BMJ editor writes to Hunt over misuse of weekend mortality data
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5624 (Published 21 October 2015) Cite this as: BMJ 2015;351:h5624All rapid responses
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I was dismayed by the interview by Fiona Godlee with Jeremy Hunt. I am all for dialogue, but this was just a one sided account.
I was left with the feeling that he has a vision of future which includes seven day working, improved staffing levels on hospital wards, greater transparency on hospital wards and an improved safety culture. The trouble is that the service is bursting at the seams, and an over-arching vision of a utopian future is actually damaging if it is based on a drive to divert resources from other struggling areas, conflict with health professionals and workers, squeezing efficiency savings from other areas already pared to the bone. The future never arrives, and the reality deteriorates.
The issue of deprivation is not mentioned at all. Hunt says that areas with low deficits perform well. Are these perhaps also more affluent areas?
I was further dismayed that this appeared in the BMJ without any critique. Were rhe interviewer and reporter blinded by Hunt's charisma? In effect, the article is an encouragement of his policies.
References
[1] BMJ 2016;352:i1632
Bill Vennells.
Competing interests: No competing interests
Your editor in chief has taken England’s health secretary to task for misrepresenting an article in the BMJ, earning herself well merited applause.
Splendid, but where were the BMJ, and the BMA, at a time of real danger, and many governmental misrepresentations, before the Health and Social Care Act became law in March 2012?
They were vacillating, confused, in a state of ‘critical disengagement’, explained Davis and Tallis, in an account which remains unchallenged. (1)
All the more reason for the BMJ to admonish the health secretary now, the editorial team may surmise, when the BMJ and the BMA need to identify with the indignation of junior doctors at their new contract, imposed at the behest of the health secretary.
Misrepresentation is not the prerogative of the health secretary. The BMJ has been doing it for years, without a qualm.
You have often printed unprofessional, vulgar, abuse of medical homeopaths, in letters (2), editorial (3), and Personal View (4) contributions to the print and online editions, which in turn elicited reasoned replies (5, 6) that had no effect on the editorial tendency to repeat further offensive and uninformed comments.
For the second time in a month your careers section has highlighted the negative effects of rude and disruptive doctors. (7)
It itemises precisely those behaviors (“ abusive language..rudeness or shaming others.. demeaning comments .. gratuitous negative comments about another physician’s care ..” ) which have been consistent elements of your coverage of homeopathy and medical homeopaths. The article points out that “..disruptive doctors do not seem to learn from their mistakes, because they cannot admit that they have made any.“ This is no surprise to those medical homeopaths who have attempted to engage constructively with abusive colleagues, and with the BMJ. There is no response, unless it is to repeat the abuse.
Your careers editor deserves congratulations for his efforts to bring doctors’ negative behavior to your readers attention. (7,8)
Last month your international editor wrote that the BMJ is “open to airing disagreement with what we publish .. “ (9)
Your senior editor for patient partnership has reminded us that the BMJ “ is dedicated to promoting partnership with patients “. (10). An admirable mission, but a difficult one to sustain when attitudes within the editorial team are possibly disparate. (11)
If the BMJ editorial team have collective responsibility for the journal’s content, may we hope that these constructive voices among them will ensure that the BMJ is never again a platform for those rude, disruptive doctors whose behaviour has been detailed in recent BMJ careers sections? Their attitudes bring nothing to the practice of safe, compassionate and effective care.
1 NHS SOS, Ed by Davis and Tallis, One World Publications 2013
2 www.bmj.com/content/343/bmj.d5960
3 www.bmj.com/content/339/bmj.b5432
4 www.bmj.com/content/347/bmj.f5448
5 www.bmj.com/rapid-response/2011/11/03/homeopathy
6 www.bmj.com/rapid-response/2011/11/02/editorial-ignores-evidence
7 http://careers.bmj.com/careers/advice/Editor’s_Choice%3A_Disruptions_and_divisions
8 http://careers.bmj.com/careers/advice/Editor’s_Choice%3A_The_importance_of_being_civil
9 www.bmj.com/content/351/bmj.h5083
10 www.bmj.com/content/351/bmj.h4396
11 www.bmj.com/content/351/bmj.h4396/rr
Competing interests: Peripatetic homeopath. BMA member.
Prof Keogh is quoted as saying [1],“There is an avoidable ‘weekend effect’ which if addressed could save lives. This is something that we as clinicians should collectively seek to solve. It also strengthens the moral and professional case for concerted action". Further, citing Keogh and Academy of Medical Royal Colleges, DoH claims, this is "likely to be a consequence of variable staffing levels" [2]. Thus, it appears Keogh is to some extent supporting Hunt's view. Wonder whether Dr Godlee and BMA would now change their minds. Propagating hatred against Hunt is unlikely to help the interests of junior doctors. As a trade union, the BMA must remind themselves their professional obligations to its fee-paying members before resorting to self-promoting, confrontational publicity stunts.
References
[1]NHS medical director coy on 'weekend effect' of hospital deaths (http://www.theguardian.com/society/2015/oct/25/nhs-medical-director-week...)
[2]BMJ 2015;351:h5624
Competing interests: Do not trust the BMA
Dear Dr Godlee, as a junior doctor I applaud you and thank you for your brave stance against the misinterpretation by the Secretary of State for Health of the results of the Freemantle et al study data published in the British Medical Journal (1), which he is using as justification for the DDRBs proposals for the Junior Doctor Contract.
This superficial and biased interpretation of the peer-reviewed study is contrary to that of the authors and the BMJ and is recurrently used by the Secretary of State in statements to the press and to parliament. A fact that seems ironic considering that he has recently and very publically accused juniors doctors of being misled by the BMA and all UK doctors of lacking professionalism and a sense of vocation. Over 20,000 doctors have taken to the streets in defence of our patients, our NHS, and our careers. We have demonstrated to Mr Hunt that our sense of vocation and professionalism is alive and well. You have demonstrated to Mr Hunt that we are highly trained professionals, who know how to interpret data and distinguish it from political spin. The idea that we are unable to interpret the DDRBs proposals and would be misled by the BMA is, therefore, a puerile argument and a further attempt to undermine and discredit the medical profession.
Your letter proved a welcome respite from the negative rhetoric of recent weeks. I cannot help but reflect that the wonderful contribution and example that you continue to provide to the profession as a whole, and to female doctors with academic and family aspirations in particular, will no longer be achievable in the future if the Secretary of State achieves his objectives.
1. Freemantle N, Ray D, Mcnulty D, Rosser D, Bennett S, Keogh BE, Pagano D. Increased mortality associated with week-end hospital admission: a case for expanded seven-day services? BMJ, 2015; 351: h4596
Competing interests: Junior Doctor, Research Fellow, Mother
Dear Dr Godlee (Fiona),
Thank you for your letter to Mr J Hunt - clear, concise and accurate. Everything that the recent misrepresentation of the facts has not been.
We want a strong, sustainable, safe NHS with a workforce that is happy and feels valued and supported.
Thank you for continuing to protect those ambitions and defend our young doctors deliver that service.
Yours, Jane Williams and John Duffy
Competing interests: No competing interests
Editor
I enjoyed the article but i am really respondng to the three responses so far
1. It is perfectly permissible for a journal editor to challenge interpretations of an article published in her journal if she feels they are heavily spun or mis-leading and try to correct the imbalance - whether or not that journal is part of the BMJ group. Good on Dr Godlee for doing so.
2. Even Sir Bruce Keogh the NHS Medical Director who was an advocate of 7 day servics well before Mr Hunt was secretary of state has said in a parliamentary committee and other places that the data on apparently excess mortality need to be interpreted with great caution. And as for "the mandate to take decisions based on expert medical advice", I can assure the respondent as an ex National Clinical Director in the Department of Health myself, that the NCDs and Sir Bruce are based in NHS England not Whitehall and it is highly unlikely that they or indeed the Academy of Medical Royal Colleges who are also broadly supportive of 7 day service provision have ever advised Mr Hunt to go around the media and in parliament quoting the "11,000 excess" deaths statistic with no qualification or intepretation. Nor will they have advised him to accuse doctors have having a nine to five culture, a loss of vocation or to accuse the BMA of mis-representing doctors' views. And i would be amazed if they had advised him to "impose" new contracts on junior and senior doctors who already work at weekends and nights and who are in any case not allowed to opt out of urgent/acute weekend working.
Imagine what real transparency and honesty and political maturity might look like?
"I am concerned that even though emergency departments, intensive care units, coronary care units, acute stroke services, acute trauma and surgery services, acute medical units, urgent imaging etc have a strong senior presence 7 days a week and a responsive acute service well into the evening, that in the "deeper hospital" there are insufficient staff (consultants, junior doctors, allied health professionals and support services outside hospital especially in social care and community health services) weekends still look very different from weekdays. Some papers (though not all) describe excess weekend mortality even when adjusted for casemix and acuity but the reasons for that aren't clear. And besides which, patients who arent likely to die deserve to see senior doctors more evened out across the week and have a better chance of access to decisions, investigations and the chance to go home. We can't even begin to do this yet in every hospital (let alone for routine and eleccive services however convenient weekend appointments might be for working people) because hospitals in England are forecasting major deficit are falling over under performance pressure, primary care and community nursing have serious workforce crises and social care has received major funding cuts.
We do know that one or two hospitals - generally ones with a strong track record of recent success and stable leadership, have worked closely with clinicians to develop more even services across the seven days of the week and have done so without imposing any contract changes but instead by asking clinicians to collaborate closely with hospital managers on their own solutions. Even here, more staff have often been required and the cost-benefit relationship isnt entirely clear. We know that 80% of consultants in acute specialities most of whom already work weekends are already in favour of moving towards these arrangements and so far only 5 out of 12000 consultants identified by FOI requests to hospitals opt out of weekend work in their contract anyway. The UK already has relatively few doctors per head of the population and both junior and doctors are already working very hard without much spare capacity. So we will need to increase the medical workforce and the workforce and capacity in areas which work closely with it. This kind of transformation will probably take 5 years or more to achieve and will go well beyond my life time as a minister or the lifetime of this government and even then may not deliver the increased benefits for safety that i am hoping they will."
Sadly, that kind of honesty will remain a pipe dream despite Mr Hunt's committment to transparency.
Dr Godlee was quite justified in saying what she said and I applaud her for doing so
David Oliver
Competing interests: No competing interests
In their review of the evidence base for clinical leadership in health care, Professor Michael West and colleagues provide the follow description of effective individual leaders:
“They insist on transparency in relation to errors, serious incidents, complaints and problems and they regard mistakes as opportunities for learning. They act effectively to deal with poor performance and proactively address aggressive, inappropriate and unacceptable behaviours”1
In her superb letter to the Secretary of State, Fiona Godlee demonstrated these skills commendably and in doing so, provided inspiration to thousands of current and future clinical leaders across the country to promote transparency and act always with integrity and courage.
1. West M, Armit K, Loewenthal L, et al. Leadership and leadership development in health care: the evidence base. London: FMLM, 2015.
Competing interests: No competing interests
Surely the answer to this apparent difference in interpretation of Professor Freemantle's paper is to ask Professor Freemantle to respond to Mr Hunt in a letter to the BMJ please?
It is all too easy for lay people to misinterpret data in scientific papers, as may have happened with the Health Secretary, but part of the blame must surely lie with the authors for not making their findings clearer for ALL who read their work. A degree in medical statistics should not be a prerequisite for reading a paper in the BMJ, surely?.
Professor Freemantle's paper concludes with the following key messages:
Patients admitted at the weekend are more likely to be in the highest category of risk of death
Patients admitted on Saturday or Sunday face an increased likelihood of death even when severity of illness is accounted for
An additional risk of death exists for admission on Monday and Friday extending the weekend effect to these two days
Around 11 000 more patients die each year within 30 days from admission occurring between Friday and Monday compared with admission on the remaining days of the week
It is this last point that Mr Hunt has seized upon. He does not claim that each and every death could be avoided by having more doctors in hospitals at weekends but has highlighted a problem that many hospital senior doctors, in private at least, recognise to be true.
The inference Mr Hunt has taken from this paper is that a substantial number of deaths MAY be avoidable if more senior expertise were available to patients under the care of over worked junior doctors..
Can any of us claim that this is not the case? Anecdotally we can all remember disasters at weekends through under staffing issues and poor decisions made by junior doctors on our wards. Ask any Coroner!
Let us have an honest debate please and stop this knee jerk belligerence towards a Health Secretary who has a mandate from the electorate to act on best advice from medical experts in order to improve patient care.
Competing interests: No competing interests
It is more than likely that the BMJ Editor is aware that Jeremy Hunt has repeatedly accused the BMA of misleading junior doctors and, in particular, referred to a misleading calculator on the BMA's website. Despite such direct challenge, the BMA or Dr Malawana has not confirmed or refuted such specific allegation. As the BMJ is owned by the BMA, the Editor's letter to Hunt gives the impression that Dr Godlee has now taken up a trade union role and is attempting to deflect the said central allegation of Hunt. Thus, wondered whether the BMA has run out of steam, and is using the skills of an 'independent' medical journal editor to resuscitate its negotiating weaknesses. Given the current impasse in contract negotiations, does Dr Godlee believe that further public alienation and humiliation of Hunt & Government is better than constructive dialogue in the wider interests of junior doctors?
Competing interests: Do not trust the BMA
Government needs to publish their analysis of the impact of the imposed junior doctor contract on NHS
Dear Sir Bruce Keogh (NHS England)
Dear Dr Godlee (British Medical Journal)
Dear Ms Katharine Viner (Guardian)
Government has gone so far as to impose a contract on junior doctors despite an overwhelming rate of disapproval by the profession. The justification for this decision has been an “alleged” increased weekend mortality and a manifesto pledge of 7 days NHS. Although the paper used by Secretary of State (1) has been challenged multiple times by doctors as well as British Medical Journal (BMJ) (2 3) the Department of Health (DoH) has never come clean on their “scientific” analysis.
Secretary of State eventually used vague reference to some papers and a few quotes from Sir Bruce Keogh and Sir David Dalton and commanded the imposition of the contract (4).
It seems that such an important decision on one of the most important services of this country, NHS, has been made based on personal opinion of a few senior decision makers and not on the basis of a robust scientific analysis, or, we have not seen any peer reviewed analysis of data for the basis of this decision making.
Here in Britain we pride ourselves of pioneering in science, may be it is time that DoH published their modelling of the effect of the new contract on the important outcomes in the hospitals as well as outpatient clinics. One would expect that such an important decision has already been modelled by highly trained statisticians, clinicians and academics and has been peer reviewed by independent scientists. By all means, it should be ready at hand for Secretary of State for health and medical director of NHS England in their inbox; “just a click on send” to submit. This analysis can be submitted to BMJ and they can process it and send it for peer review as they normally do.
May be the publication of this analysis will put an end to the long dispute with junior doctors. After all, the junior doctors understand a robust evidence based decision. The publication of the analysis will prove that government has considered all possibilities in their modelling and have thought it through for all aspects of the care which will be impacted by this new contract. The least is to prove that this new contract will improve the so called "weekend effect”.
I somehow know this is naïve to ask a government to publish evidence for their decision but this is the pride of the nation; NHS!
Every member of the public has every right to understand the way forward and see how the government has evaluated it in detail. For once we need to know a fully detailed analysis performed by the government for their decision. They should be put to test!
This letters has been written to
1- Sir Bruce Keogh as the person who should be able to readily provide the scientific background of the decision made for the imposition of the junior doctor contract and I sincerely hope that he immediately submits that to BMJ for a proper peer reviewed analysis and publication.
2- BMJ as a highly respected medical journals who have been involved in the discussions around the contract. I urge Dr Godlee to publish my letter and share my request with the colleagues in the health system in the NHS. Also, add their weight to the request from the DoH for the publication of the above analysis in an open and peer reviewed manner.
3- Guardian as a highly respected newspaper with a track record of investigative journalism and openness about their findings. Sir Bruce Keogh wrote an article in Guardian (5) this weekend, and I suggest that Guardian please publishes my letter as well. Perhaps, Guardian would also be able to add their pressure to this request from the DoH for the publication of that peer reviewed analysis.
I sincerely hope you all agree with my request.
Best Regards
Dr Hamidreza Mani
NIHR Clinical Lecturer, University of Leicester
Honorary Specialist Trainee at Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust
NOTE; the views presented in the letter are my own and does not represent University of Leicester, National Institute for Health Research or University Hospitals of Leicester NHS Trust.
References
1- BMJ2015;351:h4596
2- BMJ 2016;352:i417,
3- BMJ2015;351:h5624
4- http://hansard.parliament.uk/Commons/2016-02-11
5- http://www.theguardian.com/society/commentisfree/2016/apr/09/emergency-n...
Competing interests: I am a junior doctor for the 50% of my time that I work in hospital. [My other 50%, I work as researcher funded by National Institute for Health Research]