Last time I checked people were still becoming unwell seven days a week, including Christmas Day, during the World Cup and even during the EastEnders omnibus, so why do we insist on running a large proportion of the NHS five days only?
This might be a silly suggestion, I am sure some of you will tell me that it is, but I am sure we would offer a more efficient, higher quality service and save a considerable amount of money longer term by investing in a health service which didn’t differentiate between weekdays and weekends. Yes, I am talking about radically changing the way we manage health in this country. Have I gone completely mad?
Planes are only useful when flying, airlines operate every day of the week. If planes were to operate Monday to Friday only we would need something in the region of 40% more planes and capacity at airports and almost certainly the risk to passengers would be greater. Operating theatres are only useful when being used for operating. If we were to run elective operating lists between 8am and 6pm on weekends we could increase capacity by 40%, so why do we frequently hear organisations saying that they have insufficient capacity and that they need to start building expensive new facilities?
Some hospital services are only available 40 out of 168 hours per week and patients might be at greater risk as a result. The number of emergency admissions remains the same at weekends, yet we know that the number of discharges decreases. Why is this? The infrastructure within the hospital is insufficient, with staffing reduced to deal with only a certain cohort of patients and (this list is not exhaustive) community and primary care services are also either significantly reduced or closed. Many organisations will have made small local investments, for example in therapy staff at the weekend increasing discharges.
There was an article in the Guardian last week about weekend emergency patients having a higher death rate. This clearly needs more research but it highlights that there is some kind of problem and no, I suspect it isn’t only to do with alcohol and sport.
No one would disagree that patients should be admitted and diagnosed, treated and then discharged safely and as quickly as possible. I have heard three examples recently where people self discharged, they were feeling fit enough to go at the weekend, not getting any medical input so literally just sitting in a bed.
Many organisations think they have capacity issues when the reality is that actually a considerable amount of expensive capacity is available after 6pm in the week and most of Saturday and Sunday. I’m not suggesting we should start running theatre lists late in the evening, of course not, but a percentage of the population would be grateful for evening outpatient clinics, pre-operative assessment and weekend elective work. I realise that we need to re-provide care closer to home, moving some care from the acute setting back into the community. Of course this is right but at the same time we need to think about how we use hospital estates, which are very expensive, to achieve better economies of scale. I realise it is a deeply unpopular topic but how can anyone dispute having fewer hospitals providing high quality care and running efficiently is better than having a number of very expensive facilities running inefficiently and as a consequence potentially taking staff from front line positions in a desperate attempt to scrape together a few savings here and there?
I remember being invited into the CEOs office in 1999 when one of the surgeons had announced that he couldn’t meet the 18 month standard for inpatient treatment (before someone corrects me it could have been 21 months, I can’t remember). I am pleased to say that we are a long way from waits this long now and whilst it is fair to say that we have achieved 18 weeks, we have done so at considerable cost and this continues to be the case - so much for pathway redesign, there wasn’t time. Paying consultants to operate on their NHS patients at the weekend or sending patients to alternative surgeons privately is expensive, some organisations will have formalised this and will have recruited staff for permanent elective sessions at the weekend, but many have not.
We talk about shared leadership and accountability, well let’s do it properly. I don’t mean that we just have to change the way doctors, nurses and AHP’s work etc, I also mean the managers. It is also time we addressed the thorny issue of Consultant job plans and rotas, some of course already have but the majority are tinkering round the edges and just because it’s unpopular does not mean we should shy away from it. This also does not mean that rotas need to become onerous and people’s lives get severely disrupted - huge change yes, and it means everyone needs to work together but before the baby is thrown out of the bath water it’s worth reflecting that it could work well; meaning less on call and not having each weekend disrupted.
We know we have to save money. We have to save a considerable amount of money. We know it’s going to be hard. For those that think that this isn’t going to affect them, either directly or indirectly, then take a walk round the block or as long as it takes until you realise that it is. Some leadership in the NHS is shocking and is about as far from effective as Spam is from having any goodness in it whatsoever. It is easy to be outraged at the cost of management consultants and at what has been suggested for the NHS, but the majority haven’t come anywhere near to doing even half of this ourselves and some of it is fairly basic. Furthermore I’d suggest that we’re too scared to even suggest it let alone do it. Where is this tough, robust leadership that is needed for the future?
The NHS is here to treat patients safely and efficiently and patients need treating seven days a week. The NHS isn’t in place to provide us with jobs that are convenient for us.
Someone must have done some work on this but go on; hit me with comments that tell me I’ve lost the plot and that this is a stupid idea. Stupid idea maybe but QIPP alone is unlikely to deliver everything that is needed and my greatest fear is that we’ll end up making poor decisions and not tackle some of the tough decisions which have needed tackling for years.