Sunday, 15 December 2013

It's more than 7 day working we need to change

7 day working is back on the agenda. It's been cropping up now at regular intervals - it keeps cropping up because it is something we haven't yet solved.

It sounds like a good idea to have consultant presence on the wards 7 days a week, and it reflects a reality of modern day health care: consultants are the means through which investigation and treatment plans are currently achieved. Another solution might be to have teams that function effectively even in the absence of the consultant, but this does not seem to be a solution on the wider agenda. Consultants are the de facto clinical leaders, and they should be the experts. More junior doctors may be expert as well, and in many cases they offer leadership - but there is too much variation. The difference in expertise between a first year registrar and a final year registrar can be huge. The best way for the system to guarantee the best expertise is to focus on the provision of those people who have successfully navigated the training, and demonstrated the ability deliver the level of care required to be a consultant.

How well our training system does this is the topic of another conversation. But I can see why the currency of expertise in the current health service is measured in terms of consultant numbers.

Consultants are useful tools around which a health service can be shaped. But they are also the most expensive tools. We have to ensure that consultant time is used to the greatest possible utility.

If we look at how we might offer greater presence of consultants on the wards at weekends, there are a number of solutions that we might choose.


  1. Employ more consultants - costs more money, and requires more consultants to be trained. 
  2. Pay current consultants more money to work more hours - costs more money, risks burn out, risks deterring young doctors from entering specialties that require 7 day working
  3. Focus 7 day provision on acute services, and cut elective services to create the capacity for more acute work - this will lengthen waiting times, and perhaps create a perverse incentive for more people to use acute services for chronic problems: we might arrive at a situation where the best way for patients to receive timely, expert care is through the acute services. 
Something has to give, and it is not simply an issue of giving the problem money: even with unlimited resources, we would not currently be able to staff 7 days services across the country, for the want of appropriately trained consultants to take up the work. Within geriatrics at the moment, within current service provision models, many trusts across the country are struggling to recruit suitably trained doctors. 

Therefore, we need to decide how important this is, compared to the work that consultants already do. 

And this, I suspect is where the possibility for change lies. Implicit in the attention being focused on 7 day working is the knowledge that the acute pathways are struggling with demand, and the evidence that emergency outcomes, and surgical outcomes are worse at the weekends. 

Now this really is a complicated issue, but I've had a simple thought about it: the acute services experience high levels of demand, not just because we have high levels of sick people, but because they are the only services that mirror the preferred usage patterns, and expectations of the patients. They are the only services that respond to patient's needs when they have them; they are the only services which provide patients with answers in the time-scales that they feel they need, or they expect.

And let's remember, many of the people who use A&E are not really patients: 40% of them are sent home with only advice. This is telling us something. 

I know there has been a whole heap of work done around how people use health services, and how we can provide better out of hours care for non-urgent problems. But perhaps it tells us something else as well, and perhaps one of the areas that needs real scrutiny is how we provide routine, elective and non-urgent care.

If we accept that acute services respond to individual's needs in the time-frame that patients expect them to be, then what does that say about the way we deliver out-patient and elective care. 

If you take the kinds of out-patient services I have worked in, then it is evident that the nature of care provided to patients is significantly organised around the capacity and structure of the service. The ability of a clinic to review new patients is often a function of clinic capacity, not of patient need; and the frequency and time between follow-up appointments is not always dependent on clinical need, but on the nature of the service. 

Too much out-patient care is based on an old-fashioned and historical structure which bears little resemblance to the health care habits of the modern day. The time of need is not weeks or months after the referral was made, but on the day that they went to their GP with the problem in the first place, or the day that the ailment started. 

Too much out-patient care is delivered too late, too infrequently, and is influenced too much by the limitations of the service. 

This is the area of care that we need to deliver differently. This is the area of our system that we could revolutionise to provide more rapid diagnostics, assessments and treatment plans, and the area of our system that could share more of the burden currently borne by the acute services.

So let's figure out how we can use consultant time more effectively for the benefit of our patients, but while we have the chance, let's also figure out, at the same time, how we can adapt the way we work, to help consultants help patients better.