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.
My GP colleagues get paid more than me, and do not have the frequency of arduous night shifts. For most of my cohort, choice of speciality in medical school was based around enjoyment of the speciality, status and quality of working life and to a much lesser extent money (we all get paid well enough!).
The problem is complex- including deficits in primary and secondary care. An acute deterioration can be prevented, but I doubt focusing on the few hours prior to admission in primary care is the key. To my mind, primary care is most efficient at 'prevention' and pre-empting problems and when the patient is sick (needing iv therapies, imaging and testing quickly) secondary care has the most important role. For the sick patients attending hospitals as emergencies at night, what are the attendances in general practice like in the preceding days? Are we missing opportunities to prevent deterioration?
In secondary care, our resources are not adequate, but in addition to that, we are not using these meagre resources optimally. Improving the function of the current team is a 'quick win'; as Candace says, the Hospital at Night model is far from realised. Improving team work, communication and procedures for escalation at night would be an easy first step. Most trusts do not support night workers- with quiet areas for rest, availability of decent food etc. It would be nice if our importance in the system was recognised in some small way by the organisation.
The traditional hierarchy in medicine - and the associated status that comes with that in terms of money, power and priviledge (including shifts worked) is a well established tradition that presents a barrier to many of the changes needed.(ie. a shift from hospital based to community based care, from autonomous practice to working in interdisciplinary teams, from physician centred care to patient centred care and from silo thinking to systems thinking.....
For example, the solution put forward by Harry Longman - Chief Executive, Patient Access ("Greater access and continuity in primary care",) would require more GPs. Changing the focus from a hospital based illness model to a primary, community based, wellness model would require more GPs. Yet GPs are paid less and have less status than specialists. More medical students opt to become highly paid, highly specialized and hospital based than to become GPs. It is a vicious circle that requires system solutions.
I think the issue goes beyond Doctors. It is very disrespectful to other professionals and people working in Hospitals to try and imply that the lack of Doctors is the only significant factor in the lower quality of care at night or during the weekends. Generally during the weekends, night shifts and the summer holiday (August aka "The Killing Season") there is a siginificant reduction in staff from all work groups working in the hospital. That is Porters, Lab Scientists, Therapists, Pharmacists, Domestic Assistants, Ward Managers, Doctors and Radiographers. Some departments close completely, while others attend to "emergency" cases only. Even the Helicopter Ambulance does not work during the night.
I think everyone has bought the idea that it is due to "there being no senior doctors theory". The result is a blinkered approach to trying this solve the issue. Doctors need blood tests, xrays, scans, medications, and support from other health professionals to be able to treat patients timely, effectively and optimally. At night, weekends and during the summer holidays, the hospital is running a significantly reduced service, with significantly reduced staffing levels, therefore it follows that the quality of care will be reduced as well.
We constantly talk about the need for change but I'm not convinced that more training and better handover will solve the challenges. Over the past decades, we have been trying to squeeze more out of less; working hours directives have led to junior doctor shift working which undermines continuity of care, not just out of hours (hard pressed staff 'monitor patients to death', missing their decline as the benchmark is reset at the beginning of each shift period!); consultants are supposed to be present more out of hours but they are also supposed to be present full time in the day providing 'consultant led care' (in my hospital, consultants do all the clinics, and have to be present at all operations, as well as providing the continuity of care no longer afforded by junior staff); number of staff are cut for cash releasing efficiency savings; more time is required to be spent on training self or others but SPAs are being cut; reductions in commissioned services reduce beds but the patients keep turning up; we are exhorted to extend our use of facilities yet staffing levels are insufficient; etc. Morale is at an all time low - you are asking staff to be innovative but remember that these are often the same staff who had to implement policies such as choose and book and PFI arrangements that completely undermined contiunity, efficiency, and quality of care!
The one thing which would turn the situation round is a reduction in demand. 10% or 20% less could make the difference between night and day in many services. This should therefore be top of mind for action. Yet we have very good evidence for how to do it, through access and continuity in primary care. Hello, is anyone listening?
Comments
The problem is complex- including deficits in primary and secondary care. An acute deterioration can be prevented, but I doubt focusing on the few hours prior to admission in primary care is the key. To my mind, primary care is most efficient at 'prevention' and pre-empting problems and when the patient is sick (needing iv therapies, imaging and testing quickly) secondary care has the most important role. For the sick patients attending hospitals as emergencies at night, what are the attendances in general practice like in the preceding days? Are we missing opportunities to prevent deterioration?
In secondary care, our resources are not adequate, but in addition to that, we are not using these meagre resources optimally. Improving the function of the current team is a 'quick win'; as Candace says, the Hospital at Night model is far from realised. Improving team work, communication and procedures for escalation at night would be an easy first step. Most trusts do not support night workers- with quiet areas for rest, availability of decent food etc. It would be nice if our importance in the system was recognised in some small way by the organisation.
For example, the solution put forward by Harry Longman - Chief Executive, Patient Access ("Greater access and continuity in primary care",) would require more GPs. Changing the focus from a hospital based illness model to a primary, community based, wellness model would require more GPs. Yet GPs are paid less and have less status than specialists. More medical students opt to become highly paid, highly specialized and hospital based than to become GPs. It is a vicious circle that requires system solutions.
I think everyone has bought the idea that it is due to "there being no senior doctors theory". The result is a blinkered approach to trying this solve the issue. Doctors need blood tests, xrays, scans, medications, and support from other health professionals to be able to treat patients timely, effectively and optimally. At night, weekends and during the summer holidays, the hospital is running a significantly reduced service, with significantly reduced staffing levels, therefore it follows that the quality of care will be reduced as well.
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