Monday, November 28, 2011

Danger at night and weekends

The annual hospital guide published by Dr Foster Intelligence using official figures shows that one in eight trusts has higher than expected death rates on Saturdays and Sundays, suggesting they are only working to a five-day week. Many hospitals have far fewer senior consultants on site outside of normal office hours, the data show, and rely on junior doctors and nurses to treat critically ill patients.

In a handful of trusts, the mortality rate rises by 20 per cent or more between weekdays and weekends. Low staffing levels in A&E have been identified as one of the long-standing problems at Stafford Hospital, where hundreds of patients died after receiving “appalling” care, and the unit will close overnight for three months starting this week.

Although I do not take much notice of Dr Foster reports, since they use crude data which is often modified when the CQC produces a more comprehensive view. (Stafford was only one of 6 Trusts identified by Dr Foster - the other 5 were exonerated). Nevertheless, out of hours care has been one of the problems identified by the NHS as one of its deficiencies. As a result there have been major changes to the provision of care. Vascular surgery has been confined to small groups of expert vascular surgeons, who are ready with their teams to appear where the problem is. No junior doctor ever gets to lead on emergency vascular surgery. It is true of almost all elective surgery, which is now conducted between 9 and 5.

When I was young it was quite commonplace for major colorectal surgery to take place in the evening for an elective list arranged by the Senior Registrar from 7pm to 11pm. But we had different types of junior doctors then.

When I was a resident in Bristol there were 6 Senior Registrars in Surgery, aged between 38 and 44. These were very senior and experienced doctors who were just waiting consultant jobs. One of those was John Trapnell, whose obituary I posted recently. Among the others I remember were Colin Davidson, Roger Celestin and Harry Espiner. All have long since retired with great success in their careers. Today, Senior Registrars have all gone and instead we have registrars. These young men have many fewer hours of experience and their training is arranged so that they will get fewer yet. At the age of 35 they expect to get consultant jobs, but although they may get expert in microspecialties (just doing breasts or stomachs or pancreases) they will never become the General Surgeons that their predecessors were.

Physicians were always younger than surgeons when they became consultants, and I was particularly young at the age of 30, but 33-35 would be average. I was always on an on-call rota of at least 1 in 3 throughout my whole career, but we trained a mixed junior doctor/ senior nurse cadre who were competent to deal with the medical emergencies that we would have to deal with urgently (mainly neutropenic sepsis) and more complicated problems (mainly transfusion and coagulation difficulties) could be dealt with from the confines of a warm bed.

General Physicians have largely disappeared from the NHS. Elective work is done in daytime by Gastroenterologists, Chest Physicians, Neurologists, Endocinologists, Cardiologists, Rheumatologists, and Rehabilitation Specialists. We and others have set up Acute Medical Units, attached to Accident and Emergency Units where an on-call Senior Doctor is responsible for the first 24-48 hours of an admission only, although referral to an intensive cardiac unit or stroke unit may be required earlier. Expert endoscopy, CT scanning, MRI and ultrasonography is also available within the first 24 hours.

Changes in junior doctor training have forced more senior involvement at nights and at weekends and have in the best hospitals rethinking on how things should be done. There is one major deficiency that I have identified, though. The European Union forced through its European Working Time Directive, with the consent of the last Labour Government and against protests of the British Medical Establishment. This meant that not only were junior doctors not allowed to work for more than 48 hours a week, but included in that time would be on-call time, when the doctors would be sleeping, not working. This has meant a total revision of doctors' rotas that has neither helped the service they provide nor their training. Now even the Germans think it was a mistake and have conceded that this may be one of the things that the UK can have back to its own control if there have to be renegotiation of the EU charter because of fiscal rearrangements.

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