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24/7 hospital care: “That’s what happened in retail”

August 18, 2013

’24/7 care: here’s one NHS reform we should all agree on’ urged the headline of Jackie Ashley’s opinion piece in the Guardian last week. The article went on to detail the ludicrousness of many current hospital arrangements and contrast them with the reality of patient need. Surveying a weekend and Bank Holiday landscape of skeleton medical cover and diagnostic facilities with shutters firmly down, Ashley rightly pointed out that ‘people get ill at any time of the day or night, people are born and die at the weekend as well as on weekdays. Yet much of our NHS remains doggedly nine to five, Monday to Friday’.

The result, says Ashley, is a scandalously under-acknowledged patient safety issue. The official statistics are truly shocking. Ashley writes that ‘NHS England estimates that 4,400 lives could be saved each year if mortality rates at the weekend matched mortality rates during the week. At present, if you are admitted to hospital at the weekend, you are more likely to die. It’s that simple’.

For ward-based nurses, the prospect of 24/7 operation for all departments may seem academic. After all, we already work just as hard at nights and weekends as we do during the week. The major battlegrounds on this one are likely to be elsewhere: physiotherapists, for example, clinical specialists and technical staff – people who have not traditionally provided full out-of-hours support. Come to think of it, round-the-clock availability of everyone else in the hospital would actually go a long way towards easing some of the stresses we face: instead of the usual Friday night aggro from patients frustrated to find that they are now not going to get their scan/see their consultant/get their mobility assessment until Monday, we would be able to call up someone there and then. Patients could get out of hospital faster and be treated more promptly while they’re in. It’s a win-win.

Ashley’s article was based on a programme she made for BBC Radio 4 (The Night Hospital) which was broadcast in the same week. The focus of the programme was an investigation of why patients are at increased risk of dying if they are admitted to hospital at night or over the weekend, and what can be done about it. A number of interested parties (doctors, nurses, patients, MPs etc) gave their views. One of them was Sean Worth, a former advisor to David Cameron.

He said: “In retail they faced huge problems in the [19]80s and 90s to meet customer demand. They responded to that because they had the flexibility and the innovation…to do it. The NHS is much more important. Hospitals need flexibility to ask their staff to come in at the weekend without having to pay them 80% premiums to do it. In retail, they just changed their hours, they said ‘look…our customers want us to open on Sundays; can you come in on Sunday and have Wednesday as your day off?’ That’s what happened in retail. That doesn’t happen in the public sector because of all the rigid rules and basically trades union national pay bargaining that they’re stuck with”. In other words, any move towards round-the-clock service is likely to be accompanied by a renewed government push towards local pay deals and the abandonment of unsocial hours payments for nurses.

The promise of 24/7 working could also throw a lifeline to the hospital closure programme. In many ways, this could be a positive development – can there be anyone left in Britain who doesn’t know that rationalisation of London’s stroke services has meant that the capital is now the ‘best place in the world to have a stroke’? – but hospital closure is so unpopular with local communities that the whole subject has become politically untouchable. In Ashley’s radio programme the executive director of one London hospital, almost audibly throwing his hands up in despair, dubbed it an ‘insoluble problem’. Realistically, the NHS could afford to staff the full range of medical input around-the-clock only in larger units; the trade-off for improved out-of-hours hospital care would be the acceleration of A&E closure/downgrade at smaller hospitals and the consolidation of specialist services into regional units.

So should nurses support the call for 24/7 hospital services? It’s an interesting question because as with so much in health care, it pits the rights of the health care worker (to a life outside work, to adequate financial reward for working at times when others expect not to be at work) against the right of patients to receive the best possible care whenever they happen to require it. Complication is added to the arguments because despite the fact that (to quote a professor of medicine who replied to Ashley’s article) ‘it is ethically unjustifiable to provide a lesser standard of care at weekends’, the public, in its opposition to hospital closures, has demonstrated that the retention of highly-valued local services can be viewed as more important than overall safety gains.

But are those safety gains so clear-cut anyway? Another response to Ashley’s article came from a professor of emergency medicine. He said: ‘Although death rates are higher at weekends, it is not clear how much of this is due to different standards of care. There are fewer admissions at weekends and patients tend to be sicker…Current methods [of statistical analysis] do not take illness severity into account…The prediction that 4,400 lives could be saved each year by 24/7 care is therefore likely to be an overestimate. Unless we know how much difference 24/7 working will make, it’s difficult to know how much it is worth spending (or sacrificing) to achieve it…Unattractive pay and conditions will mean unfilled posts, as currently seen in emergency medicine. Centralisation may help, but if patients have to travel further, deaths may increase. There may be more deaths overall, but spread more evenly over the week’.

So, despite its obvious common-sense attractions, 24/7 hospital care is still basically another NHS journey into the unknown. For example, we don’t seem to know which conditions are the most lethal to contract out-of-hours. Elsewhere in healthcare, we talk about ‘targeting’ services, but here we seem to advocating massive wholesale reconfiguration when it may well be the case that relatively small adjustments would contribute significant gains in crude out-of-hours survival rates.

Nurses should not be asked to sacrifice their pay and conditions for an idea that may be as much about politics as it is about patient safety. Of course this is an issue that demands attention, but there should be no knee-jerk reactions. We need to look at what the best hospitals are doing right; we need to look in detail at the patient pathways of people who died after a weekend admission, find out what – if anything – could have been done differently, and learn from that. If, as predicted above ‘unattractive pay and conditions mean unfilled posts’, Trusts will be forced to choose between paying over-the-odds for agency cover or running short-handed. And how safe is that?

For Jackie Ashley’s article, see http://www.theguardian.com/commentisfree/2013/aug/11/24-7-care-nhs-reform-weekend-dying#start-of-comments

For letters written in response to the article, see

http://www.theguardian.com/society/2013/aug/13/nhs-seven-day-24-hour-care

For a readable account of the benefits of concentrating services into larger hospitals, see Roger Taylor’s recent book God Bless the NHS.

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