7 day NHS: part 2 – who?

I’m on holiday at the moment, so I haven’t been part of the #imatworkjeremy selfies that have been going around social media this weekend. I’ve seen the tweets and news reports; and I’ve heard the stories from patients who’ve experienced care this weekend.  I’m incredibly proud to be part of the NHS, especially when I see what my colleagues are giving up this weekend. I’m also incredibly worried about some of the things that I’ve seen and heard this weekend.

My twitter feed is flooded with images of children who won’t be seeing their parents this weekend, because they are working. I can see people who’ve tweeted on their way home because they haven’t had a chance to before this; of colleagues who are several hours late finishing their shifts, travelling home, and then coming back with a few hours rest to do it all over again.  There are consultants who are supposed to be “on-call” for the whole weekend, but who will spend most of that 72 hours in the hospital providing care.  

I’ve also seen the concerns that this level of care isn’t widespread throughout the NHS. Even if it is, I think it’s clear that we need to improve services for acute and ongoing care throughout the week.  I’m lucky that my Trust has worked hard to implement the RCPCH guidelines which mean that new admissions are reviewed by a consultant rapidly (in practice, this means on the ward round or during their time on the admissions unit).  

It’s a good start, but it isn’t enough. With the focus on new admissions, what happens to patients already on the wards who might need a more senior review or ongoing medical input? Watching @adsthepoet and his family asking for help over a weekend; getting increasingly desperate for care in hospital was painful to watch. And I know he wasn’t the only one, because patients and families have also been sharing their stories of when it goes so horribly wrong.   Even a delay of 24 hours in getting results or specialist advice is 24 hours for somebody away from their home, with increased risk of adverse events, and outside of their normal activities (I am paraphrasing @betabetic, but she has the expertise here!!)

So we need better cover in admissions units, and on the wards; specialist advice that’s accessible (again, my local paediatric endocrinology team are fab at this: 24/7 consultant cover throughout the Trent region with discussions about complex patients; I’ve had consultants call throughout the night to check results and make plans, or just to check that the patients on their radar are ok). We need safer care throughout the week.

The question that’s been worrying me this weekend especially is this: who’s going to provide this extra care? There seems to be a thought process that says if the wage bill can be cut, suddenly there will be more man hours available and more doctors caring for patients.  I don’t think that’s true.  What I’ve seen this weekend is a cohort of professionals who don’t have the additional hours to to give. 

More worrying are the numerous examples of people providing additional services in their own time: from the shifts that are regularly worked without a loo break (13 hours without a wee does give you incredible bladder control) and that finish 2 hours late, to the routine clinics held on a Saturday morning without remuneration to keep waiting lists down, I’m seeing a system that doesn’t have any more to give. (These are examples from patients btw).

The obvious answer is to move some “surplus” doctors from the Monday -Friday, 9-5 hours (I presume that is the rationale for changing the definition of unsocial hours). There’s just one problem with this: there isn’t a surplus. Rotas are already struggling to be filled. Every week sees a request for us to work additional shifts in our own department just to provide basic cover out of hours.  Pulling somebody off a day shift to make sure that the night is covered is safer than not having night cover, but it leaves the day team short.  It means that trainees have their learning opportunities cut: attending clinics becomes a luxury; practical procedures end up being done by the same people over and over because they don’t need as much supervision (and then they miss out on other opportunities). It’s a poor investment for health care in the future, and I can’t see that this has benefits for patients in the long-run.

Do we go back to working 100-hour weeks to try and deliver this service? I don’t think that’s feasible for two reasons. First, the concerns about patient safety and quality of care delivered by doctors who are exhausted are, in my view, justified. Second, it’s obvious from the posts and patient comments that staff in the NHS are already working significantly beyond their contracted hours and conditions of work. Is there really any more to give? 

I worry that the discussions about 7 day services have focused on money, as though changing salaries will magic up more hours in the day, or that we can clone staff out of thin air.  The recent attempt to increase GP cover through making places for trainees to do a 5 week training course (rather than a trained GP) is even more concerning.  It takes time and effort to train a high quality workforce, and good patient care is about more than just the number of professionals present in a particular building in a Sunday morning.  

Surely 7 day services should first be about improving the quality and safety of care?  What is the vision for a 7 day NHS? And just as importantly, who will be providing it?

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