So the world and his wife is demanding seven day working from the NHS. NHS workers, doctors, nurses, journalists and patients alike are jumping on to Twitter to tell us that “it is the least we should expect” and they tell us about very real experiences of sub-standard care received at a weekend.
Why shouldn’t we be using the expensive NHS infrastructure 7 days a week? After all that would be maximally productive… we could all be operating, doing clinics, and holding multidisciplinary team meetings.
As it stands, dedicated nurses (who already work 7Seven shifts by the way) say they can’t find a doctor to review their patients; the doctors complain that they can’t get the x-rays and CT scans that they need; everyone moans that there aren’t enough physios and occupational therapists (if any at all) – and that’s just in hospital. Try getting to see a GP who actually knows something about you on a Sunday,. And as for social services, well at one stage last week over 100 patients were in a local hospital, medically fit for discharge with nowhere to go…
There are islands of hope within this sea of weekend confusion. I was on-call last weekend for surgery in my own hospital and there were 3 other consultant surgeons in the hospital seeing patients and helping me out. We are not alone, and many other trusts provide an equally good, if not better weekend service.
This is fine in a teaching hospital, with lots of senior staff divided into teams of specialists who can provide their own weekend rotas. But what if you work in a small district general hospital with 4 surgeons? I don’t think anybody in their right mind would expect them to be in the hospital every weekend… would they?
And surgery doesn’t get it bad. My wife is an Emergency Medicine (A&E to you and I) consultant in one of the busiest departments in the country. They are already asked to work more antisocial hours than anyone else in healthcare, and seem to get all the blame for the 4 hour target breaches, despite having no control over patient flow through the hospital.
This really is quite a simple concept – if the back door is shut and the front door stays open, there will very quickly be “no room at the inn”, the Emergency Department queue is just a manifestation of the systemic failure of the NHS and social care to provide a joined up service. At weekends… nothing moves.
I will venture onto dangerous ground now, but before reading on be assured that I am not asking for sympathy because I decided to do what I do because I love it.
Somewhere amongst our noble desire to demand and provide the best quality care the first time, every time, no matter what time of the day, or day of the week, we forget that it is human beings that do the caring. We have families. Our children go to school (during the week) and sometimes like to see us at weekends. Our friends do things at weekends and occasionally invite us along. We might even have a sporting interest that helps keep us normal and healthy; most teams play at weekends. Between us, my wife and I give 15 weekends a year to the NHS (21 if you count Friday night into Saturday morning), I think this is enough..?
So the care system is complex, but it should not be beyond the wit of man to work things out.
Perhaps the answer is to finally grasp the nettle of centralisation, and do it properly. Not every town will have an A&E as we currently know it. Doctors, nurses, managers, politicians and patients will have to get over their parochial attachments, and accept that – for the sake of their own health, and that of their patients – they will have to work with the hospital down the road and not against it. It is inevitable that complex surgery and interventional medicine will centralise further – if I have a heart attack at 3am, I want my angiogram and stent straight away – and I don’t care if you a have to fly me there to get it.
Some hospitals will have to close… and probably more than you think.
Here is the rub: the population seems to want world-class 7Seven care on their doorstep, but fail to realise that this is impossible. Whilst they might agree with the arguments in principle, they don’t think it is “their” local hospital that should close (look what happened to the children’s cardiac surgery review). Politicians are perhaps the worst offenders, it is seen as career suicide to support the closure of a local facility (even if it makes sense) and, as the general election looms, they will all be out insisting that they will “never” let the local hospital shut.
And when smaller trusts try to do something sensible, the special interest groups (NIMBYs in my opinion) get their knickers in a knot and make referrals to the competition commission… assuming they have any idea about the best way to run a complex health care service, that is a MONOPOLY provider by the way.
So are we ready for what 7Seven will really look like?
Fewer acute hospitals, further apart, using doctors and nurses from around the region to make their working life bearable.
Patients and relatives travelling that bit further for the best care, with the emotional, time and financial demands that this brings.
Small hospitals closing, merging or changing shape completely. This is happening for trauma care right now and outcomes are better… much better. It could be coming to the rest of medicine sooner than you think.
And what if we don’t change… well the scandal of Emergency Medicine recruitment gives us the answer. Nobody wants to train to be an A&E doctor right now because it’s all antisocial high-pressure working. The shifts are terrible, their leave is dictated to them, and they are blamed for the failings of the health service as a whole… I wouldn’t do it and I am proud and amazed that Mrs U does.