Now the publication from the Royal College of Physicians, Hospitals on the edge? Time for action, – and hot on its heels, The state of medical education and practice in the UK, from the General Medical Council – provide further compelling evidence for the need for change. In essence both these reports describe a fundamental misalignment of the medical workforce, and the way in which care is organised, with the needs of the patients. The RCP report in particular makes salutary reading.
The RCP describes wide variation in the seniority of the medical staff available on site at night and at weekends, ranging from junior doctors just out of medical school to consultants. There is also a worrying variation in the number of patients that doctors are expected to be responsible for out of hours. The patient to doctor ratio varies from 1:1 to 400:1, with an average of 61:1. Overall, there is a general lack of consultant input to care – particularly specialist geriatric input – often with no consultant assuming overall responsibility, with the result that frail older people with multiple conditions may be moved several times during their stay. Finally, there is lack of adequate handover between clinical staff working different shifts. According to the RCP, the consequences of this are excess mortality at night and weekends, poorer outcomes and excessive lengths of stay.
These findings not only reinforce our recent report but also echo the conclusions of The King's Fund's work on the care of older people. They also have particular resonance for me. In 2003/4 I led the development of the 'Hospital at Night' model for the Modernisation Agency, the brainchild of Professor Liz Paice from the London Deanery. She argued that junior doctors working at night should work as part of a multidisciplinary team including senior nurses, with the composition of the team determined by the numbers and needs of the patients that the team was expected to support. Effective handover between teams was seen as critical for patient safety, and the overview of all the patients that it provided ensured that care could be targeted at those in greatest need. The traditional model had been for junior doctors to work in relative isolation at night, responding to calls from the wards as and when they arose, with little formal handover before taking on the 'bleep'. The RCP report reveals that eight years later, despite most hospitals nominally having Hospital at Night teams, Professor Paice's original vision is far from realised.
So what is to be done? The RCP identifies ten priority areas for action including changes to medical practice across primary and secondary care – increasing availability 24/7, changing the way in which care is organised, and reforming medical education and training. It argues for a much stronger application of national standards in the interest of patient care. It remains to be seen whether this approach is adopted in a 'liberated NHS'.
The RCP report adds further compelling evidence to support 'a case for change'. There is an urgent need to realign the health and social care system, including the working practices of doctors, to better meet the needs of patients. In the new system these messages need to influence the priorities set by local commissioners and the new provider-led local education and training boards (now holding the NHS training budget). Let us hope they do.
See our related work: Transforming the delivery of health and social care