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Doctors take to Twitter to refute Hunt’s claim that NHS has weekday working culture

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3950 (Published 20 July 2015) Cite this as: BMJ 2015;351:h3950

Response to Government's Petition Reply - Vote of No Confidence in Rt Hon Jeremy Hunt MP

The Government response to petition 104334 of almost 200 000 signatures calling for a vote of no confidence in the Rt. Hon. Jeremy Hunt MP, Secretary of State for Health is disappointing.

The response plainly avoids the question at hand, making no mention of Jeremy Hunt or a vote of no confidence. Instead it focuses on seven day working, assuming incorrectly that this is the signatories’ only concern.

The Government wants to talk about seven day working.

It must first be made quite clear that NHS healthcare workers are absolutely committed to improving the quality and safety of NHS care on many fronts, not least better seven day working practices. On this we are in complete agreement with the Government. However, it is the detail of how reforms have been proposed and potentially unilaterally imposed that has caused serious concern.

The Government response, as has been the case for much of their ‘evidence’ backing seven day working, is both flawed and misleading.

The Government are deliberately using poorly evidenced, inflated figures to win headlines and generate fear. To fully understand it, the reader requires in-depth statistical knowledge. A lack of references leaves the reader unable to verify the accuracy and robustness of the statistics used.

Weekend mortality statistics

The Government claim there is a 16% higher chance of dying if admitted to hospital at the weekend – this is misleading [1]. The actual data show there is a 16% increase in absolute risk of death if admitted on a Sunday instead of on a Wednesday. The figure for Saturday is 11% [2].

That is an absolute risk reduction on an absolute risk of death of 1.32%. Thus the risk of death is increased from 1.32% to 1.53%. The authors of the original study did not describe how the severity of patients’ illnesses were taken into account, potentially seriously confounding the results.

The figures above demonstrate an association but do not explain the cause.

There are likely to be many reasons for this difference in mortality, but these have not been fully explored. They may well include the fact that patients probably present with more advanced illness and so are more unwell at the weekend, though clearly more study is merited [3].

In fact the original study found that in patients who were already in hospital, the chances of dying on a Sunday were 8% less than a mid-week day. Ironically, they are more likely to be on longer stay wards and therefore much less likely to see weekend consultants than those newly admitted to acute care. Besides all that, using mortality is not an effective marker of care quality [4].

The consultant opt-out clause

The response is fixated on the consultant ‘opt-out clause’ of the 2003 NHS consultant contract. This clause covers non-emergency (elective) work only. The response’s argument focuses on making hospitals safer at the weekend – this relates to emergency work and highlights the critical lack of understanding of what actually happens in the NHS. It is again emergency work to which the above mortality figures relate. There is no opt-out from emergency work, but it is critically underfunded and poorly resourced.

A Freedom of Information request responded to by 13 acute NHS trusts so far has revealed just one consultant opting out of a total of 3755 consultants (0.027%) [5]. That’s equivalent to just 12 out of the roughly 40,000 consultants working in the whole of England. This destroys the Government argument that the opt-out clause is a “major barrier” to a 7-day service. The opposite is true, it is no barrier at all.

Furthermore, the response claims that the ‘opt-out clause’ allows doctors to charge for expensive out of hours payments. The FOI data shows that this is not the case. These extra charges are for additional work hours needed to fill existing gaps in staffing due to an overall lack of consultants, NOT because consultants are opting out.

Consultant pay

Naturally, the report moves to highlight consultant pay. It quotes an average consultant salary of £118,000. Where has this figure come, how was it calculated and what are we comparing it to? The NHS consultant pay scale for England is £75,249 rising to £101,451 after 19 years as a consultant.

Can consultants work more? Most full time consultants work 10, 11 or 12 programmed activities a week (40-, 44- or 48-hour week) as a routine. On-call work happens on top of this. Therefore most consultants already work in excess of a normal 40 hour week from the outset to cope with the demands of the NHS even before on call commitments.

For example, a consultant might work five days a week. Their on-call weekend occurs on top of this time. They still come back to work again the following week, often enduring a 12 day stretch. They don’t have Monday and Tuesday off to compensate, and if they did who would do their elective work on these days?

It is difficult to see how current working patterns of 40-48 hour weeks (plus on calls) have any space for manoeuvre. Police officers, firefighters (note: not firemen as per the government response) and prison governors who demonstrate admirable seven day working, are not expected to work in excess of 40 hours a week to do so.

The NHS is in a state of chronic staffing shortage and this affects patient safety. Acute care had its worst winter crisis for years with worse predicted this winter. There is a shortage of health professionals and a shortage of beds. Every day hundreds of unfilled shifts remain empty forcing already overworked professionals to do the work of far in excess of one person, compromising safety, quality and dignity.

Discharging a patient requiring social care during the week is like wading through treacle, let alone at the weekend. The catastrophic cuts in health and social care mean that patients wait weeks for a care package or an urgent ‘fast-track’ palliative care placement as this cannot be done over a weekend. These, and emergency care are far more pressing issues for the Government to tackle, rather than picking a fight with doctors on an issue on which we all agree needs improvement.

The determined Government focus on forcing consultant seven day elective working is not based on any evidence that the opt-out clause is any major barrier to seven day working. It is unworkable in isolation and may have catastrophic consequences for the NHS. Jeremy Hunt is focusing on the wrong entity; far bigger issues affecting patient care are being ignored and swept under the carpet.

Why do NHS staff have no confidence in Hunt?

If seven day service proposals and some belligerent remarks about doctors were all that had angered NHS professionals, there would be no petition.

Jeremy Hunt has a track record of bad decisions, poor policy and failure to engage with professionals. This was the last straw. The NHS sat up, took note and decided enough was enough.

Outlined below are just some of the many reasons NHS workers have signed to support a vote of no confidence in Jeremy Hunt:

• Co-authorship of a book advocating the denationalisation of the NHS
• An enduring lack of engagement with NHS professionals and a refusal to involve them in shaping the future of the NHS
• A non-existent understanding of what happens ‘on the shop floor’ and how the NHS really functions as a health service
• A promise of seven day GP working services with no credible plans for addressing the GP workforce crisis
• Suspension of the NICE safe staffing programmes focused on minimum safe nursing levels for inpatient wards
• An acute care crisis with deteriorating accident and emergency performances, closure of inpatient beds and personal haranguing of NHS trusts repeatedly missing targets
• A calamitous lack of understanding of evidence based medicine leading to the promotion of homeopathy as an evidence based intervention (it’s not) and misleading information about drug advances such as dementia drug solanezumab
• Lack of apology for patient breach of confidentiality despite his own introduction of Duty of Candour regulations – if this had been a health professional there would have been a disciplinary proceeding likely leading to a Fitness to Practice hearing
• Persistent propaganda and misinformation to the public about the NHS
• Complete lack of experience in the healthcare sector
• Closure of emergency services such as West London Accident & Emergency departments and attempted closure of Lewisham Accident & Emergency despite the A&E crisis
• Overseeing progressive privatisation of the service which clearly does not work
• Six-fold exaggeration of costs incurred by foreign nationals using the NHS
• Public health budget cuts of £200 million despite a ‘focus on public health and prevention’
• Regarding Mr Hunt, the message is becoming even louder and clearer. NHS staff and the public have had enough.

1 McCartney M. The zombie statistic behind the push for seven day working. BMJ 2015;351:h3575
2 Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, Roche WR, Stephens I, Keogh B, Pagano B. Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med. 2012;105:74-84
3 Mikulich O, Callaly E, Bennet K, O’Riordan D, Silke B. The increased mortality associated with a weekend admission is due to increased illness severity and altered case-mix. Acute Med. 2011;10(4):182-187
4 Hogan H, Zipfel R, Neuburger J, Hutchings A, Darzi A, Black N. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. BMJ 2015;351:h3239
5. https://www.whatdotheyknow.com/user/kiara_vincent?utf8=%E2%9C%93&user_qu...
Accessed 26 July 2015

Competing interests: Dr Zoe Norris – Presenter for NB Medical Hot Topics. No other competing interests. Dr Mohsin Khan - Currently holds and has held a number of voluntary positions for Liberal Democrat organizations. No other competing interests. Dr Daniel Furmedge – No competing interests. Dr Benjamin Dean – No competing interests. Dr Hugh Harvey – No competing interests. Dr Natalie Silvey, No competing interests. Miss Stella Vig – No competing interests.

28 July 2015
Mohsin Khan
CT1 in Core Psychiatry, North West London Deanery
Dr Daniel Furmedge, Dr Benjamin Dean, Dr Hugh Harvey, Dr Natalie Silvey, Dr Zoe Norris, Miss Stella Vig
(Response is in our private capacities). CNWL NHS Trust, Stephenson House, 75 Hampstead Road, London, NW1 2PL