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Costs of being ever ready

Posted on 7 January 2013 by Shree Datta  15 comments

NHS medical director Professor Sir Bruce Keogh wants 24/7 healthcare to meet the needs of patients in our ‘increasingly consumer-based society’.

His aim is to ensure more hospital services are available all day, every day and he believes the NHS has much to learn from private sector companies such as Tesco.

There is no doubt that we should strive to improve the service we offer patients at all times, let alone at evenings and weekends. The evidence suggests that patients don’t do as well if admitted as emergencies out-of-hours. And there is an emerging consensus that patient outcomes are improved by ensuring senior doctors are available in hospital for patients who are in the greatest need.

A quick glance at the newspapers suggests the solution is simple. The Daily Mail reported 'NHS doctors to be forced to work weekends for the first time in push for improved seven-day a week care'. The problem is, this plan assumes consultants do not currently work evenings or weekends.

I’m a newly qualified consultant obstetrician and gynaecologist, and my daytime schedule is pretty full, doing the things you would expect a consultant in my specialty to be doing. My time is split between covering clinics for scans, ward rounds, colposcopy, team meetings, teaching and time in theatre.

On top of the daytime work, I am on call every other Wednesday between 5pm and 8.30am and do regular on-call work at the weekend. This means that after leaving the hospital at 8pm, like my colleagues, I can get called in to work overnight on the wards, before resuming my day duties the next day.

Although, like me, many consultants already do evening and weekend work, to staff hospitals with senior doctors 24/7 will require a massive expansion in consultant numbers. This is not something that can happen overnight. And a drive to increase the hours that consultants are required to work at weekends and evenings will have an impact on the service on weekdays — we will need time off in the week to rest.

Providing better care out-of-hours must be a priority. But promising 24/7 healthcare in the current economic climate seems at best overly ambitious and at worst doomed to failure. Instead of looking to mimic Tesco (who have to close on Sunday evenings, not to mention Christmas), we should focus on ensuring services are properly staffed and appropriately organised to meet the needs of patients — whenever they happen to be in hospital.

Shree Datta is member of BMA Council

Posted in:  NHS system reform

Tags:  consultant contract hours of work on call rotas out of hours services consultants

Comments

  • Peter Sharp

    7 January 2013

    Well Shree - it can and is being done... A Plunkett and colleagues describe a new rota system for implementing consultant delivered care in acute hospital specialties

    http://careers.bmj.com/careers/advice/view-article.html?id=20008642

  • David Melling

    7 January 2013

    We already work 24hrs like tesco. Tesco closes the meat counter, deli, bakery, etc... Overnight and just offers a basic service of stocking shelves and a limited number of checkouts, for those who must shop overnight. The nhs keeps wards (see isles) open, closes outpatients and reduces some diagnostic services but still offers emergency care in AED and all specialties for those who are ill overnight. No company private or public sector offers a full service for 24hrs a day and to suggest the nhs should is ridiculous and unworkable.

  • Anne McPheat

    7 January 2013

    NHS is NOT a retail outlet and should never be compared to one.

  • Fiona Reid GP

    7 January 2013

    Sounds like political gesturing to me

  • Duncan Shrewsbury

    7 January 2013

    Some very interesting points made about a concerning topic- of course we all want what is best for patients, but it does worry me that, increasingly, medicine and the health service are likened to a private-sector industry. Patients become service users, doctors akin to cashiers...(as if all we needed to do was the occasional price check and shelf stocking).

    It is not unreasonable to expect a high standard of care to be available out of hours, but does this necessitate round-the clock non-emergent care? After all, there are so many times when us juniors are bleeped when on-call to review a rash- only to arrive, when priority allows, to find a sleep-dazed and disgruntled service user who wanted their price-check a few hours ago when they pressed the call button...

    If, however, hospitals are to offer a greater range of services for longer, then some basics staffing need to be addressed. For example:

    1) There are too many hospitals with too few juniors doing the basic ward jobs during the day (which, for decades, despite EWTD etc, have required juniors to write-off social lives, family commitments etc to stay over-hours to get on top of)...lets get this sorted before stretching those already at capacity any further.

    2) As Shree points out- more seniors will be needed. Consultants, middle grades, but also the non-doctors who make things run and happen including, dare I say it, managers.

    3) Personal, non-rota time, will become even more precious...people will be driven to be more concrete about their ideas of acceptable (over-)working hours when they are so routinely placed and valued as a small cog in a 24hr vending machine...this means that being able to actually take annual leave, and leave within at least an hour or so of 'finishing' a shift...as well as the basic need for rest between shifts or keeping up with other activities (I would say family life, but this too is shared with upkeep of portfolio and CPD).

    4) Training...there are rotas out there that actually stop people from attending the minimum number of mandatory teaching sessions...it could easily be argued that patients come first (as they do) and that the experience gained trumps the half-day teaching session...but those arguments offer no comfort to the junior who is defending their ePortfolio that is contingent on ticking boxes and meeting quotas for attendance etc.

    ...the list could go on and on. I am sure I have missed plenty, and am aware that this reflects my own narrow view and experience as a junior- but aren't the concerns of the whole workforce valid and important in approaching a means of keeping this ship from sinking? I am not complaining either- I signed up for this, and love being a doctor. I just don't like the idea that the whole team could be stretched and spread so thinly that patients are actually put at risk, and enjoying the job becomes even harder.

    Whilst my understanding may be simplistic- haven't Lansley's disruptive legacy, and the examples highlighted by Mid-Staffs and Hinchingbrook (different sorts of failings and concerns, I know) tell us something about rushed policies and ill-directed change. Isn't it important not to rush things and to really consider these sorts of ideas?

  • Mark Hinton

    8 January 2013

    The thing that annoys me most is the impression the public is given by these headlines in the press. You get the feeling drs are being portrayed as largely a 9 to 5 bunch who think about their own convenience above the patients (if I am still allowed to call them that). I recently passed the age of 50 and have not yet experienced a working week less than 50 hrs and have only recently stopped working weekends and overnights. (I'm a GP by the way) When will someone say something positive about how dedicated we all are already?

  • Andrew Todd

    8 January 2013

    As a consultant of 28 years standing I have no problem about a push for 24/7 NHS care

    I do have a problem with the misguided belief that making consultants work 24/7 will solve the problem! I may be good at making 'senior'decisions at the front door, and am very comfortable doing so but without a full team backing me up there will be no improvement in the provision of care

    Let's have some realism: realistic costing to cover my and my team's full shift working (same on Sunday night as Tuesday morning) compensatory time off, significant media efforts to explain to the 'customers', politicians and the GMC that treatment will be provided by a team not an individual consultant, clear revision of clinical governance issues relating to team rather than individual responsibilities and 24/7 primary care that actually functions rather than simply refers anything mildly complex to hospitals with dwindling resources!

  • Philip Das

    8 January 2013

    Where will the funding come from?
    The reason Tesco opens all hours is so that people can come in and spend money.

  • Bill Lamb

    8 January 2013

    A glorious example of 'back of a fag packet philosophy'!

    There is no doubt that patient outcomes would be greatly improved with a more patient centred approach which effectively means offering a full 16 hour a day service.

    Physiology alone dictates avoiding elective work and routine consultation after 9pm. The idea of a full 24 hour service is a complete nonsense outside of a handful of services such as A&E ITU, neonatology and obstetrics.

    For this to work the entire service must be functional, labs, catering, cleaning, radiology,etc. All none service based management, i.e. strategy meetings etc is pretty well a waste of resources anyway.

    EWTD means maintaining sensible time off and could result in more family friendly hours, ie parents being off on some school days, as there would be no such thing as fixed weekends in this scenario.

    Yes it would require some organisation but if managed properly (there's a thought) might actually not cost too much more as demand would be spread out over a larger period and staffing would not have to be at current peak 9-5 levels.

    Likelihood of happening under the present regime? same as a snowflake floating in the fires of hell.

  • SONIA LLOYD

    8 January 2013

    Why can't consultants, and ALL hospital staff work shifts?
    Monday to Friday for those who like to struggle thro busy traffic to get away at weekwnds
    Saturday to Wednesday for thise who would like a mid week break to golf in relative peace and quiet; to visit the Lake District when there are no queues of traffic.
    I know since I retired I have really appreciated the wonderful tranquillity of eating out, travelling away, when the roads and restaurants are quiet, during the week.
    Surely those who have older children, would have the same feelings ? and even those with younger children...............where ther's a will there's a way.........get an au pair !

  • Shaun Anderson

    8 January 2013

    Exactly. The more hours Tesco work the more money they make and that's what they exist for.
    The more hours a Hopsital works the more money it spends and where is that to come from?

  • Victoria Holt

    8 January 2013

    As a GP and mother who has been priveleged to be able to work part-time in order to spend plenty of time with my son I take great exception to the simplistic suggestion that everyone works shifts and that an au pair is the solution. If you have school age children weekends are precious. And we should all unite in trying to preserve weekend time for our colleagues with families (and without for that matter) whether they be consultants or GPs, with on call commitments that are reasonable. I established a GP Co-op in the 1990s for this reason, long before becoming a mother..

  • T Maimoon

    10 January 2013

    Is Dr Todd even aware of the extreme measures GPs are being subjected to to reduce emergency admissions and A&E attendances and that statistics repeatedly bear out that non-GP sources and especially self referral are the main sources of emergency attendances - please dont bo so quick to apportion blame in such a way if he could care to look there are plenty of answers elsewhere

  • Jonathan Lovett

    13 January 2013

    Anyone watched 'Casualty' recently? I've done so a couple of times and been struck how everyone seems to go off work together at the same time in the evening (clearly before the pub closes). The script writers tend to have someone saying '...and it starts all over again tomorrow.' Clearly this is how the public thinks the NHS works and it is shameful that the NHS Medical Director reinforces this view. I am so glad to be retired!

  • Paquita de Zulueta

    27 January 2013

    Some very helpful remarks here. Duncan Shrewsbury's the most comprehensive. But he and others have spotted the dangerous and fallacious analogy that the NHS can be run, or worse, be the same as a retail business. I have just been talking to a young man working for a supermarket chain. He says things are better now as he doesn't get shouted at anymore as he is more senior. Why do the they shout? Because they are understaffed and there is not enough time and everyone is stressed and fed up. But they are packing goods, not treating people.
    The other key issue is that all those private 'any qualified providers' muscling in (over 50%) are profit making companies. The agenda of many is to asset strip, maximise profits and minimise costs - we know who will suffer and no amount of regulation will prevent it. Look what happened to the Southern Cross homes. Why was it not required for AQPs to be non-profit making organisations like the NHS?
    The more one reads the more disquieting it becomes...

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