Posted by: ayrshirehealth | October 21, 2015

Seven Day working – Part 2 by @micmac650

Seven Day working – Part 2 by @micmac650Seven day working: it’s a no-brainer

Days of weekAnother paper shows increased hospital mortality at the weekend.

The statistics may be dubious, and it’s even more doubtful that seven day working will abolish this effect; but we all want the same high quality emergency healthcare whenever we need it, whether it’s Sunday or Wednesday – and we all know that’s not what is provided.

It was a poor model of care, but it was the best we could offer.

When I started working as a consultant in 2004, I joined a team of ten physicians. We were on duty for seven consecutive days on the Medical Receiving Ward, looking after 30-35 new patients each day.

Ward round 2At the weekend,

– if a patient came in with a heart attack, and needed a temporary pacemaker, we put it in;

– if a patient came in with acute kidney injury, we inserted the neck line for dialysis and prescribed the immunosuppressive drugs;

– if a patient was bleeding from oesophageal varices, we placed the Sengstaken tube in their gullet;

– if a patient was breathless from a pleural effusion, we put the drain in their chest to remove the fluid.

That was seven day working. 

It was a poor model of care, but it was the best we could offer.

Not sufficient for high quality care

When patients are admitted as an emergency, seven day working is necessary but not sufficient for high quality care.  One of the apparently cheaper solutions is an increase in generalist consultants, paid for by a decrease in specialists.  This is the quickest way to fulfil the seven day promise: saw consultant, box ticked.  However, definitive decisions may be deferred till Monday, when the patient can see the specialist.

2015-calendarOr delayed till a week on Tuesday, when the specialist drops in from the ivory tower (unless he’s on holiday, in which case it’s three weeks on Tuesday).

Or perhaps the patient receives a lower standard of care, as in 2004.

Fast forward to 2015.

Now, we have 27 funded consultant posts. At the weekend we have four consultants to deal with the 40-50 admissions each day: two acute or general medicine consultants, one cardiologist and one nephrologist. If you need a pacing line it’s done by a cardiologist, rather than someone who last did one five years ago. If you need dialysis it’s initiated by someone who does this every day of the week, rather than someone who has never worked in a renal unit. If you have a pleural effusion, there’s still a 1 in 3 chance there won’t be a chest physician present to deal with it. If you have a variceal bleed we rely on the goodwill of our two gastroenterologists to come in when they are not on-call.

MoneyOur department’s annual spend on consultant salaries alone has increased from £1.2m to £3.4m (after allowing for inflation).

Improving the quality of our seven day services has cost a lot of money.  

In 2004, we had one or two consultants in each specialty. To provide a seven day rota sustainably, probably requires five or more consultants in each specialty, and we’re still not there.

 It’s not just about assessment units

Clinical Decisions UnitMuch of our focus on improving weekend care has been the assessment unit.  But increasingly our problems lie downstream. Every patient sick enough to be in an acute hospital should be reviewed daily by a doctor. But that would cost about £3.1m annually for our department.

And it’s not just about doctors. I can get a CT scan or an ultrasound at the weekend, but not an MRI, an endoscopy or an echocardiogram.

Patients don’t get routine access to physiotherapists or speech and language therapists. And if a patient needs social care to get home on Sunday…

What about Wednesdays?

If it is essential for patients to be seen by a consultant on Sundays, then what about weekdays? In my hospital, while all newly admitted patients are seen daily, after that most medical consultants see their patients twice a week. Patients are reviewed by junior doctors on the other days. To move to five day consultant review would require ~25 new consultant appointments at an annual cost of £3.1m. And even if the money was available, we would struggle to recruit. Presumably there is a diminishing return from increasing frequency of senior review.

Every second day would be a reasonable aspiration, and a lot less costly.

Elective care at the weekend

Sir Bruce Keogh, the NHS medical director in England, used the example of someone with a breast lump – why can’t she be seen on a Sunday to be diagnosed, rather than wait till Monday? NHS EnglandWhy should she have that anxiety for another day?

The logic of this argument is that every clinic should be provided seven days per week, with no waiting time.

Yet few clinics are provided every day of the week, even during weekdays, and even fewer with zero waits.

In my specialty, we provide clinics on four sites, so that patients don’t have to travel so far – this is particularly important for elderly patients reliant on public transport. There are insufficient patients for daily clinics, so we would travel to see one or two patients. We could just provide the clinic in one central location. One daily clinic centrally, or four weekly clinics locally – the weekly clinics are more financially efficient, but which is better for patients? And of course, this does nothing to address the general lack of clinic capacity, unless additional resources are put in.

Systematic and evidence based

7-day-workingWe will improve seven day emergency care over the next decade, just as we have over the last decade. But it can’t be our sole, over-riding priority.

Indeed, the cost of seven day services exceeds the usual threshold for cost-effectiveness. If we commit resources to this, we will be diverting £597m-1,045m per year away from more cost-effective interventions, when we are experiencing the most severe financial constraint in the history of the NHS.

Implementing seven day services as a blanket goal, will harm more patients than it benefits. What this debate can achieve, however, is a more systematic and evidence-based approach targeting high risk areas.

Seven day working is a no-brainer. But it doesn’t mean we shouldn’t use our brains to get there.

This week’s blog was by @micmac650 (Dr Mark MacGregor), Associate Medical Director, Consultant Physician and Nephrologist, University Hospital Crosshouse, NHS Ayrshire & Arran

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Responses

  1. the winter crisis is nothing of the kind, it’s back to back 4 day weekends

  2. […] deaths “are avoidable would be rash and misleading”. Addressing the issue will require a more nuanced response than just appointing doctors, but also ensuring seven-day access to a range of diagnostic, […]


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