‘Personal Views on Healthcare in Wales’
Sue Hill, Royal College of Surgeons England
What’s not to like? A seven day fully functioning NHS. Preferably fully functioning twenty four seven!
In 2012 the Academy Of Medical Royal Colleges UK set up a group chaired by the then President of the Royal College of Surgeons of England. This group recognised the benefits of consultant care and emphasised those benefits should be available to patients seven days a week. (Seven Day Consultant Present Care. Academy of Medical Royal Colleges December 2012). This publication gained media attention very rapidly, and the aspirations of the Academy document became misinterpreted and understood to propose 24/7 care across the board. As debate intensified the Chairman of the Academy group, Professor Norman Williams clarified the recommendations of the steering group (NHS England blog, October 2013). In fact these recommendations were relatively modest: That if necessary hospital patients should see a consultant at least once daily, that consultant supervised interventions, investigations and reports should be available daily if they would change a patient’s outcome or care status, that support services in hospital and the community be available daily.
Thus the original Academy Steering Group was not really proposing anything particularly revolutionary. Most consultants are contracted to provide care as part of a rota which involves weekends. In the case of surgeons, the majority of consultants in specialties with a high emergency workload such as General and Vascular Surgery expect to see patients daily throughout the week. It follows, that recommending that patients who need to see a consultant on a daily basis should do so, does not require a massive change in working practice.
The second recommendation, that investigations and interventions which will change the outcome for a hospitalised patient should be available seven days a week, seems perfectly reasonable. In practice, most investigations which fall into such a well defined group are available.
I would suggest it is the third recommendation which is the most difficult to achieve. I would also suggest that being able to implement it would be the single action which would have the biggest effect on the overall functioning of the NHS. Across the NHS, and, latterly in Government the realisation has dawned that it is only by improving social care that the Service will be able to work to its full capacity. Unless frail patients stop being admitted to hospital because there is nowhere else for them to go, and are not delayed in hospital while an appropriate care package is organised, they will continue to cause delays in the unscheduled care system, and block beds.
This being the case, the pledge made prior to the 2015 UK election for “routine NHS services being made available seven days a week by 2020” (David Cameron), shows a lack of understanding with respect to the complexity of the issues. First and foremost in a hospital with virtual 100% bed usage there is no capacity for increased through put of patients. The weekend hiatus with respect to elective services at least allows some time for patient turnover.
The next most obvious shortcoming with respect to the open all hours model of NHS working, is that in an environment where working times are limited and recruitment is rarely full, spreading the available staff across seven days, let alone with a longer working day, would be challenging. There is much talk of more efficient working practices, but moving from a five day to a seven day working week even without extension of the working day must add 40% to the budget, if only in wages?
The premise of seven day working in the National Health Service was to a great extent predicated on the data from HES (Hospital Episode Statistics)demonstrating higher surgical mortality for weekend admissions. However interpretation of the data is complicated, and recent data concerning emergency Vascular Surgery, a specialty with very high level of consultant involvement in emergency cases (over 90%), confirms that there is a higher surgical mortality at weekends, but there is no difference in the proportion of patients dying on any day of the week (RCS Bulletin March 2017). It is suggested that the increased mortality at the weekend is not due to lack of consultant input but rather that the individuals who have to be operated on at weekends are those with the most serious and high risk conditions who by definition have a higher death rate. Between Monday and Friday a proportion of unscheduled surgical admissions will be dealt with on a routine operating list. At the weekend the cases operated upon are the true emergency cases who need immediate surgery and have a high associated risk.
Another article in the same RCS Bulletin further suggests rolling out seven day routine surgical services might be more complicated than imagined. Elective weekend operating was studied with respect to the effect it had on the emergency workload; by stretching the resources both human and infrastructural the risk to emergency patients could be increased! At present odds of death in the thirty days after elective surgery at the weekend are 82% higher than if the procedure was performed on a Monday (Alyn P et al BMJ 2013;346:2424), at first glance a terrifying statistic but one which could be explained in a number of ways. Such a statistic could be used to increase facilities and staffing throughout a seven day working week such that elective procedures became safer.
What about primary care? As a hospital consultant I am sensitive to criticism for commenting on community and primary care. I would observe that getting a routine appointment with a general practitioner is more difficult than it once was and that might be helped by holding routine surgeries on Saturdays and Sundays. I would welcome comment on my assumption. It also seems to me that emergency out of hours domiciliary visits would be likely to keep the elderly and frail in their own homes. I assume that the shortcoming in my thinking might be a paucity of general practitioners with inadequate community support?
Whatever the reasons and however the data are interpreted I draw the following conclusion:
High quality seven day working in the NHS for both elective and emergency patients can only be achieved through a massive injection of funds into not just the Health Service but also Social Care.