By Dominic Wilkinson @Neonatalethics
At the bedside of a critically ill infant at 5am this morning I was tempted to tweet the latest meme, adding my voice to a chorus of NHS clinicians over the weekend. Last week, in a speech to the King’s fund, Health Minister Jeremy Hunt launched a drive towards 7 day NHS. In particular, he focused on consultant contracts, proposing that newly qualified hospital doctors will be required to work weekends as a condition of employment.
The motivation for the change in contract is recognition of the significant increase in mortality for patients who are admitted to hospital out of hours and on weekends. In one series from 2009/10 patients admitted to the NHS on Sunday were at a 16% higher risk of dying than those admitted on Wednesday. Hunt proposes that increased access to senior doctors would help prevent complications like these for seriously ill patients.
We should be concerned about lack of services on weekends and after hours. Our health system should provide high quality, timely and appropriate medical care at any time. Illnesses and medical emergencies don’t conveniently occur between 9am and 5pm Monday to Friday.
However, there has been a vigorous response to Hunt’s speech over the last few days on the part of health professionals. Why the protest? Many have highlighted that large numbers of hospital doctors already work weekends and night shifts, including many unpaid hours. Furthermore, the relationship between mortality and time of admission is complicated by the fact that patients needing admission during the night, or at weekend are often sicker than those admitted during office hours. After carefully controlling for severity of illness, a large epidemiological study of UK intensive care admissions found no difference in risk out of hours.
Twenty-four hour consultant cover seems like it might well improve outcomes for patients. If this were the case anywhere, surely it would apply for the sickest of patients, needing the most complicated medical care? Yet strikingly, a number of studies have failed to show improvements in mortality in intensive care units with 24 hour physician cover. One hospital in the US performed a randomized controlled trial in their intensive care unit with 7 days of consultants either on call from home, or on site. There was no difference in patient outcome. Observational studies appear to suggest that having consultants available overnight did not improve outcome in units that already had high levels of staffing during the day.
A significant concern, then, about Hunt’s proposed contract changes, is that pushing for more consultant cover overnight and at weekends may not produce the desired effect. One potential reason for this is that delivering the same care out of hours as in-hours requires more than just medical and surgical consultants. It also requires, pharmacists, physiotherapists, radiographers, biochemists. Without all of those essential health care professionals, there will still be a limit to treatment, and there may still be a difference in outcome.
Perhaps a greater ethical concern, is that Hunt’s proposal was accompanied by no explanation of how an increase in medical staffing out of hours would be funded. Hunt explicitly rejected any increase in medical working hours. It appears then, that the proposed model must either be covered by increased consultant numbers* (estimated to cost in excess of 2.2 billion pounds) or by reducing coverage during office hours.** Yet both of these pose serious trade-offs. In the resource limited NHS, where will the funds come from to pay for these additional consultants (not to mention the other health professionals required to deliver a true 7-day health system)? If no increased funds are made available, any improvement in care at the weekend will be at the price of reduced care during the week.
*Simplistically, for services currently providing consultant availability Monday to Friday, to provide the same cover on weekends would require a 40% increase in consultant numbers. To cover evenings would require a doubling of the consultant workforce (assuming current coverage from 8am to 8pm).
**Distributing existing consultants across seven days would lead to a 30% reduction in consultant coverage during week days. Distributing existing consultants across weekends and overnight, would lead to a 66% reduction in consultant cover during the week
Wouldn’t the sensible thing be for a trial to be run in a relatively small number of NHS hospitals to determine the impact? If it replicates the studies you’ve mentioned here, then there’s no need to even worry about the issue of additional funding or cuts to other services.
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