Eight Days A Week

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7-day healthcare, explained using 32 Beatles song titles. Give yourself a pat on the back if you spot them all.

You’ve probably heard people talking about a “7-day NHS”.

What does it mean? It seems obvious – healthcare, available 7 days a week. On the face of it, it’s something few would argue against. Look closer, and it’s a deliberately vague sound bite that people in Government keep on blindly repeating without any attempt to define it. Healthcare is a very broad term. If you have a stroke, you need urgent treatment, whatever hour of the day, whatever day of the week. (And that treatment is already available.) But if you want your ingrowing toenail removed, it might be ok to wait until Monday.

The Conservative Party manifesto prior to the recent general election contained this statement:

“We will continue to increase spending on the NHS, provide 7-day a week access to your GP and deliver a truly 7-day NHS – so you know you will always have access to a free and high quality health service when you need it most.”

Inside the manifesto, there is a little more detail:

“For years it’s been too hard to access the NHS out of hours, even though sudden illness and events which you and your family cannot plan for do not respect normal working hours… We will make the NHS more convenient for you. We want England to be the first nation in the world to provide a truly 7 day NHS. Already millions more people can see a GP 7 days a week, from 8am-8pm, but by 2020 we want this for everyone. We will now go further, with hospitals properly staffed, so that the quality of care is the same every day of the week.”

On the face of it, none of this should be controversial. We all want the best medical care for emergencies, whenever they happen. We all want hospitals to be properly staffed on weekdays and weekends. We all want the NHS to be convenient. And it would be nice to be able to see a GP on any day of the week.

But weekend healthcare can mean two quite different things.

First, there is emergency medical care. If a heart attack disturbs your golden slumbers in the early hours of Sunday morning, you should get the same treatment you would get if you had a heart attack on Tuesday at teatime. And emergency medical treatment includes access to emergency GP services out of normal working hours.

Second, there is routine care. Look again at the Conservative Manifesto: “We will make the NHS more convenient” is not a statement about saving lives.

Let’s consider four levels of medical urgency…

  1. The blue-lights flashing, sirens blazing emergency

help

It’s late on a Saturday evening. John is sat at home, watching Liverpool on Match of The Day, when he feels a sudden crushing pain in his chest. He dials 999, and tells them “Help! I’ve got a feeling I’m having a heart attack. Don’t let me down!” The ambulance comes quickly. He’s too weak to reach the door, but the female paramedic manages to get in (she came in through the bathroom window). His heart tracing suggests a major heart attack. The ambulance crew know that he needs urgent expert treatment, so they take him straight to the nearest “heart attack centre”. They phone ahead, so the consultant cardiologist on call is on her way in before John even arrives. He is assessed on arrival and rushed straight to the angiogram suite, where he’s attended by 2 doctors (minimum), and a handful of other staff (nurse, angiogram assistants, porters etc.). Once his blocked artery has been opened up, he’s taken to a specialist high dependency unit.

The difference between this out-of-hours chain of events and what would happen during working hours is…nothing. And the same is true for all time-critical medical emergencies. If Paul has a stroke, he’ll be rushed to a dedicated stroke unit. He’ll be seen by an expert stroke physician, who will report to his consultant (something like “I’ve just seen a face with a left-sided droop”) and he’ll be given state-of-the-art treatment. If George suffers an acute asthma attack, he’ll be treated the same whenever it happens. If Ringo is stabbed, the nearest trauma team will be waiting when he’s wheeled into the nearest trauma centre. Fixing a hole is their job, eight days a week.

Life threatening emergencies don’t differentiate between social and anti-social hours, and neither does the NHS, when it comes to treating them.

  1. A+E Minors

lennon

It’s Friday night, and Lizzy is dizzy. “I’m so tired” she thinks “and maybe I’m already getting better. I will just let it be.” Another girl might have done just that, but she calls the out-of-hours GP service, and a doctor advises her to attend A+E. She has a CT scan to look for a stroke. The scan is normal, and a life-threatening emergency seems unlikely. She needs a more detailed brain scan, an MRI, to check for other, less urgent problems. But in many hospitals, Dizzy Miss Lizzy might have to wait until Monday for her scan. It won’t affect her life expectancy, but it’s not very convenient for her. And it’s not very convenient for her doctors, who would have liked to send her home if the MRI scan was normal.

It’s Sunday morning, and Mr Mustard attends the emergency department with a painful hand. He was drunk yesterday night, and has a vague memory of punching a wall. An X-ray shows that the hand is broken, and he needs surgery. The orthopaedic surgeon is happy to operate, but it’s Sunday and there is only one operating theatre working (with one set of theatre staff). He goes to the bottom of the list. By 10pm, he still hasn’t had his operation, and the doctors decide he can wait until Monday, when there will be more theatres open and more surgeons available. Mean Mr Mustard is not pleased, especially as he’s been told it won’t be long, and has not been allowed to eat all day because he might be going for surgery. The delay in his surgery is not convenient for him. It prolongs his pain, and his hospital stay. But in the long term, the outcome for him will be the same. His hand will heal.

If there is no life-threatening emergency, then weekend care falls away as sharply as the fool on the hill’s hill. Plenty of medical tests are not available over weekends, like Dizzy Lizzy’s MRI, and operating theatres will have to prioritise the most urgent cases.

  1. GP time

Pam wants to see her GP about her bowels. She works on weekdays. And her GP surgery isn’t open on weekends. She cares deeply about her job as a disposable plastic cup saleswoman, and doesn’t want to be late for work or take a day off. So Polythene Pam doesn’t see her GP, and her bowels go without Doctor Robert’s advice.

Maxwell works hard all day in his job as a silversmith (he is working on a silver model hammer for Her Majesty’s Royal Guild of Toolmakers). He’s been meaning to make an appointment to see his GP about his sore toe. But, he says, “when I get home, I forget to call for an appointment”. On weekends, when he has time to call, the office is shut. End result – Maxwell’s silver hammer is coming along nicely, but his sore toe goes without medical input.

Most GP surgeries don’t offer routine appointments at weekends, although many surgeries will open late one or two evenings a week for people who can’t attend during the day. There is emergency access to GPs on weekends, either in walk-in centres or by phone.

 

  1. Inpatients

sexy sadie

Sadie was a model in the 1960s. But the days when Sexy Sadie used to stalk along the catwalk are long-gone. She is overweight and diabetic, and has an infected foot ulcer. After her admission on Saturday morning she is seen by a consultant, and started on antibiotics. She could keep taking the antibiotics at home, but she needs to see a nurse who specialises in diabetic complications such as foot ulcers who won’t be in until Monday. Also, Sadie needs a daily visit by a district nurse to dress her foot, but this can’t be arranged over a weekend. She’ll need help with washing, dressing, preparing meals and shopping as “I can’t walk on my painful foot or drive my car”, but this can’t be arranged over a weekend. On Monday, she’ll be handed over to one of the various medical teams that operate during routine hours. Their main task, with the hospital’s social workers, and discharge coordinators, will be setting up a care package so Sadie can get back home.

Michelle has been in hospital since Thursday, when she had sudden abdominal pain. By Friday her pain has gone (“I feel fine”) but her consultant wants a couple of further tests. They aren’t available on weekends, so she’ll have to wait until next week. She spends the weekend playing with her phone, doing word-searches and talking to the lady, Madonna, in the next bed. She’s checked on by the nurses, but no doctor sees her over the weekend.

Once you’re through A+E and into the hospital, you’ll find the wards and their inpatients have emergency cover only, and stable inpatients may not see a doctor during a weekend. Discharging fragile patients over weekends is tough, as social services won’t usually pick up their care until a working day. Hospital pharmacies, which dispense drugs for patients to go home with, work shorter hours on weekends, and sometimes don’t open at all on Sundays. Non-urgent tests are rare over weekends – if you’re in hospital waiting for a diagnostic test on a Friday evening, you’ll probably still be waiting on a Monday morning.

What should be changed?

The current system for weekend care is designed to keep people safe, with the minimum number of staff.

Or, to use management-speak, to keep people safe in the most efficient way possible.

Or, to use austerity-speak, to keep people safe in the cheapest way possible.

NHS hospitals are already staffed on weekends to deal with emergencies. There’s no cause for complacency, and there is always room for improvement, but there is no scandal of poor care here. The Government’s repeated attempts to claim that death rates are higher on weekends, parroted at times in the media, are wrong, or at best misleading – more detail in an earlier post here.

It would be nice to have all services running all of the time. It would be nice for Sadie, who could get back home faster with all the necessary care in place, for Michelle, who wouldn’t have to sit in hospital over the weekend waiting for her tests. It would be nice for Pam and Maxwell, who could get checked by their GP on a weekend. This is about convenience, not about safety. Paul, who is critically ill, won’t notice that it’s a weekend…

Doctors are already working during the weekends. And you’ll struggle to find any doctors who wouldn’t welcome an extension to what’s currently offered at weekends. It’s just as frustrating for doctors as it is for patients, especially on busy weekends with full hospitals, and patients on trolleys here, there and everywhere.

But it is blindingly obvious that it can’t be done for free. The infrastructure is there – the MRI scanners are standing idle, there are empty operating theatres, clinic rooms and endoscopy suites. But to get these facilities working on weekends will need extra doctors, nurses, carers, radiographers, dieticians, pharmacists, physios and receptionists. And all these extra staff will cost money. And money, apparently, is in rather short supply at the moment.

So it would be nice to see fewer sweeping but meaningless statements about 7-day services, fewer references to imaginary excess weekend deaths, and less doctor-bashing from the politicians. We don’t need a revolution. But the medical profession would welcome any sensible, evidence based and adequately funded proposals to improve weekend care.

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