigated whether it is the number of junior doctors or registrars at weekends which might impact mortality, only an Association study on the number of Consultant Physicians on call at weekends has ever been attempted, and so the cost effectiveness of increasing the numbers of others vs Consultant Physicians has never been considered. At present , big hospitals do not achieve significantly better mortality outcomes than smaller hospitals ( apart from surgery,stroke and MI) and indeed the DGHs appear to be more cost effective? Do we really have all the evidence to be embarking on a wholesale dismantling of hospitals ?Do we really believe that by reconfiguration and reduction in beds that we will have sufficient numbers of hospital beds to deal with the needs of the ageing population or the increasing population?

    Should the RCP not be interested in having a good evidence base on the workforce skill mix before making its recommendations to dismantle hospitals enmasse? Will the RCP take responsibility for patient mortality which results from the lack of hospital beds or time it takes to transport a septic patient to a "large regional" hospital?

  • Dr Patrick Zentler-Munro

    22 January 2013

    I wonder if Dr Boardman has ever been a seriously ill in-patient? Evidence-based policy is certainly preferable where available, but in its absence common sense - coupled with patients' as well as doctors' reported experince - has to prevail. Surely it is obvious that if subspecialty consultant advice is needed mid-week, it is also needed at weekends - without casting aspersions at the often hard-pressed "general medical" (in other words, another subspecialty) consultant who is already in most of the weekend. I seem to recall, in fact, one study which did attempt to compensate for the justifiable "admissions at the weekend are iller", and showed that increased mortality at weekends could not be attributed to this factor. And we are concerned with all in-patients, not just new admissions.

    It also makes no sense to have expensive equipment, clinics, theatres etc lying idle for 2/7 of the time. Just as GPs have (or are supposed to have) moved to patient-friendly hours, so should we, with seven day working.

    But this must apply to ALL services - laboratories, Xray, pathology, physios, secretaries, porters, IT staff, canteens etc etc. And everyone must be given two consecutive days off mid-week if they wish.

  • Dr Richard Worth

    22 January 2013

    The very last sentence from Dr Zentler-Munro is crucial in this debate and the implications are constantly overlooked. Thus having hospitals fully staffed at the weekend will inevitably mean that there will be FEWER staff than at present in and working from Monday to Friday - so LESS work can be done Monday to Friday. This fact does not seem to be taken on board in grand statements by politicians!

  • Nick Lewis

    22 January 2013

    The reason for the differences in mortality at weekends needs to be analysed properly before changes are made.

  • Dr M Willams

    23 January 2013

    I can't help thinking that further analysis just postpones the inevitable. Although the evidence does not exsist to support any change there is equally no evidence to support that two days of the week require less input than the other five.
    Patients become ill and derteriorate every day of the year. If they are unfortunate enough to need increased medical care on a weekend they are less likley to get timely intervention with the same level of senior cover they might expect on a weekday. It does not reqire much imahginiation to understand how this present s increased risk at weekends. A risk we should not be accepting.
    I would also support Dr Patrick Zentler-Munro in his assertion that this should include all aspects of patient care and not just one staff group.

  • Tom Hughes

    24 January 2013

    There seems to be a difference of opinion as to whether there is sufficient evidence to make this change. Perhaps the RCP Hospitals on the Edge document provides it. Perhaps it doesn't. The road to hell is paved with good intentions, and there will be unintended consequences of any change.

    If the evidence is not sufficient, and many of us look for high quality evidence before making significant change to our clinical practice, a randomised controlled trial may be necessary. The NHS in England and Wales is very well placed to carry out such a trial. The unit of randomisation would be the hospital, and the trial could be done in one year. Collecting data on averse outcomes such as the effect of the absence of consultants during Monday to Friday on morbidity and mortality would be as important as data on benefits.

  • Dr Patrick Zentler-Munro

    6 February 2013

    Me again! The null hypothesis must be that patients require the same level of care regardlless of the day of the week - Policy should be based on the null hypothesis until disproven. But, as Dr Worth points out, this will involve some expense. How much is more difficult to predict: senior staff are already absent two days per week, but they have no planned activities those two days (weekend), whereas they will do on a t least one day of the two they would take off midweek. If the second day were otherwise a planned take day, then they should have no planned activities - though this is still honoured more in the breach!

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