How Jeremy Hunt derailed clinician led progress towards a seven day NHSBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i187 (Published 13 January 2016) Cite this as: BMJ 2016;352:i187
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
As a physician involved in training and supporting those trainees with differing needs, the current junior doctors' strike may cause more harm to trainees than we perceive.
I offer an old folk tale. Some 200 years ago in a nameless village in a rural English county there was a village elder. He was an intelligent and principled man who was concerned for the people of the village.
Autumn and Winter were tough in the country and provided challenges for all the villagers.
As he pondered this difficult season, he observed a strange phenomenon. Just before the nights darkened and cold winds began to bite, the village cuckoos would fly away. As the days began to warm, months later, and the green shoots began to show the cuckoos returned. He was a wise man but wanted to check what he was seeing was true, and so he asked another elder to verify his findings. Indeed, the observation was predictable and reliable and so they both sat down and considered what to do. The decision was clear, they called all the village to a meeting to discuss the plan. If the cuckoos were not to leave, the winter would not visit the village, and summer warmth would give way only to green shoots of Spring. All agreed that what they said had merit and the obvious course of action was to capture the cuckoos and not let them go. Much effort resulted in finally marshalling all the beautiful birds, reluctant though they were, into cages. But the winter still came and the birds, unable to resist the cold weather, one by one died.
The moral of the story - The explanation for all we observe is not always what we believe it to be and if we force a solution we may harm those who are not responsible for the issue we are observing.
As the government considers a problem we are all eager to solve, let's hope they first "Do no harm" to those most valuable to the sustainability of the future NHS.
Competing interests: No competing interests
Yesterday I watched a YouTube video of NHS England Medical Director Prof Sir Bruce Keogh being interviewed on the BBC Andrew Marr show in December 2013 (1). The focus of the interview was his vision for extended seven day NHS services as endorsed by Secretary of State for Health Jeremy Hunt. This predated the current discussions and so provides a useful insight into prior strategy and planning. The rationale is well summarised in this interview and begins with a statement of need relating to excess deaths associated with admission to an NHS hospital at the weekend. The interview ends with a discussion of plans to force change in the doctor contract and with a statement regarding planned “radical changes” and the availability of the necessary “hard levers”. This has caused me to research the definition of “hard levers” and also to revisit the primary driver for change of “excess deaths associated with weekend admission”. You may find my observations interesting.
My attempt to understand the term “hard lever” led me to the web-site of Dr Peter Fuda “a prolific change agent, and a globally respected authority on business and leadership transformation.” (2) He states that “transformation is not a matter of intention. It is a matter of alignment.” He also states that “Organizational alignment is achieved through 11 levers.” There are 5 “hard levers” (which act like “bricks”) and 5 “soft levers” (which act like “mortar”). The final foundational “lever” is “leadership Impact” which is said to be as important as the other 10 “levers” combined.
In the 2013 Marr interview Bruce Keogh makes it clear that he and Jeremy Hunt are united in their leadership of the proposed “radical change” to the NHS and so also united in bringing to bare the foundational “lever” of “leadership impact”. Stated in that interview and then later by Jeremy Hunt (July 16th 2015; 3) – is the perceived need to force change in the doctor contract. In advancing this “muscular” approach to change both have sought to use the concept of excess weekend deaths as a “hard lever” for change. Indeed coincidental to Jeremy Hunt’s announcement on July 16th 2015 has been the completion of a new and “definitive” analysis that advances the concept of an annual excess of 11,000 deaths in association with weekend hospital admission (4).
In a stunning example of the “cup being half empty” we are informed that there is a 15% greater chance of death over the 30 days following a Sunday admission as compared to a Wednesday admission. For an emergency or urgent admission this risk is slightly less at 13% (5). By default this approximates to a 20% excess risk for an elective Sunday admission. This provides the strongest evidence, currently in the public domain, that the risk adjustment model is flawed (6; Fig.1). The nature of an elective admission is that it is not an emergency nor is it urgent. Furthermore, we know that elective procedures do not take place on a Sunday – but also that very high risk elective surgery is frequently scheduled for the following Monday.
So we are left with a “hard lever” which has instead become a “stick” that is being used to aggressively drive change (7). We have been promised "a 7-day NHS, safe in our hands - for every generation to come" (8) but instead are experiencing the reverse transformation (9). In my opinion this is due to adverse “leadership impact” and also due to failure to adequately value the 5 “soft levers” of transformational change (i) shared behaviours (ii) communication (iii) the organization’s existing assets (iv) leadership time, focus and money (v) how the change effort sustains itself.
If the “seven day NHS” vision is to stand any chance of getting back on track (7) then there needs to be an immediate and dramatic change in “leadership impact”. If the public / NHS staff are content to see further transformation into a “denationalised” and “out-sourced” healthcare system - then no further action is required.
Alistair S Hall
Consultant in Cardiology / Professor of Cardiovascular Epidemiology
Leeds Teaching Hospitals NHS Trust / Leeds School of Medicine. @alistair5hall
Competing interests: BMA Member. Father of two Junior Doctors Mentor to many other Junior Doctors. Consultant who delivers weekend patient care.
1. “Sir Bruce Keogh on 'supermarket' NHS.” Recorded from BBC2 HD, Andrew Marr Show, and 15 December 2013. https://t.co/ZReDMJQCuh
2. Fuda P. “The 11 levers of Organizational Alignment.” Posted on January 29, 2015. http://www.peterfuda.com/2015/01/29/11-levers-organizational-alignment/
3. The Rt Hon Jeremy Hunt MP. Speech at Kings Fund July 16th 2015. Speech. “Making healthcare more human-centred and not system-centred.” https://www.gov.uk/government/speeches/making-healthcare-more-human-cent...
4. Freemantle N, Ray D, McNulty D, et al. “Increased mortality associated with weekend hospital admission: a case for expanded seven day services?” http://www.bmj.com/content/351/bmj.h4596
5. Freemantle N. “Rapid Response.” 28 October 2015 http://www.bmj.com/content/351/bmj.h4596/rr-45
6. Smart C. “Rapid Response.” 20 October 2015. http://www.bmj.com/content/351/bmj.h4596/rr-40
7. Godlee F. (Published 13 January 2016) “How Jeremy Hunt derailed clinician led progress towards a seven day NHS.” http://www.bmj.com/content/352/bmj.i187
8. The Rt Hon David Cameron MP. “PM on plans for a seven-day NHS.” https://www.gov.uk/government/speeches/pm-on-plans-for-a-seven-day-nhs
9. Sky News. January 6th 2016. “NHS Under Pressure, Admits Health Secretary” http://news.sky.com/story/1402915/nhs-under-pressure-admits-health-secre...
Competing interests: Competing interests: BMA Member. Father of two Junior Doctors Mentor to many other Junior Doctors. Consultant who delivers weekend patient care.
In the English Premier League, significantly more goals are scored attacking from the right side than the left, so clearly the FA should instruct managers to make defending players spend more time on the left side of the pitch. What could possibly go wrong?
A minister taking on a challenging new brief like healthcare will naturally look for a quick “goal-on-the-break” – ideally one which can be shown to “save lives”. What better target than the long-rumoured “weekend effect” in hospital deaths - obviously due to the fact that consultants spend their weekends on the golf course, leaving a few inexperienced house officers to hold the fort (a not-too-outrageous caricature of the NHS 40 years ago)? Doctors are always harping on about “evidence” nowadays, but by a miraculous coincidence a group of senior medical academics and directors, including the clinical director of the independent NHS England, are about to publish a definitive study of nearly 16M admissions and 290,000 deaths, comparing weekend and weekday mortality rates .
To the untutored eye this shows that there are 1,170 fewer deaths annually among patients admitted on Saturdays and Sundays than on average weekdays, but the Profs made sophisticated statistical adjustments to allow for the fact that there are 60% fewer admissions on weekend days, far fewer planned admissions and some differences in measurable “case-mix”. Allowing for reduced numbers of admissions and converting numbers to proportions is enough to change an annual deficit of 2,340 deaths on weekend days into an unhealthy surplus, which can be easily worked into parliamentary speeches.
When it was eventually published – with some further adjustments to remove Mondays and Fridays (with inconveniently higher death rates) from the weekday base-rates – the study stamped the seal of scientific respectability onto the weekend effect [1,2]. Even though there was no way of allowing for the obvious tendency of people with milder symptoms to wait until Monday before calling the doctor, the statistical modelling was impressive enough to convince many doctors as well as politicians that the adjusted hazard ratios of 1.1 and 1.15 for Saturday and Sunday admissions were real , and that something needed to be done.
Thus a difference in mortality rates of just under 0.2% in absolute terms, indirectly estimated by comparing completely different patient populations, became both a political and a clinical priority. As scientists, the authors cautioned: “to infer that (the excess deaths) are avoidable would be rash and misleading” (less than 5% of hospital deaths are thought to be avoidable ). Yet one of the paper’s key messages reads "around 11,000 more people die each year within 30 days of admission to hospital on Friday, Saturday, Sunday or Monday compared with admission on the remaining days of the week” and the title itself leaves little doubt that the authors are pushing an agenda for action. Notwithstanding the complaints of journal editors , who are politicians to argue with ex cathedra pronouncements like these?
So clearly new formations must be tried. Players must be switched around - and the louder they complain the better it looks for managerial and political machismo. Contracts need to be changed to wipe out the distinction between weekends and weekdays, even if this provokes the first doctors’ strike in 40 years and promotes an exodus which allows governments in the former dominions to reduce their medical training budgets: “11000 lives saved” is a headline worth striving for. Obviously the doctors’ representatives know better what needs to be done and will condemn any alternative view as an attack on the founding principles of the NHS.
Nobody familiar with busy weekend medical or surgical takes will dispute that staff can sometimes be dangerously overstretched or that access to investigations and other resources needs to be improved. The NHS is a funny old game, though, so it is not always possible to predict the consequences of any tactical shift. Silly suggestions, like trying to identify potential ways of reducing avoidable deaths by getting experienced clinicians to do regular audits of critical incidents in other trusts, are obviously impractical. Extremist radical ideas, like allowing different regions or trusts to try out different rotas and contracts, perhaps even on a randomised basis to give comparisons of performance measures and mortality rates a semblance of validity, can be dismissed with a wave of the hand. Far better to continue producing regular league tables, using a conveniently opaque scoring system, and change the managers each time a trust drops into the relegation zone (regression to the mean will at least give new managers a good chance of a successful start).
With the Health Service, just as with our national game, everyone is an expert. If the NHS is the closest thing we have to a national religion, let’s all join a crusade to save our New Jerusalem - even if it ends up being destroyed in the process.
1. Freemantle N, Ray D, McNulty D, et al. increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351: h4596
2. Aylin P. Making sense of the evidence for the “weekend effect”. BMJ 2015;351:h4652.
3. 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
4. Rimmer A, Kmietowicz Z. BMJ editor writes to Hunt over misuse of weekend mortality data. BMJ 2015;351:h5624
Competing interests: No competing interests