Skirmish over seven day workingBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4082 (Published 29 July 2015) Cite this as: BMJ 2015;351:h4082
All rapid responses
This brief appraisal of the UK medical establishment and leadership is frank and long overdue when it comes to national health issues. Unfortunately, none of the current organisations for doctors have the representation and vision to lead in the way Newbold suggests. The traditional distaste for all things 'managerial' has made way to a reluctant preference for 'leadership' without delivery. The British Association of Medical Managers (BAMM) tried to fulfill this role but it is now defunct. It remains to be seen whether the Faculty of Medical Leadership will be more successful.
In order for doctors to step into an effective and naturally non tribal role in national health, fundamental changes in their education and training are required. Medical education for university and postgraduate purposes must have management and leadership modules tested by examinations. Training posts should routinely have meaningful management and leadership components as core objectives and some posts should be half time or full time dedicated to the employing Trust or NHS objectives. Some minor improvements are emerging, but still too few and far between.
Finally, medical management should brought back to the centre of the NHS by having a career structure and supporting system including middle grade managers as any other NHS directors have access to. Part of the task will be to address the lack or weakness of joint and binding objectives for medical professionals and the 'general managers'. Without this, we have little chance of successful medical leadership.
Competing interests: No competing interests
I thank Dr Hudecek for his remarks but he has not correctly interpreted my position. I have said both in my response, in articles in the BMJ and in the HSJ that
1. There are serious workforce issues not just in hospital medicine but general practice, therapies and nursing
2. There are serious funding issues threatening the sustainability of the NHS and serious underfunding in social care
3. There is insufficient capacity in a whole variety of step down community services not least at weekends to support hospitals
4. There are serious issues around variation in quality and care gaps especially in services for older people with complex needs and frailty
5. It is a very good thing to ensure that senior doctors are available and present in urgent care services 7 days a week till well into the evening
6. In my own service in my own speciality this is exactly what happens
How he comes to the conclusion that I think every service is fully up and running 24/7, I dont know, nor that a twitter campaign will solve all these problems
Clearly he hasn't been reading the same articles and comments I have been writing
Competing interests: No competing interests
Both Professor Newbold and Professor Oliver (in his lengthy reply) seem to suggest that optimal hospital day care round the clock is the norm and only a poor leadership is responsible for the true message not coming across.
It is, however, no secret that on a number of occasions the situation on the wards is suboptimal. Hence various initiatives like Early Warning Scores, Outreach Teams, Consultant Nurses etc. These are a poor man’s substitutes for a regular assessment of patients by adequately trained doctors. Professor Oliver raises 11 points but none of them prove that the patient care is sufficient regardless of the day of the week. Anecdotal examples about the hard working and dedicated profession are no replacement for facts. And these should not be difficult to come by. All you need to do is to take a representative sample of hospital notes and compare the daily entries (or lack of them) to indicate who saw the patients and how they were managed each day and night.
In the bad old days a patient was admitted under a consultant and his/her team and - unless deemed otherwise - stayed with the same team until his/her discharge. A team consisted of two House Officers, a Registrar and a Consultant. Teaching hospitals had the luxury of a Senior Registrar. Two consultants shared two wards (male and female). All juniors attended either consultant’s ward round. Thus virtually no patient was unknown to whatever doctor was on duty.
Now we have a consultant led service. Eventually we shall have three consultants per trainee (a euphemism for the resident doctor). Thus we have many generals and a very few foot soldiers. Despite the plethora of “generals” there is no leadership. Continuity of care (and quality of training) is a problem with junior doctors moving from one consultant to another every few weeks.
Like the GPs, consultants have done very well with the present contract. Most of these contracts consist (at the most) of four days of clinical work and the rest account for supporting activities (whatever they may be) and infrequent (compared to the past) on call rotas (these are anyway likely to bring in extra paid programmed activities).
A sad fact is that hard and extra clinical work (especially in the acute settings) brings no extra reward whatsoever. It is actually detrimental to gaining clinical excellence awards as little time is left for visiting various meetings, being an examiner (i.e. a person in possession of an answer sheet with tick boxes) and being involved in mostly dubious research (preferably some meta-analysis or a scrutiny of questionnaires) or making look grandiose mandatory improvements.
Changes to the present fairly inflexible consultant contract with its Programmed Activities (instead of contracted hours) should be opened to discussion. Chaos on the wards due to a ludicrous lack of physical beds compounded by the trend towards wards with mixed sexes and specialities make organised care extremely difficult and inefficient. Perhaps the time has come for the consultants to be graded by seniority and the junior ones taking some responsibility for resident cover as is the case in many of the Continental hospitals. Those involved in acute care should be amalgamated into functional teams and not rely on a so called cover by a colleague (who has not a faintest idea about the “covered” patients). Some routine outpatient care could be delegated to doctors wishing to work as office based specialists.
With the proviso that true academia is protected the money for clinical excellence awards should be directed towards efficient clinicians. With consultants' salaries some of the highest in the world some teaching (and virtually all self study) could be easily done outside normal working hours and time thus saved devoted to patients' care.
To conclude: If the medical profession thinks that the present unsatisfactory status quo can be maintained by a few indignant Twitter messages then the question of effective leadership is truly pertinent.
Competing interests: No competing interests
1. You can skirmish as much as you like. No use.
A thunderbolt might help. Let ALL the holders of CBEs, Knighthoods, Companionships of the Most Noble Order of Bath (CB for short) who are medically qualified and are on the GMC Register, return their honours to Her Majesty on a pre-arranged day.
You lose nothing, ladies and gentlemen. You will create such a storm in Westminster that the ministers will seek shelter in geriatric hospitals.
2. Professorships of Health Leadership?
All political leaderships end in failure - plummeting from dizzy heights to the depths of "has been".
You cannot lead - except by example of probity. And then too, you may be let down by self-seekers.
Too many professors.
Competing interests: No competing interests
Professor Newbold in his original article made it clear how diverse a profession medicine is, not just the split between general practitioners and secondary care specialists, but within those specialities, a very diverse range of roles and skills, not to mention public health. So the agendas within say general or trauma surgery, paediatrics, obstetrics or acute physician specialities including my own of geriatric medicine, opthalmology, microbiology, pathology or oncology are very different. Within the various disciplines I would re-iterate that doctors and their professional bodies have consistenly set out cohesive visions for change - for instance recently in the RCGP coalition for collaborative care or the RCP Future Hospitals Commission or the BGS Fit for Frailty and Care Home Medicine Campaigns or the national movement to improve palliative care and advance care planning through initiatives such as the Gold Standards Framework. Doctors have also driven much of the detail around training, revalidation, career structures etc (though have a legitimate right to oppose elements of Shape of Training) and in defining and measuring quality through good practice guidelines, national audits and registries. So Dr Newbold can't be referring to this type of work. I also note that NHS England has a Medical Director working alongside a number of national clinical directors and programme leads - which doesnt deal with similar issues in the devolved nations I realise but that NHS England is routinely having its toes trampled on by the DH and its ministers despite its statutory separation from the DH. But I am sure that Mark Newbold isnt referring to any of this.
What I think he is getting at is a clear and compelling vision of how medicine needs to change and adapt to meet changing population needs, different public expectations and therefore ways in which medical training, professionalism, regulation or workforce planning and deployment might need to change to address this.
Without being "austerity deniers" a starting point has to be realism about money and workforce and expectations. The recent Economist Intelligence Unit report (for those who feel the Commonwealth Fund report is ideology and opinion heavy and data poor) confirmed that UK health systems provide excellent value for money compared to most of OECD, have relatively few hospital beds doctors and equipment and provide good equity of access and value for money. So it's not unreasonable for doctors to say as part of the "vision" "let's resource services properly and staff them properly". If there is a serious crisis in recruitment and retention of GPs or Emergency Physicians, we should and must highlight this. We should also make the case for adequate social care funding and highlight the impact of the cuts. And we should make the case for realism and evidence behind promises (for instance the blind faith placed in admission prevention and "prevention" - which whilst good aims are not going to solve the urgent financial crisis. That realism and that call for adequate resource and staffing has to be central to any cross-speciality medical vision for change. Same applies to public health with drastically reduced budgets - a key part of the vision has to be adequate resources.
Having openly discussed money, workforce, and expectations if Professor Newbold is suggesting that we need a radical change in the way we do things, I would suggest that doctors' leaders (as shown in some of the initatives I have mentioned) realise that we need:
A shift towards prevention and wellbeing
A shift towards more generalim and care co-ordination, integration and continuity alongside vital specicialist roles
A shift towards more person-centred care and outcomes that matter to patients
Easier ways of communicating with clinicians or accessing information
Care models based more around users needs than what providers want to do
These realisations are shot through every document you read though easier to talk about than deliver consistently for everyone
I am therefore not sure what Professor Newbold is suggesting in implying that we haven't realised that all these things are important in the new world or aren't focussed on solutions
But a system in which someone with no background in the service, not inclined to listen to expert advice or work with professions, who has previously set out his desire to see the NHS model broken up, who is likely to be in post for a short time and often seems to bypass the very body set up for operational oversight and guidance to to the NHS and behaves as if wicked problems in a complex adaptive system can be solved with soundbites and which is being underfunded needs a strong voice of informed opposition - which is by the way, advocating for patients.
Just as it's possible to enjoy watching football and serious drama on TV or to have both clinical updates and new science side by side at medical conferences, so it's possible for doctors to set out constructive solutions but also challenge and debunk nonsense and defend themselves from attacks by politicians
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I am grateful to Oliver and Nesbitt for taking the time and trouble to respond in such detail.
It is unarguable, as Oliver describes, that individual doctors and the wider profession, at all levels and certainly including the NHS England Medical Director and the Royal Colleges, are responsible for devising, supporting and implementing a wealth of service developments and improvements. On a daily basis, they are continually leading and moving the service forward. All the more frustrating then, that similar influence is not achieved at the highest levels of public debate and policy making.
If Nesbitt's assertion, that the quality of DH and government leadership is open to question, is correct, then surely this supports my contention that a more cohesive and effectively led medical profession should be able to make the running at this level?
There are indeed different types of leadership. All approaches are valid, including the mounting of opposition and campaigning, and all can be effective in particular circumstances. But the health service faces many significant challenges that are not presently addressed, as Oliver describes so vividly.
What is needed now is a vision, and a set of proposals behind it, that describes a constructive and realistic way forward. If the medical profession had these, and united behind them, it would be much better positioned to lead this critically important national debate.
Competing interests: As described for main article
Newbold is correct to assert that the details of the consultant contract are relatively less important than the wider debate over healthcare policy.
He states that medicine needs visible leadership able to debate issues in terms relevant to the public, and that the leadership culture within medicine needs to be developed.
I would agree that there are many weaknesses in current UK medical leadership, but of greater concern and of lasting impact is the quality of leadership in the DH and government.
Politicians and governments have far greater power and ability than medical leaders in the manner of how to frame the issues of the day.
Repeatedly, history has shown that successive governments and health ministers have distorted and misrepresented facts, and have failed to reconcile or adequately explain often mutually exclusive, contradictory and ideologically driven policies.
The drift towards cutting services, reducing per capita funding, introducing insurance based schemes, and a number of more important issues currently occupy far less media space than the deliberate misrepresentation of consultants’ working patterns. This is a cynical and unhelpful approach to a difficult problem, and is largely driven by deliberate (or incompetent) government actions..
In 1940, Churchill offered only blood, sweat and tears, yet inspired a nation faced with defeat and occupation to fight on. Despite less dangerous times, Hunt’s chosen behaviour is to blame NHS staff for excess deaths and a lazy attitude to work.
Setting aside that these “facts” are flawed and misrepresented, or simply wrong, Hunt is, at the very least, a bad leader. He may also be badly informed, badly advised, and may even be a moron (this seems to be an acceptable term of political description these days).
The NHS faces enormous challenges (and most observers regard the financial targets as completely unachievable). To have a man leading the system whose staff have expressed extraordinarily low confidence levels in his ability to exercise this leadership does not auger well for success in meeting these challenges.
So, Hunt should go, but no-one should expect much change in the medical-political landscape with his successor, and that is more a reflection on our government than on the quality of our medical leaders.
Competing interests: No competing interests
Doctors are showing admirable collective leadership in response to Mr Hunt's Vision Speech and 7 day misinformation
Dr Newbold is an man I admire and respect. First as one of the few doctors to take on a hospital chief executive role in England. Secondly, for the honesty and integrity he showed when resigning from it. Third for his critique at the time of the pressures making his job impossible – in particular, funding and capacity In services outside hospital and heavy handed regulation and unrealistic expectations around performance of a hospital constrained by that wider system. So certainly not afraid to leave the Department of Health and its “arms-length” bodies unscathed in the cause of “leading from inside and not outside”.
He makes some interesting points about the need for more consistency and unity of purpose in medicine as a profession – irrespective of speciality or whether doctors are a member of the BMA or a particular college. And about the impression or confidence we might project to the public if we are constantly seen in oppositional or attritional mode.
This is fair enough, but first, I don’t accept the idea that our default mode is obstructive or that we avoid leading from inside the system. So many initiatives - whether leading service innovation, developing guidelines for good practice, describing variations and care gaps or pushing for new ways of working have come from the profession itself. Just think about what’s happened in the care of people with stroke or hip fractures or acute coronary syndrome the renal registry and NCEPOD report on acute kidney injury, the surviving sepsis campaign, the development of Acute Medicine, critical care warning scores and outreach. The Royal College of Physicians was leading on the Future Hospital Workforce and Future Hospitals Commission well before Mr Hunt set out his “vision” for more joined-up person centred services and most of members polled not only work on call at weekends already but are in favour (in principle) of seven day service provision.
Doctor also take on clinical lead, CCG lead, clinical, divisional or medical director roles throughout the NHS – often without much training, support, sufficient allocated time or remuneration. Colleges and societies consult widely with government and NHS England. Senior doctors work within and NHS England to provide clinical expertise and support quality Improvement. They take on numerous leadership roles around quality, professional societies , teaching, training and research.
Far from being luddites and laggards, the profession has shown repeatedly its drive and vision. And as for being less in touch with the public mood and societal trends, its worth re-iterating that public levels of trust in clinicians remain high as does reported satisfaction with the NHS. Satisfaction or confidence in politicians falls short of this.
Nor do doctors object to being led and challenged to up their game by credible, experienced peers and colleagues. A range of national programmes to improve care, driven by colleges, by clinical networks, by national service frameworks, colleges, specialist societies and national clinical directors have delivered over the years. Why? Because as we know from experience in other countries, quality improvement works better with guidelines and performance standards and data developed and owned by clinicians, based on credible evidence and with validity to practitioners. And doctors (even if not always in agreement) will engage with and follow experienced fellow doctors who have done the job , are respected for clinical skills and knowledge and exemplify the right behaviour. Sir Bruce Keogh NHS England Medical Director and the Academy of Medical Royal Colleges have both banged the drum for moving towards seven day services without anywhere near the flack that Jeremy Hunt received. Because people respected them and because their focus was on looking at what was possible within existing workforce, learning from organisations that had moved closer to seven day service provision and thinking carefully – using their hard won expertise, networks and street-cred about what might be needed to make it happen and the workforce implications.
So rather than using the 7 day stand off to make general assertions about the behaviour of the medical profession, we need to address the specifics of what Mr Hunts’s background and agenda and what he did and didn’t say .
First of all, neither Mr Hunt nor his predecessor Mr Lansley inspire confidence in the medical profession. In a democracy, not a technocracy, we know its rare for Ministers to have any background or expertise in health services. A US style system where experts can be appointed to roles might be an advantage but we are where we are. A minister with no background should at least listen closely to expert advice (not from political special advisors but from senior people in the sector). Neither showed much inclination to do this or to let NHS England (stuffed full of career NHS people including doctors) get on with its job
The Lansley Bill is widely perceived to have been a costly, confusing , unnecessary and entirely avoidable disaster at the Rose Review “accepted in full” by Mr Hunt, acknowledged. The £22bn efficiencies have been criticised by a whole range of expert commentators and experienced leaders as undeliverable. Social care funding has been savagely cut yet barely acknowledged. There is a major primary care workforce crisis and serious recruitment problems in key acute specialities. Hospitals are between a rock and a hard place with nursing numbers and recruitment – told by the regulator and in effect by Francis to increase numbers, then criticised for overspending and in most cases unable to recruit to their own target establishment numbers. Public demand for emergency care is rising inexorably and – like the delayed transfers of care at the back door, outside the hospitals’ gift to solve.
In this context, Mr Hunts “I have a dream” speech isn’t the “vision” Mark describes but a fantasy, with no acknowledgement that with no more money and no more staff and major efficiencies to find , the legacy of reorganisation and a medical and nursing workforce crisis, simply spouting soundbites and aspirations wont cut the mustard.
The medical profession (and on this subject Mark is silent here) has a deserved reputation for advocating publicly for the NHS and for patient care, for challenging nonsense from politicians and for debunking myths. Also for the development of empirical evidence and critical appraisal so that we have an evidence base on which to make policy. It is right and proper that we challenge half truths.
So back to 7 day services.
1. There is considerable debate about the figures on weekend mortality and whether we are comparing like with like. Even Sir Bruce Keogh acknowledged this at the select committee.
2. Relative vs Absolute mortality rates are very different but the spin doctors have selectively used data to ramp up scandal
3. Consultants cannot opt out of weekend acute working and the vast majority work weekends and evening on call across all the urgent specialities
4. Older consultants spent their trainee years on onerous on call rotas through many a night and weekend and younger ones are used to shift working at unsociable hours and come into consultant jobs expecting this to continue
5. Most physicians polled by the RCP are in favour in principle of 7 day acute service provision and the future hospitals commission (pre Hunt) and AOMRC (pre Hunt) were pushing the cause
6. A freedom of information request from the #ImInWorkJeremy site has shown that so far only 1 of 4,500 consultants in 14 hospitals opts out of weekend working in any case
7. We need to focus on delivering more even 7 day urgent and acute care services before we even think about routine work such as elective lists or clinics especially as it will often be the same staff groups and there is no more money to pay for the extra work
8. 9 in 10 hospitals forecast deficit this year and most CCGs are in financial difficulty. There is no money to pay for extra routine activity
9. Hospitals who have moved towards more 7 day working have done so without “Imposing” contracts
10. Medical directors and CEOs around the country haven’t been clamouring for contract changes – help is in the eye of the beholder
11. The viral and virulent reaction on #iminworkjeremy and #weneedtotalkaboutjeremy has had little to do with the BMA, has never mentioned money/payments and has had as many nurses, AHPs, junior doctors posting as consultants – its about solidarity and camaraderie and pride and offence at being labelled as having lost a “sense of vocation” and a “nine to five culture) (Mr Hunt’s words).
If Mr Hunt wanted to move towards a more 7 day acute and urgent NHS he could have been realistic about the money, the workforce, the timescales and not spun so blatantly against the profession nor given the Impression that it was somehow the BMA or the consultant contract that were the real problem, not attacked the professional integrity and commitment of doctors
He has reaped the whirlwind and even if he wins (as is likely) his battle about the contract, he has lost goodwill and engagement from the profession at the expense of grandstanding and soundbites. He will be gone soon but patients, the NHS and clinicians who dedicate their working lives to it will still be here. I would say the reaction to what he’s said shows exemplary leadership by doctors
Leading from inside is good when clinicians can buy into the change, but opposition and mythbusting are vital parts of good medical leadership
Competing interests: No competing interests