Thursday, July 16, 2015

The Rt Honourable Jeremy Hunt MP

I've been asked for my thoughts on the statement today by Jeremy Hunt, reported in the following ways: Jeremy Hunt: 'Doctors must work weekends': Jeremy Hunt Goes to War with Doctors: Jeremy Hunt: Doctors will have to work at weekends.

It's taken a bit of time to order my thoughts but put simply I think this is a deeply cynical attack on doctors and the NHS. Let me explain:

On Radio 4's Today program he talked about the need to forge a "A new contract that brings back a sense of vocation.” And one of his justifications for this is that there are '6000 avoidable deaths' due to care being less good if you're admitted on a weekend.

Medicine is very diverse, and it varies across the specialties. I work in surgery and hence that is very much my perspective and I appreciate that things might be a little bit different in other areas. However, basically he is talking nonsense.

Of course we work weekends. There is always a consultant on duty on Saturdays and Sundays, High Days and Holidays. For the record, doctors who work Christmas Day don't get a premium pay, simply a day off in lieu.

There are apparently lots of consultants who have opted out from working weekends. I'm not quite sure to whom he's referring. Seriously, the numbers overall must be small but let me take one example where that makes sense. Breast surgery is a specialty that mostly deals with cancer. There is some benign disease as well, but most of the work is cancer-related. As such, timing of surgery is urgent but not an emergency. And the pathways (since 2001) work really well with patients being referred by their GP, seen assessed and then treated in 2-4 weeks. Such work requires multi-disciplinary teams and a lot of coordination. However there is no good reason why this needs to take place on a weekend.

If Mr Hunt is arguing that as the hospital buildings are there, they should be used to full capacity 7 days a week, that's fine. But it has very little to do with doctors. It is about making staffing levels at the weekends the same as week days. I am certain that the Honourable Gentleman is not proposing enough funding to pay for that. And how are we going to maintain the same level of staffing on week days if we are sticking to current hours limits? More worryingly for other professionals (nurses, paramedics, physios etc.) the government has muted taking away unsocial hours supplements. Seriously? You want people to work nights and weekends without any extra recompense? How do you think this will help the current recruiting crisis?

So, is there sufficient resources out of hours for emergency care? Well, sort of. As surgeons we provide 7 days a week cover in teams. It can be frustrating when some of the diagnostics (i.e. pathology) is less available out-of-hours but rarely does this actually make a measurable difference to patients. However there is some room for manoeuvre here. But this doesn't seem to be what the Health Secretary is talking about.

The '6000 avoidable deaths' Which is apparently all doctors' fault. (See the Radio 4 interview if you think I'm misrepresenting him): This figure is calculated from  some work published in 2013. It showed that if you look at admissions to hospital, there is 1.3% 30-day mortality. (That is death within 30 days of admission). However this rate varied depending on day-of-admission, with Wednesday being the lowest and Sunday 16% higher. So to put that in context the risk of death rises from ~ 1.2% to 1.4%.  The problem is that no-one is quite sure why this happens. Hunt argues that the lower number of senior doctors on weekends able to make decisions is the culprit. This may be true but you cannot tell from these data whether the patients admitted at weekends are the same as those admitted on week days. Any doctor who works in acute care will tell you that many patients admitted on a week day will be less ill - but in need of some hospital care. It is complicated and we do not have the data. If it was simply a matter of weekend care being less adequate, then why is the death rate lowest for those admitted on a Wednesday and not a Monday/Tuesday as presumably those are the least likely to be still in come the weekend. Basically, what I am saying is that is complicated. If it is due to levels of staffing not being high enough on weekends then the doctors is only one small part of that.

The press has talked about how much consultants are paid - presumably in order to shock the public that they are paid so much and refuse to work on weekends. Well, the consultant's starting salary currently is £75,000. After 5 years at medical school and at least 10 years of post-graduate training and experience. The majority of the post-graduate training self-funded. And taking on significant responsibility for the care of a large number of people. Doctors are far from hard-up, but painting consultants as on the gravy train is deeply offensive as is the argument that we as a profession lack a sense of vocation. In order to earn that, most consultants would be on something like a 1 in 6 on-call rota - hence working part of at least 1 in 6 weekends depending on the work pattern.

So what is this really about? Any analysis of Hunt's comments show they are disorganized and nonsensical at best. Although there are some aspects that he is right about and there are some things to be applauded. However the 'attack on consultants' is, at the very least odd. Here's what I think:

In the 2012 Health and Social Care Bill, one little noticed provision was the removing from the Secretary of State the duty to provide comprehensive care to the whole population that was instituted in the 1948 statute setting up the NHS. This provision is arguably only symbolic. But Symbols can be really important.

The NHS faces significant pressures, from an aging population, a big squeeze on finances (despite what they keep saying) and billions wasted directly and indirectly on a crazy reorganisation that made the NHS significantly less efficient and effective. Not to mention that the real crisis for the NHS is the collapse of social care.

In the face of this, the government is striking out first - I believe today's announcement is a deeply cynical attempt to pin the impending disaster in the NHS on doctors. I am sure other NHS staff will be next. They are playing fast and loose with both the truth and our healthcare system. In order to protect themselves from the fall-out they are trying to make you think it's all the doctors' fault.

I would never claim that my profession is perfect and we do need to improve in many ways but this is nothing short of a slap in the face to so many of my colleagues who are deeply committed and unbelievably hard working.