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Increased risk of death in weekend admissions

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.”

Tags: Consultants
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Low staff levels not only reason for death rates

By Mike Broad - 11th January 2012 8:28 am

Low staffing levels are not the only reason why mortality rates increase in hospitals at weekends, two leading experts claim on bmj.com.

Andrew Goddard, director of the Medical Workforce Unit at the Royal College of Physicians, and Peter Lees, founding director of the Faculty of Medical Leadership and Management, suggest that a contributory factor is that patients admitted at the weekend are sicker than those admitted during the week.

A recent report by Dr Foster Intelligence grabbed the headlines by supporting the hypothesis that only early assessment and intervention by experienced clinicians will result in improved weekend mortality.

The report compared hospital standardised mortality ratios (HSMRs) for patients admitted to English hospital trusts on two weekends in April 2011 with those admitted in the week, and showed a clear association between reduced numbers of senior doctors in hospitals and increased mortality at the weekend.

However Goddard and Lees’ editorial, on bmj.com, says that hospital coding (on which HSMRs rely) is not sensitive enough to allow correction for the patients being sicker at weekends.

Although patients with certain conditions - such as trauma, alcohol associated conditions, and self harm - are more often admitted at the weekend, the main reason that sicker patients are admitted at the weekend is variation in referral practice, the editorial says. Out-of-hours primary healthcare services have changed dramatically over the past decade in the UK, with increasing reliance on “emergency medical services” rather than patients’ own GP.

Provision of hospital support services is also reduced at the weekend, it says, so fewer interventional procedures, such as percutaneous coronary intervention for acute coronary conditions and endoscopy for upper gastrointestinal bleeding, are performed.

The editorial does acknowledge that even when factors are considered, the observation of increased mortality and low staffing levels cannot be discounted and pose a serious problem for the NHS - with the process of increasing doctor numbers being slow and expensive.

Emerging data show that working patterns for consultants influence mortality, with hospitals in which the admitting consultants work blocks of more than one day have lower excess weekend mortality than those with a ‘physician of the day’ model. It also calls for research into which specialties could deliver the most benefit.

The number of medical registrars (who run most hospitals at night) could easily be the defining predictor of hospital mortality, it says, despite current plans to reduce their numbers.

“This may need to be re-thought but, given the potential profound impact on clinical outcomes, decisions must be based on sound evidence,” it says.

It also suggests the problem is more significant in hospitals in the north of England.

The editorial concludes that the Dr Foster report raises more questions than it answers and calls for greater insight into community out of hours services, hospital staffing, and workforce configuration. “All need to be reviewed against the knowledge of which conditions are associated with increased mortality at the weekend. This is an opportunity that, if tackled intelligently, will improve the care of some of our sickest patients for many years to come.”

Tags: Consultants, Mortality rates, Out-of-hours
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Physicians see unpaid work hours increase

By Mike Broad - 14th December 2011 11:11 am

Consultant physicians are increasingly working above and beyond their contracted hours, a census reveals.

The study, by the Royal College of Physicians, suggests that the NHS is increasingly relying on consultants’ goodwill to deliver the service that patients need. It also shows that the amount of time consultant physicians have available to spend with trainees is decreasing.

Each week, consultants are working an extra 11.5% of their contracted hours for free. This figure jumps to 14% for doctors who work part-time. This ‘goodwill’ work accounts for the equivalent of 1,450 fulltime consultants, up by 205 compared to 2009.

The census also shows that some specialties are experiencing low levels of growth in consultant numbers.

Dr Andrew Goddard, director of the RCP’s medical workforce unit, said: “Consultants contracted hours have fallen significantly as hospitals strive to save £20 billion over the next three years. Despite this, consultants continue to work the hours they have done in previous years and so the amount of goodwill work is increasing year-on-year.”

Despite working longer hours, 52% of consultants say that time available to spend with trainees has reduced during the past three years. This change is due to consultants spending more time doing jobs that would previously have been done by a junior doctor, the study claims.

“This is really worrying as the training of future senior doctors is vital to high quality patient care in the NHS,” Goddard commented.

The Working Time Regulations continue to be seen as responsible for the disintegration of the clinical team and training. The 2010 census, in addition to showing that the majority of consultants work more than 48 hours a week, also shows that 30% of departments do not work EWTD compliant rotas in practice - despite 95% being compliant on paper. Significant concerns are expressed in the census about the impact of the regulations on training and patient care.

Three quarters of physicians report that their work pressure had increased. Two thirds of consultants reported their job always, often or sometimes “got them down”.

The RCP is concerned that this is affecting consultants’ career planning. Just over half of consultants currently intend to retire at 60 years of age or younger and the main reason given was pressure of work.

Overall, consultant expansion slowed in 2010 to 6.7% from 10.2% in 2009. Much of this was due to a large increase in numbers in cardiology and respiratory medicine, with little expansion across other medical specialties.

There was no growth in geriatric medicine, which is of particular concern considering the ageing population of the UK. Although, the RCP explained that it may due to a re-classification of geriatricians as stroke physicians.

Read the full study.

Tags: Consultants, General medicine
Posted in Hospital Dr News | 1 Comment »

More consultants would improve weekend care

By Mike Broad - 28th November 2011 10:38 am

Patients are less likely to get treated promptly and more likely to die if they are admitted to hospital at the weekend, a report reveals.

Overall, 8.1% of those admitted at weekends died compared to 7.4% from Monday to Friday, once those having elective operations such as hip and knee replacements were discounted, the Hospital Guide - by health information company Dr Foster - suggests.

Doctors’ representatives are pointing to the report as evidence that the government must continue to support growth in consultant numbers.

The report says the chances of survival are better in hospitals that have more senior doctors on site. But some hospitals have too few senior doctors in hospital at weekends or overnight.

The report calls for re-organisation of services to ensure safe care 24/7. Examples of innovation from Poole, London, and Northumbria show this can be done to ensure access to high quality services at any time of day or night, it says. Local A&E departments need to identify the services they can provide safely and link with others to provide the services they can’t.

Hospital Guide provides an assessment of hospitals on four key measures of mortality. Chelsea and Westminster Hospital NHS Foundation Trust stands out as the only hospital with low rates on every measure. At the other extreme, Hull and East Yorkshire Hospitals NHS Trust is notable for consistently high rates, the report claims.

The four measures are:

Hospital Standardised Mortality Ratio (HSMR) - a measure of in-hospital deaths;

Summary Hospital-level Mortality Indicator (SHMI) - a measure of mortality both in-hospital and for deaths outside of hospital within 30 days;

Deaths after Surgery - surgical patients who have died from a possible complication; and

Deaths in low-risk conditions - deaths from conditions where patients would normally survive.

Roger Taylor, director of research and co-founder of Dr Foster, said 19 trusts showed high mortality rates.

“A safe NHS is an NHS that provides care 24/7. This year’s guide shows we are some way from that target with significantly reduced services at weekends and nights,” he said.

“However, fewer people died in 2009 than in any year since the mid 1950s - despite the population being larger and older. A large part of that success is down to improvements in care with in-hospital mortality rates falling steadily over the last 10 years.”

The Hospital Guide also identifies 31 trusts that have an above expected rate for not treating hip fracture patients within the recommended two days of admission.

Commenting on the report, Sir Richard Thompson, president of the Royal College of Physicians, said: “At last we have data that clearly links higher numbers of senior doctors in hospitals at the weekend with lower mortality rates. Over the past 10 years the number of doctors in the NHS has steadily increased and it is therefore not surprising that mortality rates have fallen.

“We must ensure that consultant numbers continue to increase to allow higher levels of staffing at the weekend in all hospitals. The findings support the RCP’s 2010 recommendation that any hospital admitting acutely ill patients should have a consultant physician on-site for at least 12 hours per day, seven days a week. No other duties should be scheduled during this time.”

Tags: Consultants, Patient safety
Posted in Hospital Dr News | 1 Comment »

Hospital doctors’ pay scales for 2011/2012

By Mike Broad - 15th November 2011 4:12 pm

In summer 2010, the new Chancellor announced a two-year public sector pay freeze from 2011/12.

Consultants were already experiencing a pay freeze in 2010/2011, so their pay will not rise over a three-year period.

George Osborne followed this up in Autumn 2011 with a decision to cap public sector pay to 1% for the two years following the pay freeze.

The corresponding freeze in the value of clinical excellence awards will also continue. CEAs will be subject to change, and are likely to be reduced, following a review in 2011 by the Pay Review Body - which the government is yet to respond to.

NHS staff earning less than £21,000 will receive a flat pay rise worth £250 in both of the next two years. The Chancellor said the measures would save £3.3 billion a year by 2014-15.

While foundation year doctors, house officers, senior house officers, specialty registrars, specialty doctors, associate specialists and salaried GPs in England received a 1% pay rise for 2010/2011, they are now subject to the pay freeze.

In 2009/2010, all doctors received a 1.5% pay rise.

The government is also currently trying to impose reforms to the NHS Pension Scheme that would see doctors’ retirement age and pension contributions increase, while their benefits would decline.

Consultant salaries 2011/2012

Threshold 1, years completed as a consultant 0, £74,504, period before eligibility for next threshold one year

Threshold 2, years completed as a consultant 1, £76,837, period before eligibility for next threshold one year

Threshold 3, years completed as a consultant 2, £79,170, period before eligibility for next threshold one year

Threshold 4, years completed as a consultant 3, £81,502, period before eligibility for next threshold one year

Threshold 5, years completed as a consultant 4, £83,829, period before eligibility for next threshold five years

Threshold 6, years completed as a consultant 9, £89,370, period before eligibility for next threshold five years

Threshold 7, years completed as a consultant 14, £94,911, period before eligibility for next threshold five years

Threshold 8, years completed as a consultant 19, £100,446

Clinical excellence awards for consultants

Level 1 £2,957

Level 2 £5,914

Level 3 £8,871

Level 4 £11,828

Level 5 £14,785

Level 6 £17,742

Level 7 £23,656

Level 8 £29,570

Bronze/Level 9 £35,484

Silver/Level 10 £46,644

Gold/Level 11 £58,305

Platinum/Level 12 £75,796

Better outcomes with consultant-delivered NHS

By Francesca Robinson - 25th May 2011 10:27 am

An increase in consultants is needed to maintain a high quality health service, the BMA has told an inquiry into the benefits of consultant-delivered care.

But it warns that aspirations for a service delivered primarily by consultants could be “complicated” by the unpredictability of the government’s healthcare agenda.

Proposals to give employers in England greater responsibility for workforce planning are a key concern. “Individual employers are unlikely to have the expertise, insight or incentives to undertake effective workforce planning and training for the service as a whole,” says the written submission by the BMA consultants committee.

The Academy of Medical Royal Colleges (AMRC) launched its investigation because it says the debate about whether the NHS can or should afford this model of care is becoming increasingly important. It argues that there are real benefits in medical care delivered by trained doctors, who have a CCT or CESR, but the increasing numbers of doctors coming through training and the current financial climate present challenges.

Led by Professor Terrence Stephenson, AMRC vice chairman and president of the Royal College of Paediatrics and Child Health, the inquiry will focus on issues of outcome, quality and productivity and on the quality of service that patients should expect. “We recognise that this may require changes in the way that services are delivered and consultants currently work,” suggests the Academy.

The BMA says there is plenty of evidence to show that consultants provide high quality, cost effective care. Consultant involvement delivers improved outcomes and diagnoses, reduces bed requirements, achieves optimum value for money and improves patient satisfaction.

Consultants also provide leadership in service development in the secondary sector and it will be important to ensure that commissioning consortia to seek their input in the design of care pathways.

The 2000 NHS Plan recognised the need for a “consultant-delivered” service but the BMA says is prefers to promote the concept of a “consultant-based” service to avoid downplaying the role of SAS doctors.

Consultants are already delivering more of the service than ever before, says the BMA, because of an increase in designated teaching time for juniors, increased patient throughput, increased out of hours work and higher workloads resulting from a reduction in junior doctors’ hours.

The submission concludes: “Whilst changes have already taken place to the way in which consultants work in recent years, we believe that a further expansion in consultant numbers in required in certain specialties such as paediatrics and acute medicine in order to maintain and improve patient care.”

In its submission to the inquiry, the Royal College of Physicians argues that consultant-delivered care should be the preferred model. It says there is evidence that patients receive better care, fewer unnecessary investigations and may be discharged sooner if they are seen quickly by consultants in acute medical units.

Better outcomes are achieved when patients are seen daily by consultants on wards and consultant involvement in patient care reduces length of stay, follow up appointments and improves the quality of information that can be shared with patients and relatives.

The RCP cites evidence from London and Manchester hyper-acute stroke models where consultant-led care has resulted in higher thrombolysis rates and shorter lengths of stay - in London 40% of admissions go home within three days, over twice the rate in England as a whole.

The RCP also points to the Robert Francis Inquiry report into Mid-Staffordshire Foundation Trust, which highlighted the importance of the presence of consultants in the delivery of patients care to improve outcomes.

The AMRC will be hearing further oral submissions from a range of organisations and will be producing a report later in the year.

Tags: Consultants
Posted in Hospital Dr News | 3 Comments »

A disjunction between expectation and action

By Dr Mark Porter, chair of the BMA's consultants committee - 23rd March 2011 2:13 pm

The following is a summary of the annual address by the chair of the BMA’s CCSC to consultant members:

In my report to the 2010 conference, I talked of the newly formed government, the promises that they made to protect the NHS and the fierce retrenchment in public finances that was so obviously being planned. Health could not expect to be completely protected. Even then, the decommissioning of some services valued by patients was proceeding.

But still, the coalition government promised, as you will remember, that they would “stop the top-down reorganisations of the NHS that have got in the way of patient care”.

Well. It does seem so long ago now doesn’t it?

The coalition government also promised to “give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices…independent, voluntary and community sector providers.”

And then came the White Paper in which the promise was made bad with the single largest top-down imposed NHS reorganisation, ever.

We meet today one week after the BMA held a Special Representative Meeting. With the Health and Social Care Bill in committee in the House of Commons, BMA representatives from all parts of the country and all branches of medical practice came together in order to think about the implications of this Bill.

It has been relentlessly presented to the public as a move to put NHS money into the hands of doctors to spend wisely for their patients.

However, that is far from the whole truth, and may not even have represented a recognisable truth at all when we come to look back on this in ten years’ time.

That truth is that this Bill aims to transform the NHS by making the development of a market in health care the most important priority in the NHS.

That truth is the reason that the BMA decided not to support the Bill, a decision that was confirmed last week at the Special Representative Meeting.

And that truth is the reason why the government in proceeding has found itself having to ignore the advice and opinions of dozens of organisations, all saying that this is the wrong thing to do.

Why do we say this? Well, it is axiomatic that in order for competition to be meaningful, it must be possible and accepted that some organisations will fail.

Acceptance? It’s certainly been proved again and again that politicians have a strong aversion to allowing this to happen, particularly when they are anywhere near having to accept any responsibility for organisational failure. Or, as they think of it, respected local hospitals closing down.

However, this time they say that they mean it, and the legislation currently before Parliament would indicate that they do.

So what does organisational failure mean? The NHS Confederation has talked of the possibility of hospitals closing in the competitive environment. We have talked of destabilisation, of services being imperilled because of the cherry-picking activities of the alternative providers who might lever their way into the NHS marketplace.

But we are not alone in this. The government is often accused of developing policy in an evidence-free environment, but not in this case. The Department of Health has helpfully provided the evidence - not that competition will be good for healthcare, but evidence that competitive pressure can destroy the viability of some NHS services.

The effects of the current brutal resource reduction in the NHS were analysed in the Health Service Journal a month ago, building on the McKinsey work on NHS productivity from 2009, and later modelling by PricewaterhouseCoopers for the Department of Health.

You’ll all know that many local services are being closed or rationed by commissioners. If you have a Dupuytren’s contracture and live in Manchester, watch out. If you have a cataract and live in Croydon, you may not be able to watch out by the time the NHS thinks you’re worthy of surgery.

But these rationing lists are turning into something of a national initiative - and something that can be modelled by PwC.

It seems that on the most conservative commissioning assumptions about reducing low-priority services, 58 hospital trusts will be unable to cover the costs of entire service departments.

This is because of the effect of losing economies of scale, and of being left with unalterable fixed costs after removal of a proportion of variable revenue.

This situation gets even worse when one considers the toxic PFI legacy in the NHS - a legacy of modern facilities and buildings paid for by a completely inflexible fixed cost regime that will now undermine the viability of its own host. In some areas, the parasite will consume its host, and if that is not bad enough one can foresee the government baling out the private financiers who have made so much from PFI and who will have so little to lose.

This is the true cost of shifting care from NHS hospitals into the community or to alternate providers: no savings are made for the NHS as a whole, but what is left behind can become a financially unviable remnant with a greater proportion of fixed costs.

You couldn’t make it up could you? Simple to understand, easy, backed up by DoH economic modelling, but devastating in its effects upon a cash-limited health service forcibly opened up to commercial competition.

We have achieved government acknowledgment of the deeply-held and widespread concerns about price competition in the NHS and the Bill’s references to a maximum tariff, and amendments have been laid to remove this. Nevertheless, the government must move further to listen to the voices questioning their plans.

This government’s stubborn and obdurate refusal to listen is starting to look as if the purpose in this Bill is more the exercise of ideology and authority, than a desire to engage doctors in improving healthcare.

I want to consider money for a moment. We all know that in various ways across the United Kingdom, consultants are subject to a multi-year pay freeze. Since the government has not arranged to provide a freeze on the costs of living, this means that the freeze will remove about 11% of the purchasing power of our salaries.

For the government to then try to remove clinical excellence awards feels like special punishment for consultants. Punishment for consistently demonstrating performance at a level of excellence, but having the temerity to do so while working for the public.

Roughly 8% of the consultant pay envelope is paid out in clinical excellence awards, and we have debated the fairness of the scheme many times in this conference. I believe that for a profession to have a totally flat pay structure with no recognition of discretionary effort or ability would be a wholly extraordinary thing.

With that in mind, having about 8% of consultant pay invested in a merit scheme rewarding those who can demonstrate better outcomes in clinical care, leadership, innovation or quality control is surely a proportionate device.

One might even say that it is cheap at the price for a scheme designed to encourage aspiration, and this was certainly the view of the health departments until recently. Consultants are not asking for bonuses, the holding back and distribution of a percentage of short-term turnover. But consultants are asking to retain a valued scheme that rewards a career-long commitment to excellence in a public service profession.

Like many of you here, I am shocked that the tone and thrust of public discourse in this country is so antagonistic towards the public sector and those of us who work in it. As professional people exercising a great deal of skill and dedication for our patients, we are rewarded at what remain - just - reasonable rates.

We can justify what this pay rewards by looking at the length and difficulty of selection and training for our jobs, along with the constant vigilance of high professional standards and continuous lifelong learning.

But to listen to some commentators one would have thought that we just moved stuff from one place to another and skimmed a percentage while doing so.

The Public Accounts Committee of the House of Commons published a report last week on the management of NHS hospital productivity. Among its conclusions was that over the last decade - the decade of Labour’ NHS Plan - hospital productivity has fallen by 1.4% per year. That is to say, value for money is going down. Further, the committee felt that one of the reasons for this was the failure to manage consultants appropriately.

They’re not the only people to say this. The Audit Commission and others have been there before.

This is uncomfortable stuff. You’re all sitting there thinking of reasons why this may be.

And yet, the reason is contained on the first page of the summary - the bit that no newspaper or government spokesman managed to pick up, even though it was the Department of Health that provided it.

Productivity is defined as the ratio of the volume of resources put in, to the quantity of healthcare put out, adjusted to reflect their relative costs and quality. And yet there is no agreed method of accounting for quality improvements made by the health service - by you and me.

So, let’s consider our NHS in 2011. To quote, “One of the things that we’ve done over the last few years is to increase the amount of face-to-face contact time between clinicians and their patients. So, [consultants] now spend more of their time face-to-face with patients than ever before and each individual patient is seeing more time. None of that is reflected in the kind of figures that we have there.”

That citation was from Sir David Nicholson, the NHS chief executive, giving evidence to the Public Accounts Committee.

And he’s right. He went on to talk of a patient’s care being devised and planned by a multidisciplinary team of several consultants, giving better specialist care than one individual consultant and yet consuming more resources to do so - so despite quality increasing, the report has productivity going down.

Let’s think about the 1.4% that so upset the Public Accounts Committee. 1.4% of an operating list is a little over three minutes. Do three operations and it’s one minute per case. Invest that one minute doing the now mandatory surgical safety checklist - team brief, sign in, time out and sign out - and a bean-counter will tell you that your productivity has gone down by 1.4%.

But someone who knows what they are talking about will realise that you have made a real improvement in the quality of care by adhering to the best professional recommendations on safety of care. Oh, and following the government’s instructions, of course.

There is a theme here. It is that those who govern us expect much from us, and yet refuse to provide the means for us to do it.

They expect us to embed safety protocols in care, and then say we are less productive.

They expect us to reflect on the quality and safety of medical care, and then increasingly refuse to allow us the SPA time to do that.

They expect us to develop an integrated and comprehensive service, and then encourage the transfer of the profitable bits to any willing provider.

It is this disjunction between expectation and action, between what is said and what is done, that is so demoralising for consultants.

The challenges are many and there has not for a long time been such a need for a strong BMA to face them, or to provide a shield and support to its members.

Tags: Consultants
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“More consultant cover needed out-of-hours”

By Mike Broad - 2nd December 2010 9:58 am

Senior doctors need to be more available to work in acute admissions units, a survey finds.

The research, by the Royal College of Physicians, on the way care for very ill patients is managed recommends that hospitals need to increase the out-of-hours availability of consultants for acute care.

Care for very ill patients has improved significantly over the past few years due both to the introduction of acute medical admissions units in most major hospitals, and a major increase in the number of consultant physicians specialising in acute medicine to assist other hospital specialists working in acute medical admission units.

Despite these changes, the RCP says, many patients are only seen once per day in a formal ward round instead of the recommended two daily ward rounds. In three quarters of the acute medical admissions units accepting patients directly from GPs, there are regular bed shortages, so the report recommends that there are sufficient beds in future to ensure that very ill patients gain appropriate access to acute admissions wards.

Sir Richard Thompson, the new president of the Royal College of Physicians, urged the government to address the standard of care in hospitals in the evenings and at weekends. He said new working patterns are needed.

Forty eight per cent of consultant physicians responsible for assessing and treating the acute take still have to do routine clinics or other parts of their job as well as at the same time seeing the urgent patients. These duties should be cancelled on those days to allow physicians to concentrate wholly on the very ill patients.

Only 3% of hospitals provided weekend cover from consultant physicians specialising in acute medicine for nine to 12 hours and none for over 12 hours. Nearly three-quarters of hospitals in the survey had no cover from consultant physicians specialising in acute medicine over the weekend.

An accompanying statement from the RCP council recommends that consultant physician cover is available in hospitals every day for 12 hours per day.

Dr Jonathan Potter, clinical director of the RCP’s clinical effectiveness and evaluation unit, said: “Despite improvements in facilities and staffing, hospitals still need to address working arrangements to ensure that senior doctors are readily available to provide a consultant led service in acute medical admissions units seven days a week.”

Previous studies show that a consultant-delivered service is best for patient treatment and recovery.

Representatives of 126 hospitals completed the survey - 114 from England, six from Northern Ireland and six from Wales.

Read the RCP president’s blog on the issue.

Tags: Acute medicine, Consultants, Out-of-hours
Posted in Hospital Dr News | 4 Comments »

Patients deserve better out-of-hours care

By Sir Richard Thompson, president of the Royal College of Physicians - 9:52 am

For many years now the Royal College of Physicians has been working to improve acute care in hospitals, from creating the specialty of acute medicine to producing two major reports.

As a result, there have been major improvements in the organisation of acute care, but there is mounting evidence of poor care being delivered at night and at weekends, particularly the recent NCEPOD reports.

It is clear we need to do something extra to increase the amount of care delivered by consultant physicians.

Last week the RCP council agreed to recommend for the first time that any hospital admitting acutely ill patients should have a consultant physician on-site for at least 12 hours per day, seven days a week, who should have no other duties scheduled during this time. All medical wards should have a daily visit from a consultant; in most hospitals this will involve more than one physician.

We know that doctors are already working long hours - our latest census results say an average of 50 hours a week, which is four and a half hours more than their contract. More than half of those surveyed were working longer than the 48-hour limit set by the European Working Time Directive.

We are not expecting anyone to work longer than that, nor to increase their hours overall, instead we need to change job plans to reflect the different working patterns, which must include arrangements to ensure adequate rest.

The Department of Health are also considering policy in this area, and I have asked health secretary Andrew Lansley for a meeting to discuss the issue.

“Consultants must work more flexibly”

By Mike Broad - 9th June 2010 1:22 pm

Consultants hold the key to solving juniors’ lack of access to training following the implementation of the European Working Time Directive, a government-commissioned review finds.

The review, chaired by Prof Sir John Temple, acknowledges there are problems but suggests that they will not be eased by either increasing trainees’ work hours beyond 48 hours nor lengthening training programmes.

Instead, the Temple review suggests that rota gaps can only be overcome with a fundamental change in the way training and services are delivered. It says that, despite a 60% increase in consultant numbers over the past 10 years, hospitals remain reliant on juniors to provide out-of-hours services.

Sir John recommends a move to a consultant delivered service, with seniors more directly responsible for the delivery of 24/7 care.

Training should continue to be delivered in a service environment, says the review, called Time for Training, with appropriate consultant supervision. But, consultants should be prepared to work more flexibly and place a higher priority on training juniors.

It says some specialties, such as obstetrics and paediatrics, have already moved to more flexible consultant working, allowing trainees to gain experience under supervision.

Sir John said: “I recognise that the WTD may be reviewed in due course. However, the transformation of training needed now is paramount and must be addressed regardless of any modifications in order to produce well-trained professionals for the future.

“Training is patient safety for the next 30 years.”

The Temple review says trainers and trainees must use the learning opportunities of every clinical situation, with handovers being an effective learning experience when supervised by consultants.

Services must be designed and configured to deliver both high quality patient care and training. It suggests that reconfiguration of elective and emergency services, and an effective Hospital at Night programme, are two ways to support training. And rotas require organisation and effective management to maximise training opportunities.

However, the Temple review warns that as the ratio of trainees to consultants changes with increasing consultant numbers, it may no longer be feasible to train in all hospitals.

Dr Shree Datta, chair of the BMA’s junior doctors committee, commented: “The report makes it clear that high quality training can be delivered within the constraints of the 48-hour working week, however, this is dependant on implementing the recommendations in full. It cannot simply be put on a shelf to gather dust.

“It is also essential that there is an emphasis on resolving the problems faced by doctors working in specialties where the impact of the WTD on training is most severe. Seeking the input of those worst affected, such as surgical trainees, will be key in improving the opportunities for training at work.”

Earlier this year a BMA survey claimed that half of juniors were missing out on training opportunities following WTD implementation.

Mr John Black, president of the Royal College of Surgeons, said: “We are relieved that this report openly acknowledges that the WTD has critically damaged medical training in the UK. However, we are deeply disappointed that the remedies proposed are unworkable. It is unrealistic to put training concerns above those of patients and there are not the bottomless resources available to fund these proposals. The one obvious solution for the acute specialties - that of removing the WTD itself - is not assessed at all.”The Temple review recommends that consultants, in substantive roles, should remain clinically responsible for service delivery and training. “An expansion of any other grade will not support the move to a consultant-delivered service model,” it says.

Tags: Consultants, Rota gaps, WTD
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