Seven day NHS: part 1 – the vision

So, this is my first disclaimer: I’m not a patient. I’m a doctor. 

But I still want a seven day NHS. From reading the papers and a lot of social media over the past 24 hours, I think my seven day services don’t match up with Jeremy Hunt’s ideas. It would be a lot easier to work together to deliver something useful for patients if we could be clear about what that vision was, but the details seem somewhat sparse. In fact, all I can gather, is that it should involve doctors working seven days a week, and as that already happens (despite the media seemingly believing otherwise), I don’t really understand how this is going to benefit patients. I have my own vision for a seven day NHS, and it doesn’t involve having consultants flood the wards on a Sunday evening. (I’ll explain why I don’t think this is feasible in another post, but as we’re talking visions, I’ll stick with my dreams for now).

I want an NHS that can get a child who may have suffered abuse or neglect to a safe place that isn’t a hospital seven days a week. If a baby comes to hospital with some suspicious bruising, they will have a full medical examination carrie out by a registrar or consultant.  In addition, there are a host of medical investigations that need to be carried out. Some of those, like blood tests to look for medical causes of easy bruising, will normally be done and results available within a few hours. Others, like a head scan to look for any evidence of injury, will usually be done “in hours” if the child is well. A baby will often need some sedation to lie still enough for a scan, and will be accompanied by a trained staff member. They’ll also have a series of X-rays to look for old fractures. Once all those results are back, there is a meeting betwee social workers, medical staff, police, and safeguarding staff to discuss the results. A baby who comes in on a Monday or a Wednesday will probably be discharged (if medically safe) within 48 hours. If that baby comes in on a Thursday, they might not get out until the Monday or even Tuesday. None of that process will be speeded up by having more doctors around on a Saturday. It might be if we can get more radiographers, trained social workers, police staff, emergency foster carers…

I want an NHS where I can tell parents if their child has meningitis or a urine infection just as easily at 3am as I can at 3pm.  Both are potentially serious infections in little ones, and the test for both involves a sample of fluid (spinal fluid or wee) being looked at down a microscope by a skilled technician.  During the day, somebody can do that. Out of hours, they will come in from home, which means that they won’t be available during the following day. So there are strict criteria about what I can and can’t request.  Even that will only give us some clues.  The definitive test is to see if that fluid grows any bugs, what the bugs are, and the antibiotics best suited to treating them.  That takes up to 72 hours from the point of preparing the sample in the lab.  In hours, that clock starts as soon as the sample reaches the lab.  Out of hours? If the technician comes in to look at the sample, then they’ll also start growing it. Otherwise, it sits there until the morning.
Doing a lumbar puncture on a child isn’t something we do lightly, and these samples are precious.  (Anyone who’s tried to get a urine sample from their baby will agree that urine is also precious stuff!).  So, the next dilemma is this: do I send it through the pod system where it might end up stuck or lost? Or do I call one of our porters to hand-deliver it to the lab? Ideally, one of our team in the ward would walk it over, but that would mean somebody being off the ward. So, I call a porter.  The same team of porters moving patients to theatre or scan; delivering blood for transfusions; collecting samples from around the hospital… 

I want an NHS where I can get a baby with significant weight loss some breast feeding advice on a Saturday afternoon that doesn’t come from my network of colleagues on social media.  I want the advice that they get to come from a trained professional before they go home, by themselves, over a weekend.  

I want an NHS where I don’t have to order intravenous feeds three days in advance and hope that the salt levels stay steady enough over the weekend. I want pharmacy cover in case a bag of TPN breaks and my patient needs a replacement. (TPN – total parenteral nutrition is used for babies and children who aren’t able to take enough nutrition orally. It’s a complicated mixture of sugars, fats, fluids, salts and trace elements.  Making it up is a highly skilled process).

I want an NHS where I can call an experienced pharmacist on Saturday afternoon to ask about a possible reaction to chemotherapy.  I’ll have access to my pharmacist during the week, the one who knows childhood cancer drugs inside out, but on the weekend I might get the one interested in gastroenterology or rheumatology instead. 

I want more than all of this though.

I want a hospital that families can get to on a weekend because the public transport system actually works beyond 4pm on a Sunday. (We’re in the middle of town, not out in a suburb or outskirts.)  

I want a canteen or a hospital shop so that families can get a meal if they need to stay for a few hours.  And no, if you’ve just been told that your child has a wee infection and not meningitis; if you’ve not eaten all day and not slept for three days; then a half frozen cheese sandwich from a vending machine isn’t good enough.

I want a play specialist 24 hours a day, seven days a week. Doing bloods in the middle of the night is upsetting enough; not having somebody trained to distract and support the child through that makes it worse. 

I want a housekeeper and a laundry service so that I can get a pillow and a blanket for someone who hasn’t slept.  I want a decent supply of tea and toast.  

I want access to notes on a Sunday. I want GP records so I can work out what dose of medication somebody’s on. I want to know that IT will come and fix the printer on a Saturday (or any day – that at least doesn’t seem to happen whether it’s Monday or Sunday) so that I can send a family home with a letter explaining what happened to their child.

I know what I want because as a doctor, I’m there with my colleagues on the weekends; we are there after 10pm on a Sunday getting the “medical” bits done. 

Seven day medical services already happen in our NHS. And really, we’re not that important.  We’re just a part of the whole. And if we want a truly seven day service, we need to get some of the essential staff in there too. 

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