How should we handle Jeremy Hunt Re-booted?

It’s been a week of filling jobs. A new prime minister, who then filled a new cabinet. One particular appointment seems to have caused more than a little bit of interest among health care workers. Off came Jeremy Hunt’s NHS lapel badge (accompanied by cheers in some hospitals we hear), then some comments on Twitter from someone else saying they’d turned down ‘a role in the cabinet’, followed by the lapel pin re-appearing on JH, the ‘sort of new’ secretary of state for health.

This of course caused a deluge of negative comment in all areas of the media, printed and social.

I’m not a great fan of direct attacks on individuals. I try to remember to play the policy and not the politician (sometimes it’s hard and I fail). Not just because it’s a bit rude and not the way my parents brought me up but also because it is probably counter productive. I don’t know where the policy and then manifesto pledge came from for ‘7 day services’, I think there’s every chance it came from someone medical rather than a politician (although the politicians would desperately like the public to think that great out of hours emergency care is a politicians idea). I also think that if you asked the average consultant or junior doctor if we would like to improve emergency out of hours care that most would say yes. Few of us have an argument with that bit. Where I do think we have an argument however is how we get there and the dichotomy between emergency and routine 7 day services.

Has there has been a DOH change in the focus of 7 day services? Kathy McLean wrote in May to medical directors regarding the implementation of the quality standards www.nhsiq.nhs.uk/media/2746158/clinical_standards_feb_2016.pdf (go and read them, they apply to you!). In her letter she made the point that public demand for routine services is currently low and therefore urgent and emergency work should be the priority. I think most would roll with that. Although the next section which said ‘with diagnostics, some cancer treatment and day case procedures in the future to maximise choice and convenience’ would probably not be supported in the same way.

There is no doubt that we have a lot to do over the next few months; the juniors contract was rejected by the majority of juniors and final year medical students but is still going to be ‘introduced’; The consultant contract is still under negotiation and when finished will be balloted on. There remain huge questions over the actual practicalities of 7 day services, who’s going to do the work, who’s going to fill the gaps in the week, has any body actually listened to us repeatedly saying that the issue isn’t contractual but about support staff, services and resources? We need to direct our energies toward holding the Department of Health and Jeremy Hunt 2.0 to account on the facts rather than personalities.

My guess is that the autumn is going to be choppy in the NHS for multiple reasons. The new contracts, the application of NHS Improvement CEO Jim Mackey’s comments on the stretching of nurse ratios from 1 in 8 in order to save money. If this heads in a toxic direction then that may be the time for a new health secretary with the government hoping that the current incumbent would take the poison with him.

When it comes to filling jobs it’s not just the prime minister who has had some difficulty. My wife, who’s a gasser tells me that the anaesthetic junior rota for August has more holes in it than than an NHS cellular blanket. Some are covered by doctors of other grades but it’s unlikely to be sustainable. In the medium term probably similar to the tenure of the man involved in causing the staffing crisis in doctors and nurses in the first place, but whatever the name of the minister the root cause seems clear; the NHS remains under resourced.

Weekend admissions

It seems amazing to me but I’ve been in medicine now, as student and doctor for 30 years. During that time I’ve seen time and again the routine of patient admitted to a specialist service, seen by a junior doctor, reviewed by a less junior doctor, tests organised, decisions made as far as safety and knowledge allows and then a final review by the consultant with the timing of that review based on how ill the patient is (within minutes of admission if needed). When scientific papers that suggested a higher death rate at the weekend (which is a world wide phenomenon) it led me to a bout of professional soul searching. While the politicians and clinicians associated with them were quick to jump to causation (not enough consultants available at the weekend) this just didn’t feel right to me.

This deserves its own paragraph: Correlation is not causation.

It’s probably worth looking at the real world difference, the absolute increased risk of death if admitted at the weekend as an emergency is 0.3% so for every 1000 deaths within 30 days of a weekday admission 1003 people might die within 30 days of a weekend admission. As you can imagine only a small change would be needed to cause this effect.

Is there evidence that patients are sicker at the weekend. One of the earliest papers to look at this was a paper from Dublin http://www.ncbi.nlm.nih.gov/pubmed/22111090 this looked at nearly 50,000 episodes and carefully took into account not just medical co-morbidities (in other words multiple illnesses) but also biochemical (blood test) markers of illness severity. They found once patients were matched in terms of these other factors there was no difference in outcome. So weekend patients were likely sicker on admission.

A new paper http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html looking at 17 million UK attendances and admissions found that the weekend increased mortality could be described by the difference in proportion of patients who were admitted at the weekend. Most patients are of course treated and sent back home. So the proportion of just in case admissions was lower, thereby skewing the results. Again, the patients admitted at the weekend are sicker.

So far there aren’t papers that show evidence that the problem is due to lack of senior input at the weekend. There are papers which show that the patients who are admitted are different between weekdays and weekends.

In a hospital with good working relationships and doctors who know when to escalate problems appropriately lack of senior cover is unlikely to be the issue. From a practical point of view most doctors will tell you that they have worked in jobs where there are simply not enough pairs of hands, not enough doctors on the rota, not enough support workers to help with tasks like ECGs, echocardiographs etc, not enough emergency theatre space, or recovery, or ITU beds. These are all real and addressing them would cost more money. This is not a matter of doctors having the wrong contracts but not enough staff or resources.

Maybe we should just try out 7 day services and see if it works? The NHS has a body to look at the cost effectiveness of medical interventions. Its called NICE, it looks at the cost of a medicine or operation and declares whether it is cost effective enough to be available on the NHS. This paper http://onlinelibrary.wiley.com/doi/10.1002/hec.3207/abstract takes the NHS calculated costs of an NHS 7 day service of £1 billion and looks at whether 7 day services would be cost effective if it really did produce a reduction in deaths (as we have seen very unlikely). The answer is that if it were a new treatment NICE would rule it as not cost effective and would not allow its use within the NHS.
Many would argue that the cost of taking the NHS from a 7 day emergency and 5 day routine service to a 7 day emergency and routine service would cost more than an extra £1 billion on the overall budget of £115 billion so the true NICE calculation would likely be worse. That's not to say that doctors wouldn't welcome improvements in the support services we get at the weekends we'd love it.

All hospital doctors in the UK have contracts which specify that they must provide emergency services on a 24/7 365 basis. There is no opt out for any group for this work. Consultants just like everyone else are in hospitals out of hours providing care.

It looks like we have mounting evidence that the push for contract negotiations for doctors based around ‘7 day services’ is much more about politics than evidence or science. Meanwhile consultants, juniors and specialty doctors are happy to work to improve care at all times of the week and day. It must be recognised however that this will have resource implications which need to be properly calculated and funded.

One of the abilities that we work hard on in medicine is to take in fresh information, blood test results, comments from colleagues regarding a patients diagnosis or management and change our direction if it's in the patients interest. Don’t hold on to fixed ideas but practice flexibility of thought. Sir Bruce Keogh of course has a professional duty to do this and I would urge the Secretary of State Jeremy Hunt to do the same. Healthcare should not be about political dogma. Changing contracts to save money dressed up as improving safety is being economical with the truth at best.

Consultant contract negotiations update, a personal view

What seems like a very long time ago we were called to contract talks with the government and employers. Not because the BMA felt that the 2003 contract had run its course but at the behest of our negotiating partners. They felt that changes were needed to facilitate the provision of 7 day services. My hospital and I’m sure yours has had services provided throughout the  week in many areas. You will have all noticed however that the number and range of these services has steadily grown and so too has the amount of work that cannot really be deemed ‘emergency’. You will probably also know that the 2003 contract stipulated that consultants could only be asked to provide ‘routine work’ outside of 7am-7pm, Monday to Friday (this is in section 3 paragraph 6 of the contract, often shortened to S3P6) by agreement. This last word is of course vitally important.

The government have made a policy decision to expand further the amount of work done at the weekends. As seen here 7 day service standards.

Initially it will be enable the new quality standards, i.e. all admissions seen by a consultant within 14 hours (two ward rounds a day for on call consultants), all patients in for example SAU seen twice per day and every hospital in patient seen daily by a consultant unless specifically not needed (it is worth noting that when these standards were suggested by the AORMC they were felt to be aspirational and currently unaffordable). In addition to this work there are waiting list initiatives, Saturday and Sunday convenience clinics, using spare operating lists to foster local service reconfiguration etc. Clearly it can be argued that not all of this represents emergency work.

As a group, consultants have seen their real terms take home pay fall by 30% since 2003 and employers are obviously worried that consultants might use this as a lever to regain some of their lost income, exposing NHS trusts to unpredictable wage bills. The talks were therefore started with the government’s aim that contract changes would render enhanced 7 day services as ‘affordable’ although this very rapidly became cost neutral. Which you may feel is a rather different word.

Why did we agree to talk at all? As I have said, there was not a strong feeling that renegotiation would be in our interest. There were however areas of the contract which it was felt could possibly be improved. The 2003 contract is based around a consultants emergency duty being on call with occasional return to hospital. This is clearly not the pattern experienced by many consultants in 2015/16. Consultants are not well protected from enormous amounts of work performed out of hours. A set of protections against this was felt to be useful. Similarly the present CEA scheme is not supported by all consultants and at the outset of negotiations it seemed we might have the opportunity to work on enhancements to the scheme. The current pay scale is not a good match to the CARE pension that new consultants will have most of the their lifetime pension entitlement based upon.

As one would expect, some of things that we might hope to achieve during a negotiation may not come to pass and likewise some of the things that we would not wish to give away are sought by the other side!

We have had a very able group of negotiators with the support of a professional negotiator so whatever has been achieved is not through lack of expertise, intelligence or trying. There has been a strict timescale imposed by the government and talks were guillotined prior to Christmas.

The current situation is that the negotiation document has gone to government for comment, approval and costing. We hope that government will bear in mind that an agreement which is acceptable to the vast majority of doctors is the only one that will see the kind of contractual change they seek. Usually that will need to be via some sort of benefit to most clinicians. In a cost neutral environment they clearly have a very difficult task on their hands. By the end of the month we will no doubt get to see both the carrots and sticks. We’ll then be touring England and Northern Ireland in our blue satin BMA tour jackets to let you know all about it and vitally hear your views. Until that time consultants up and down the country will of course continue to provide 7 day services where they realistically expect them to make a difference to their patients, all remarkably on their current un-altered 2003 contract. Makes you wonder.

Happy new year.

Mike Henley