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Orthopaedists express concern about 7-day full coverage mandate in United Kingdom
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The National Health Service in the United Kingdom is working toward true 7-day general practice coverage by 2020 to improve outcomes for emergency and urgent care, according to the health service. The mandate, however, has been criticized by some physicians who contend there are insufficient details about how the coverage will work and a lack of funding for such extensive services.
Stephen R. Cannon, MA, MCh Orth, FRCS, MRCOG, a consultant orthopaedic surgeon at the Royal National Orthopaedic Hospital in Stanmore and past president of the European Federation of National Societies of Orthopaedics and Traumatology (EFORT), told Orthopaedics Today Europe orthopaedic services are currently covered 7 days a week in the United Kingdom.
Great care provided each day
Cannon noted the National Health Service (NHS) plan is not to have every operating theater at work 7 days a week, but to have more staffing available to decrease the mortality rates on the weekend. The problem, he said, is the lack of a concrete plan to achieve this directive. Nobody seems to know how many doctors or additional funding it will take to make it a reality, according to Cannon.
“The plan is to improve the emergency services and have the mortality rate the same on the weekend as it is in the week. The main problem, in the United Kingdom, is manpower. There are not enough doctors and skilled specialists to do this. You are talking, essentially, about additional specialists. It takes 8 [years] to 10 years from leaving medical school to produce a specialist,” Cannon, who is an Orthopaedics Today Europe Editorial Board member, said.
This plan got underway when U.K. Prime Minister David Cameron gave a speech in May 2015 that included a pledge to deliver a true 7-day NHS.
Mortality worse on weekends
In his speech, Cameron pointed to a study in the Journal of the Royal Society of Medicine in 2012 that found patients admitted to hospitals on a Sunday were 16% more likely to die than patients admitted on a Wednesday. Patients admitted on a Saturday were 11% more likely to die, the study results showed.
“It is a shocking fact, but mortality rates for patients admitted to hospital on a Sunday can be 16% higher than on a Wednesday, while the biggest numbers of seriously ill patients arrive at the weekend when hospitals are least well equipped to handle them,” Cameron said in the transcript of his speech.
Cameron and Secretary of Health, Jeremy Hunt, later announced plans for a 7-day NHS coverage by 2020.
Seven-day commitment
The 7-day coverage will be underpinned by a £10 billion commitment to general practice (GP) and NHS doctors, according to an NHS Department of Health representative.
“We are committed to providing the 7-day NHS that patients want and deserve. That means making sure people are able to see a GP in the evenings and on weekends to suit their busy lives and that if they are in hospital and need urgent care, they receive the same high-quality service on all 7 days of the week. Doctors and GPs across the country are already leading this change, with 17 million patients currently benefitting from extended GP access and hospitals, such as Salford and Northumbria, showing the benefits of a 7-day approach for staff and patients,” the representative told Orthopaedics Today Europe.
Priority clinical standards
According to information from the NHS Department of Health, more 7-day services will be achieved through the delivery of four priority clinical standards in hospitals, which were developed by the NHS services 7 Days a Week Forum, led by Sir Bruce Keogh. In October 2015, Cameron announced 25% of the population will have access to hospitals that meet these standards by March 2017.
The four standards relate to consultants being present to assess and regularly review patients, and being able to perform interventions. The standards also ensure patients will have access to urgent diagnostic tests and consultant-led interventions 7 days a week, according to information from the NHS Department of Health.
However, not all U.K. physicians are on board with the proposed plan. Therefore, the announcement of the standards that need to be in place by 2017 have been met with sharp criticism from surgeons and medical associations throughout the United Kingdom.
Funding problems
In a press release, Mark Porter, chair of the British Medical Association (BMA), criticized Cameron and Hunt for not clearly laying out how the plan will be funded and staffed.
“David Cameron has been clear that he wants to introduce the world’s first truly 7-day NHS, but less clear about how he intends to staff and pay for it ... however, there remains a number of unanswered questions, and with hospital trusts facing enormous staffing and funding pressures, this is simply unacceptable. Given the current funding squeeze on NHS Trusts, the only way for many hospitals to increase the number of doctors over the weekend would be to reduce the number of doctors providing elective care during the week,” he said the BMA press release.
According to Cannon, under the proposed plan junior doctors would not be paid overtime for Saturday work, and that, he said, has already led to threats of industrial action.
Junior doctors’ struggle
To make up for the additional hours of coverage, junior doctors will likely be expected to cover more emergency and urgent care hours on the weekend, David L. Hamblen, PhD, FRCS, of Glasgow, Emeritus Consulting Editor for Orthopaedics Today Europe, said.
By forcing the juniors to cover those weekend hours, it will reduce training opportunities in elective surgical procedures with their senior doctors, he noted.
“Under European legislation, we are limited to 48 hours of work a week and that includes their (junior doctor) training. So the real problem is, if you move more juniors into the weekend to staff that, their training will inevitably suffer. There will be a less close link with their seniors,” Hamblen said.
Teamwork lacking
The old practice of a senior doctor having a team of middle and junior doctors working under him or her on a daily basis and being available for surgery are over, Hamblen said. Staffing will be even further stretched if the juniors are forced to cover the expanded weekend hours, he noted.
“Many of my colleagues who are still working are saying you do not know who is going to turn up in the operating room with you, or be on duty with you. You may have never seen them before. It certainly does not make for smooth care of patients,” Hamblen said.
According to George Bentley, MB, ChM, DSc, FRCS, FmedSci, there is also widespread frustration in the NHS regarding inadequate numbers of established junior and training posts and the proposal by the government to cut pay by insisting that weekend working will not be paid in the future at emergency rates. Consequently, an overstretched junior staff sees no clear indication of funding and additional staffing for the plan, which will likely be needed for it to become effective and possible.
As it stands, the government is aiming to produce a 7-day service from 5-day staffing and resources, he noted.
“Successive governments and politicians wish to make an impact so that the NHS undergoes a new review with each new administration. If the government is committed to the NHS, which many doubt, and this country could afford it and could give us a 7-day service, great. But there is not even a proven, huge demand for it. But, you cannot do it without the money. I think that is simple,” said Bentley. He is past president of EFORT and Emeritus Professor and Director of the Institute of Orthopaedics and Musculoskeletal Science at the University College of London, Hon. Consultant Orthopaedic Surgeon at the Royal National Orthopaedic Hospital, Stanmore, and an Orthopaedics Today Europe Editorial Board member.
According to information provided by the NHS Department of Health, the Spending Review gave the NHS £10 billion real terms of additional funding by 2020 to 2021 during the course of 2014 to 2015 with £3.8 billion real terms growth offered 2016 to 2017. The thought behind that is the delivery of 7-day services should provide better efficiency through reduced lengths of stay and better use of expensive equipment, for example.
On Dec. 16, 2015, the U.K. government announced additional funding in the form of a £1.8 billion sustainability and transformation fund that is designed to help Trusts reduce their deficits and allow them to focus on transforming services for patients every day of the week, according to the NHS Department of Health. However, an independent financial review by The King’s Fund reported 88% of Acute Trusts were reporting an overspend of £930 million in the first 3 months of 2015 to 2016 with an estimated deficit of more than £2 billion by year end, Hamblen noted.
Secondary 7-day care
Cathy Hassell, head of clinical programmes and team support for NHS England, presented on secondary and elective care for 7-day NHS coverage at the British Orthopaedic Association Annual Congress in 2015. She said it is the government’s commitment to ensure patients can see a GP and receive the same quality hospital 7 days a week by 2020, with hospitals properly staffed so the quality of care is the same every day of the week.
At this time, Hassell said, the NHS is not issuing a mandate that all hospitals provide elective and secondary surgery 7 days a week. If this was a mandate, she noted, the NHS realizes it would face staffing issues throughout the country.
Good concept in theory
The proposed mandate is good idea in theory, Cannon said, but is not possible to execute the way it is being presented by the government.
“The actual orthopaedic workforce is already doing this [7-day coverage]. It is not a criticism of them [the NHS] in any way, but it is the fact that the hospital services around them are not supported on weekends and out of hours. It is how you modify that, which is the important thing the government is trying to do. Every doctor would like to be treated as a patient, and therefore, we would like that service to be available, to work and to be financed. But, it is not going to be in this present financial market,” Cannon said.
He said the bottom line is many people working for the NHS believe they can no longer be completely sustained by public finance. Another methodology of financing the NHS and its departments and programs may be the correct route to take in the future, Cannon noted. – by Robert Linnehan
- References:
- British Medical Association. BMA press release archive. Questions still remain over 7-day services – will David Cameron use his conference to provide the answers? Available at: http://web2.bma.org.uk/pressrel.nsf/wall/17CDF504B63BB4CE80257ED20057E1FB?OpenDocument. Accessed Jan. 20, 2016.
- Freemantle N, et al. BMJ. 2015;doi:10.1136/bmj.h4596.
- Freemantle N, et al. J R Soc Med. 2012;doi:10.1258/jrsm.2012.120009.
- Gov.UK. Speech. PM on plans for 7-day NHS. Available at: www.gov.uk/government/speeches/pm-on-plans-for-a-seven-day-nhs. Accessed Jan. 20, 2016.
- Hassell C. BODS; Seven-day services in secondary care. Presented at: British Orthopaedic Association Annual Congress; Sept. 15-18, 2015; Liverpool, United Kingdom.
- National Health Services. NHS Improving Quality in Collaboration with NHS England. NHS services – open 7 days a week: Every day count. Available at: www.nhsiq.nhs.uk/media/2416738/every_day_counts.pdf. Accessed on Jan. 20, 2016.
- For more information:
- George Bentley, MB, ChM, DSc, FRCS, FmedSci, can be reached at Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, United Kingdom; email: profgbentley@btinternet.com.
- Stephen R. Cannon, MA, MCh Orth, FRCS, MRCOG, can be reached at EFORT Head Office, ZA La Piece 2, CH - 1180 Rolle, Switzerland; email: cannon.frcs@gmail.com.
- David L. Hamblen, PhD, FRCS, can be reached at University of Glasgow, Glasgow, G12 8QQ, Scotland; email: dlhortho@doctors.org.uk.
Disclosures: Bentley, Cannon and Hamblen report no relevant financial disclosures.
What orthopaedic services, if any, should be available in your country through true 7-day, 24-hour coverage?
Patients may suffer consequences
Austerity and welfare contraction is a feature of the current Europe, whether in the Eurozone or not. The British government, as throughout Europe, is cutting down budgets for public health and medical care services. The current struggles with registrar doctors are an example.
On the one hand, in the United Kingdom, the 7-day opening of local practice surgery services is mandated to be fully in place by 2020, and orthopaedic care is expected to be included within this new service, which looks to be an improvement of care delivery. On the other hand, new initiatives require specific budgets, and thinking that cuts are coming does not require special analysis.
Technology use is an important burden for the [National Health Service] NHS economy but an important help for the diagnosis of severe problems of the locomotor system function. Hand injuries, ankle sprains — which can turn out to be fractures — and little traumatic osteochondral lesions require a well-trained orthopaedic surgeon and the use of proper technology. Where the cut line is for spending money on continuous education programs is unknown. Patients will suffer the consequences in any case.
Other countries, such as Spain, also are following models for cutting down budgets. Prescriptions by nurses, direct eye checks for glasses by opticians, not by ophthalmologists, and some other initiatives are trying to bypass “expensive” doctors in favor of other “cheaper” professionals. So far, orthopaedic surgeons in Spain are out of the 7-day local opening of local practice debate. Regional governments have directly diminished the number of them available on call, indeed 7-days per week.
Enrique Guerado, MD, is a professor and chairman of the Department of Orthopaedic Surgery and Traumatology at Hospital Universitario Costa Del Sol, University of Malaga, in Marbella, Spain.
Disclosure: Guerado reports no relevant financial disclosures.
Trauma needs full coverage
In Norway, the orthopaedic 24/7 services should cover the following diagnoses/conditions: multi-trauma with orthopaedic injuries; unstable pelvic fractures with severe vascular injury; open fractures (Gustilo-Anderson III); fracture dislocations; joint luxations with or without neurological or vascular injuries; acute compartment syndromes; some pediatric fractures (like supracondylar fractures with a pale and pulseless hand); pediatric lower extremity fractures caused by high energy; septic soft tissue and joint infections; spinal disorders with progressing neurological symptoms; soft tissue thermal injuries; and thermal injuries with fractures.
The 24/7 services also should consist of taking care of any early onset postoperative complications. The reason for this is that these diagnoses can be life threatening, if untreated, or they can cause severe disability for the patient if treatment is started too late.
Ketil Holen, MD, PhD, is a consulting orthopaedic surgeon and assistant professor at the University Hospital of Trondheim - NTNU, in Trondheim, Norway.
Disclosure: Holen reports no relevant financial disclosures.