Hospital Dr News


Increased risk of death for patients admitted to hospital at weekend

By Mike Broad - 3rd February 2012 4:28 pm

Patients admitted to hospital at the weekend have a significant increased risk of death within 30 days of admission, a study finds.

The research analysed all 14.2 million admissions to NHS hospitals in England during the 12 months from April 2009 to March 2010, and for every 100 deaths among patients admitted to hospital on a Wednesday, 116 similar patients admitted on a Sunday would die.

However, the likelihood of patients dying in hospital is less at the weekend than during the week. For every 100 deaths among patients in hospital on a Wednesday, 92 deaths would occur among similar patients already in hospital on a Sunday. The findings are consistent for both emergency and elective admissions.

The results of the analysis in the Journal of the Royal Society of Medicine are also consistent with data from 254 not-for-profit hospitals in the US, despite differences in the organisation and delivery of care between English and US hospitals.

Lead researcher Professor Domenico Pagano of the Quality and Outcomes Research Unit, University Hospital Birmingham Foundation Trust, said: “These results offer conclusive evidence that confirms previous reports of increased 30-day mortality risk for patients admitted to hospital with emergency conditions at the weekend compared with the rest of the week. Previous reports, however, have not accounted for differences in patient characteristics associated with admissions on different days.”

He said several factors that might be associated with the increased risk of death for patients admitted with emergency conditions. Some may be more seriously ill and had they been less ill, would have had their admissions postponed until a week day. He also speculated that there may be aspects of care at the weekend that disadvantage patients, such as reduced or altered staffing and skill mix; reduced availability of diagnostics; and less availability of senior staff to review cases and to be readily available for escalation.

The study also demonstrated an increased mortality risk over the 30 days follow-up for patients admitted electively at weekends compared with similar patients admitted during the week.

Pagano said: “This could be because patients planned to have higher risk elective procedures at the beginning of the week are admitted over the previous weekend. Consequently the risk profile of elective patients admitted at weekends may be different and possibly higher from those admitted during the week.”

The study analysed all deaths within 30 days from admissions, whether in or out of hospital. For emergency cases the ratio of in-hospital to out of hospital deaths is approximately 2:1, similar for admissions at weekends and during weekdays. For elective patients the ratio is 2:1 for those admitted at weekends but is almost reversed to 1:2 for those admitted during the week.

Commenting on the study, Dr Andrew Goddard, Royal College of Physicians director of medical workforce, said: “This study is further evidence that patients admitted at weekends are more likely to die following admission than patients admitted to hospital during the week. There are many reasons for this, but the two most important are that the patients are more ill and there are fewer doctors available.

“The Royal College of Physicians has already called for any hospital admitting acutely ill patients to have a consultant physician on-site for at least 12 hours per day, seven days a week.”

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Health Bill amended to overcome resistance

By Mike Broad - 2nd February 2012 8:31 pm

The government has tabled a series of amendments to the Health and Social Care Bill in advance of its Report Stage in the House of Lords, which begins next week.

Health minister Earl Howe has tabled a number of amendments in a bid to placate concerns raised by the House of Lords.

Chief among them is a clearer directive to both clinical commissioning groups and the health secretary to promote a ‘comprehensive health service’, following fears that CCGs could ration some services.

Clauses have also been inserted requiring CCGs to give clearer evidence on how they are tackling health inequalities and promoting education and training, and to diminish the potential for conflicts of interest.

It comes in the week when the Royal College of Psychiatrists joined the Royal College of Radiologists in opposing the Bill in its current form. A survey of psychiatrists finds that 85% believe the Bill will have a negative impact on the health and social care system, and 80% consider it to be fundamentally flawed.

Other amendments include bestowing the health regulator Monitor with the power to require healthcare providers to promote integration of NHS services; a new duty on the health secretary, NHS Commissioning Board and CCGs to report annually on their progress in tackling health inequalities; and duties on CCGs and the NHS Commissioning Board to promote patient involvement in their own care.

Health secretary Andrew Lansley said: “The principles of our modernisation plans - ‘no decision about me, without me’ for patients, clinical leadership with doctors and nurses leading discussions on services, a focus on results for patients and reducing bureaucracy - have always been at the core of the Bill. These principles are widely accepted as reported by the independent NHS Future Forum. But we have been carefully listening to the ideas raised as the Bill has progressed through Parliament. And as a result we have today tabled a series of amendments to address these remaining issues.”

Report stage in the House of Lords is due to start on 8 February. The BMA and the royal colleges are yet to respond.

Professor Sue Bailey, president of the Royal College of Psychiatrists, said: “On behalf of our members and patients, we will scrutinise these amendments carefully in order to make an informed decision on whether or not they address the very real concerns of psychiatrists.”

The college wants the Bill to ensure parity of esteem between mental health and physical health; a reduction rather than an increase in health inequalities; that integrated care is safeguarded over competition; that competition is only used in the NHS where it can be shown to clearly benefit patients; and, continuation of a system of effective postgraduate medical education and training.

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Communications technology vital but has risks

By Mike Broad - 1st February 2012 10:52 pm

Communications technology has become vital to the way hospital doctors work but concerns remain over patient confidentiality, research reveals.

The online survey, by medical defence body the MDU, shows that 99% of the respondents use some form of modern communications technology in their day-to-day work.

The most popular use of technology was for emailing other members of staff with 92% of doctors stating that they do this, while 64% track test results electronically and 63% use the internet to research patient symptoms.

Sixty eight per cent of hospital doctors also revealed that they had recommended a telephone ‘app’ or website to a patient, an indication of the perceived benefit to patient care.

However, many of the doctors surveyed also expressed concerns about the impact that modern technology could have on patient confidentiality, with 41% stating that they were concerned about this aspect of patient care.

Dr Mike Devlin, head of advisory services at the MDU, welcomed hospital doctors’ embrace of communications technology and its benefits but warned that technology brings new risks and threats.

“It is important that any technology employed does not threaten a hospital doctor’s ethical and legal responsibilities,” he said. “A full assessment of confidentiality and security of data should be undertaken and appropriate policies and procedures put in place.  In addition, doctors should ensure that the use of technology complies fully with any policy that their NHS trust may have in place, many of which do not allow patient-identifiable information to be held on personal IT devices or equipment.”

Other findings from the survey include 44% of hospital doctors use a smart phone; 64% of consultants use a laptop; and, 8% of hospital doctors are using Twitter for work.

Read tips on managing the use of communication technologies.

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“Can we afford consultant delivered NHS?”

By Francesca Robinson - 31st January 2012 3:08 pm

A review which provides new evidence that a consultant-delivered health service improves the quality of patient care has provoked debate over its affordability and whether the consultant contract is out-of-date.

The report, by the Academy of Medical Royal Colleges (AMRC), cites over 70 relevant studies and written and oral evidence from professional organisations and individuals on the benefits of a consultant-delivered care throughout the week.

But it warns that to deliver this gold standard the NHS would be unlikely to be able to afford the required increase in consultants.

However, the BMA argues that the UK cannot afford not to provide consultant-delivered care and that everything the AMRC makes a case for could be delivered within the terms of the existing consultant contract.

The report says the key benefits of consultant-delivered care are: rapid and appropriate decision making; improved outcomes for patients; more efficient use of resources; better access for GPs to the opinions of fully trained doctors; improved patient expectation of access to appropriate and skilled clinicians and better training for junior doctors.

But to achieve consultant expansion the NHS has to address the affordability of an increased number of doctors coming through training. Since 1995 the number of consultants has doubled from 18,000 to 36,000 and the number of trainee doctors has risen from 27,000 to 51,000.

If current trends continue there could be an increase of over 60% in the fully trained hospital doctor headcount by 2020. If all eligible doctors become consultants this could raise the consultant pay bill to £6 billion, £2 billion more than the 2010 bill.

The report says that delivering a meaningful consultant-delivered service would require changes to traditional models of service delivery and some “reshaping” and “layering” of consultant careers and working patterns.

It says: “It could be argued that the funding of such consultant expansion is a priority for the country. However, the realities of the current economic climate and, in particular, the financial pressures on the NHS make this unlikely.”

Dr Ian Wilson, deputy chairman of the Consultants Committee, said the report added new evidence to the case for a ‘consultant-present’ service the BMA and many other organisations had been arguing for over many years.

“While some people say we cannot afford a consultant-based service I would argue we can’t afford not to have one - given the consequences of reduced quality, poorer outcomes and increased risks if you don’t have one.”

He pointed out that a shift towards providing more consultant-delivered care had already occurred in some areas of the country and in some specialities such as paediatrics, obstetrics and anaesthetics

“It doesn’t need a new contract. Everything the Academy is arguing for is completely deliverable within the terms and conditions of the existing consultant contract,” said Wilson.

He said a new guide to consultant job planning produced jointly by the BMA and the NHS Employers was now available to give trusts and consultants all the support they needed to deliver change.

“When we work together we can deliver profound and sustainable change. This report adds a huge amount to the debate about a consultant-present service. It is really well thought through and now needs to be properly debated, planned for and paid for,” said Wilson.

Prof Terence Stephenson, AMRC vice-chair, said: “The weight of evidence makes it clear that it can no longer be acceptable for some patients to have to risk poorer outcomes because consultants may not be available at some times of the day or week.

“This will mean changes to the working patterns of consultants but also to how services need to be staffed and configured in a local area to provide safe care.”

Read The benefits of consultant delivered care.

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Radiologists voice opposition to Health Bill

By Mike Broad - 30th January 2012 9:21 pm

The Royal College of Radiologists has joined the BMA, the Royal College of Nursing and Royal College of Midwives in opposing the passage of the Health and Social Care Bill.

The RCR says the Health Bill does not currently contain a clear duty on health secretary to take direct responsibility for the provision of comprehensive and equitable healthcare for the whole of the population of England.

A statement from the College said: “Recognising that whilst competition has for some time played a role in the NHS, we remain alarmed that the dangers of unfettered competition as outlined in the Bill will adversely affect integrated care in both clinical oncology and clinical radiology.”

It added that there is “great risk of widespread, and potentially embedded, health inequalities across the NHS”.

Meanwhile, a YouGov poll this week finds that 78% of 1,600 medical professionals believe the Health Bill plans will exclude more people from healthcare.

Seven out of ten think it will lead to patient charges for basic services such as ambulance, cancer screening and maternity care.

Commenting on the survey, Dr Helena McKeown, a GP from Wiltshire, said: “This poll shows what anyone who works in the NHS has known for months - Lansley’s plans are a disaster for patients. 84% have no confidence that the right balance between competition and collaboration will be struck as Lansley claims, so it’s no surprise that only 13% of NHS staff surveyed think he’s doing a good job - he’s not.”

The hardening in opposition follows the Academy of Medical Royal Colleges’ (AMRC) eleventh hour about face on publicly opposing the Health Bill. Behind the scenes ministers accused the colleges of becoming too political, and the Royal College of Surgeons maintained its support for the Bill.

The RCR statement adds: “Clinical radiology has already seen the negative impact of outsourcing on integration. Procuring radiology services from different sources would have a hugely detrimental impact on integration adding costs to the NHS overall.

“In a tertiary specialty such as clinical oncology, fragmentation will impact negatively on the capacity to deliver coherent care locally. It will also undo the excellent national co-ordinated patterns of care achieved through the cancer agenda. The capacity to deliver the right care in the right place to the right patient would be seriously undermined.”

The developments follow a series of high level talks last week including a parliamentary meeting of the royal colleges and others chaired by Lord Owen, and another between the BMA, the Royal College of Nursing and the AMRC.

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Private healthcare providers feeling the pinch

By Mike Broad - 10:46 am

The private acute healthcare industry is facing contraction despite the potential for NHS work increasing, according to analysis.

Laing & Buisson’s Healthcare Market Review shows that revenues generated by independent hospitals providing medical treatments in 2010 were flat at £3.84bn.

The main funding source for independently run hospitals is patients with private medical cover. However, the proportion of business accounted for by this audience has slipped consistently over the past five years, accounting for just 59% (£2.3bn) of revenues generated in 2010 - compared to 65% in 2005.

NHS patients using private facilities now account for a quarter of hospital income (compared to 14% in 2005) generating £957m. Latest analysis, though, suggests that this source - which has bolstered market fortunes in recent years - may be reaching a cyclical high.

Pay-as-you-go patients provided 14% of revenues (£534m) for independent medical hospitals, up by 0.5%. Other sources contribute the remaining 2.5% (£104m).

In addition to static income, the report suggests that competition is increasing. It reported a record 515 independent medical hospitals at mid 2011, compared with 454 in mid-2010. Of these, 211 offer 9,545 inpatient beds and 304 provide only day surgery. In addition, 73 private patient units within NHS hospitals also compete for a slice of the private healthcare market.

Co-author Philip Blackburn said: “There are certainly near term challenges for service providers of private acute healthcare under current market conditions, but also opportunities in the longer term.

“Delivery efficiencies from providers are being solicited, not least from medical insurers, which are seeking savings to pass on to their customers, and the recent OFT report, which found evidence of potential competition limiters in the provision of private healthcare by hospitals and consultants.”

The report also says that with the government’s proposed increase in the private patient income cap to 49% for the NHS, independent hospitals will also face competing interest from this area, though there is certainly limited scope for increased private healthcare capacity at this time.

The independent acute sector is estimated to have treated around 425,000 NHS (overnight and day case) patients in 2010. Centrally procured ISTC activity decreased only marginally in the year to £357m (2009: £365m) with Care UK, Circle and UK Specialist Hospitals the largest scheme providers during 2010, accounting for 35%, 18% and 16% respectively of the total centrally procured services.

During the period 15 schemes came to the end of their initial contracts, while two new large scale facilities carried out their first full year of activity. Revenues from centrally procured schemes are expected to dip more significantly in 2011 as a further 13 schemes are due to expire.

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Juniors being ignored on service improvement

By Mike Broad - 27th January 2012 9:43 am

Junior doctors in the NHS are willing and able to help improve health services, but they don’t feel valued or heard, a survey reveals.

The report authors suggest junior doctors are “an untapped NHS resource” at a time when the NHS needs to draw on all the help it can get.

The survey asked juniors a range of questions about their working life, including their views on their role and future.

Ninety per cent of the 1,500 respondents said it was “extremely” or “very important” to feel part of a team in their NHS organisation, with a similar proportion answering that doctors needed to be effective leaders to  “a very great” or “great extent.”

But despite nine out of 10 respondents saying that they had ideas for ways to improve services, only one in 10 said they had had their ideas implemented.

Forty four per cent had tried and failed to get an idea implemented or felt unsure how to go about it.

Lead researcher Dr Alexandra Gilbert, department of clinical oncology, St James’s University Hospital, said: “We have demonstrated that the junior doctor medical workforce has both the desire and the ability to start contributing to improvement in the NHS, but feels that the environment in which they work is not sufficiently receptive to their skills.”

When asked how valued they felt, overall, more than 83% of juniors said “not valued at all” or only “sometimes valued.”

Seventy eight per cent felt undervalued by their chief executive, a similar proportion felt undervalued by their employing organisation, while 79% felt undervalued by the NHS as a whole.

While three quarters did feel highly valued by their non-consultant medical colleagues, almost 60% said they did not feel equally valued by senior consultant colleagues, the research in BMJ Quality and Safety finds.

The authors say that their findings indicate that junior doctors are adapting to new roles within the NHS, but feel unable to realise their full potential as agents of change.

They point out that junior doctors frequent rotations between different hospitals, organisations, and specialties enable them to readily spot good and bad practice, and that all doctors on the frontline have a key role in improving the quality of care.

The research concludes: “If the government is to achieve the aim of improving productivity and quality in the NHS on a restricted budget then all employees need to feel valued and engaged to optimise organisational performance.”

Read the report.

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Doctors must not sign up to ‘gagging clauses’

By Mike Broad - 26th January 2012 10:03 am

Doctors cannot enter into contracts or agreements with ‘gagging clauses’ and have a duty to act when they believe patient safety is at risk, new GMC guidance stipulates.

The new guidance Raising and acting on concerns about patient safety seeks to increase doctors’ sense of responsibility for the care they witness and to encourage ‘whistleblowing’.

The guidance explains when doctors need to raise concerns if patient safety is at risk, or when a patient’s care or dignity is being compromised, and advises on the help and support available to them, including how to tackle any barriers that they may face.

Niall Dickson, chief executive of the GMC, said: “These clauses are totally unacceptable. Doctors who sign such contracts are breaking their professional obligations and are putting patients, and their careers, at risk.”

Doctors also have responsibility for the safety and wellbeing of patients when performing non-clinical duties - including when they are working as a manager. New guidance Leadership and management for all doctors has also been issued with the aim of helping doctors understand their responsibilities in relation to employment issues, teaching and training, as well as planning and using and managing resources.

Responding to the guidance, defence body MPS said employers had to do more to support doctors in raising concerns and remove “the barriers”.

Dr Stephanie Bown, director of policy and communications at MPS, said: “We receive calls from members who have seen things that cause them concern, and who are seeking clarification about what to do. Unfortunately many express fear about the potential consequences of ‘rocking the boat’ and that they might be penalised for speaking up.

“The readiness of doctors to fulfil this professional responsibility has been clouded by fear of the potential consequences. It’s unacceptable for organisations and clinical leaders to simply pay lip service to ‘raising concerns’ about patient safety - they have to live it and they have to lead by example.”

The GMC’s new local liaison service will use the guidance and work with medical directors, doctors and patients groups to help foster openness and a willingness to speak out.

Dickson said: “Being a good doctor involves more than simply being a good clinician. It means being committed to improving the quality of services and being willing to speak up when things are not right - that is not always easy but it is at the heart of medical professionalism.

“Our new guidance also makes clear that doctors must not sign contracts that attempt to prevent them from raising concerns with professional regulators such as the GMC and systems regulators, such as the CQC. Nor must doctors in management roles promote such contracts or encourage other doctors to sign them. Those who promote or sign such agreements are breaking their professional obligations and putting their careers at risk.”

The guidance comes into effect on 12 March 2012.

MPS’s Brown added: “It is not about an organisation having a ‘policy folder’ that they dust off when there is an issue, it’s about the organisation developing the type of working environment which encourages and supports their staff to raise concerns openly, following the appropriate procedure.”

Read the raising concerns guidance and leadership guidance.

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Mistrust clouds specialists’ role in NHS reforms

By Francesca Robinson - 25th January 2012 12:15 pm

GPs fear that secondary care specialists will dominate the decision-making process if they are involved in clinical commissioning, claims a new report.

Primary care doctors also question whether the bureaucracy and costs involved in securing specialists for clinical commissioning group (CCG) governing bodies would produce any significant benefit.

The report, by a group called the Specialists in Commissioning Network, part of the NHS Alliance, argues that current policy on involving specialists in the NHS reforms and clinical commissioning is ill thought out.

It says Department of Health proposals for involving specialists in CCGs, clinical senates and in helping to develop and support clinical networks risks creating mistrust and professional barriers between primary and secondary care.

Some GP leaders, for example, have expressed concerns that if specialists are recruited on to the proposed new clinical senates they would interfere with effective clinical commissioning. The Health Bill proposes that 15 senates should be created to enable doctors and other professionals to come together to give expert advice on how to ensure that patient care is improved in an integrated way.

The report’s author, Dr Irani Minoo, a consultant paediatrician at Berkshire Healthcare Foundation Trust and a member of the Paediatricians in Medical Management Committee of the Royal College of Paediatrics and Child Health, says another problem is the lack of clarity about how much specialists on CCG governing bodies would be paid.

Either way this is likely to be complicated - if hospital trusts are to be remunerated for all the time required by their specialist doctors to be involved in CCGs the costs for CCGs may be prohibitively high.

On the other hand if all members of CCG governing bodies (including GPs, nurses, specialist doctors and lay members) are paid at the same level then hospital trusts may not actively encourage their most senior, experienced and expensive specialists to apply for these positions.

Irani says that specialists have said little about the policy to involve them in commissioning. Early indications are that specialists remain unconvinced that their time would be best spent sitting on CCG boards unless a specific function was identified for them.

Practising specialists would be required to serve on CCGs well outside the geographical area where they work and the time commitment involved in traveling to these meetings could be another barrier. Some specialists feel their knowledge and skills would be better utilised by CCGs in discussions about commissioning for high quality local services rather than in trying to influence governance of CCGs outside their localities.

However there are consultants and other senior career grade specialist doctors who feel they should be involved in CCGs because only they are the only doctors qualified to effectively challenge poorly evidenced decisions about commissioning specialist services.

Also secondary care doctors providing highly specialist services at regional level (spanning several CCGs) are concerned that CCGs may not understand the complexity or need for some of these specialist services to be provided at population levels beyond individual CCG boundaries.

Irani concludes: “The potential contribution of specialist doctors to the NHS reforms and especially clinical commissioning appears to have been explored by policy makers somewhat as an afterthought.

“Specialists have an important role to play in supporting clinical commissioning. Simply making proposals for specialist involvement in CCGs, senates and networks, but not providing clarification or policy guidance, can create misunderstanding between GPs and specialists and risks creating barriers to collaboration on a range of issues which are crucial for the future of the NHS.”

The BMA, Hospital Consultants and Specialists Association (HCSA) and the Royal College of Physicians, have all called for specialists to be given a role in commissioning at both national and local levels.

HCSA chief executive, Stephen Campion, said a lot of consultants would be interested in doing this type of work, especially the younger ones who would welcome the chance to take on a new role that was stimulating and broadened their expertise.

However, the reality was that many consultants were prevented from doing extra work like this. The HCSA has heard examples of consultants being prevented from working for their royal college or for the Department of Health because their employing trusts were not prepared to give them time off as they did not see it as part of their role to pay for it.

“What you would expect to happen is that consultants who have reached a specialist level should be in a position to share their expertise with the wider NHS community as well as the employer that employs them. The NHS needs to understand that there is wider expertise that the consultant can bring to the NHS other than the mechanics of being a doctor,” said Campion.

Read the full report.

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Health Bill distracting NHS from making savings

By Mike Broad - 24th January 2012 11:12 am

Service integration to deliver the Nicholson Challenge is more important than NHS reform say MPs on the influential Health Select Committee.

The report on public expenditure, by the cross-party committee, says the reorganisation process in the NHS continues to complicate the push for efficiency gains. NHS chief executive David Nicholson wants £20bn of savings by 2015.

The MPs say that, although the push towards GP commissioning may have facilitated savings in some cases, it more often creates disruption and distraction that hinders the ability of organisations to consider truly effective ways of reforming service delivery and releasing savings.

The report expresses concern that trusts are currently making savings through “salami-slicing” existing processes and services instead of rethinking and redesigning the way services are delivered.

The Nicholson Challenge can only be achieved through a wide process of service redesign on both a small and large scale, the report says. These changes should not be deferred until later in the Spending Review period: they must happen early in the process if they are to release the recurring savings that will be vital in meeting the challenge.

Commenting on the report, Sir Richard Thompson, president of the Royal College of Physicians, said: “We agree that meeting the £20bn efficiency savings at the same time as dealing with the increasingly elderly population is a difficult challenge for the NHS. It is crucial that the proposed reforms help services meet this challenge, rather than distract from it. The government has failed to set out clearly how this will be achieved.

“While improving efficiency, the NHS must still at the same time invest in quality. A key priority is to provide consultant delivered care, which would both improve standards and patient experience, and save money. The health reforms must also improve the process for making decisions about service reconfiguration, for this will increase the availability of consultants, and facilitate seven day infrastructure to underpin consistent patient care. Clinicians and local communities should lead those decisions.”

The MPs says that more integration of services is vital. While the separate governance and funding systems make full-scale integration a challenging prospect, health and social care must be seen as two aspects of the same service and planned together for there to be any chance of a high quality and efficient service being provided which meets the needs of the local population within the funding available.

Dr Hamish Meldrum, chairman of BMA council, said: “Better integration of care is key to improving patient care yet many of the implications of the Health and Social Care Bill, including the government’s focus on competition, will make this harder to achieve.”

He described the Bill as a “distraction” and said it “is causing chaos on the ground even before the legislation has been passed. It is perhaps little wonder that those trying to make efficiencies are focussed on short-term issues, such as their job prospects, and making rushed decisions on savings rather than looking to the longer term”.

He added: “There is still time for the government to withdraw the Health and Social Care Bill - a bill which an increasing number of health professionals are opposed to - and work with healthcare professionals and others to agree a more pragmatic way forward.”

The MPs conclude that it is too early fully to assess the types of savings being made in 2011-12, the first year of the QIPP programme. However, the report says: “We are concerned that there appears to be evidence that NHS organisations are according the highest priority to achieving short-term savings which allow them to meet their financial objectives in the current year, apparently at the expense of planning service changes which would allow them to meet their financial and quality objectives in later years.”

Read the full report.

Read a blog on the Health Bill.

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