Jeremy Hunt was unwise to link consultants’ working patterns with an increased risk of hospital patients dying at weekends.
Jeremy Hunt has accused the British Medical Association of being a roadblock in the path to equitable care and outcomes for patients across seven days by walking out of negotiations aimed at removing a longstanding contractual opt-out for consultants who can choose not to work beyond 7pm.
This clause has been in existence since 2003, but has been effectively locally negotiated in many instances for consultants such as intensivists, anaesthetists, paediatricians and acute/emergency medics whose presence on hospital grounds is required round the clock. It is also unclear how many consultants make use of the opt-out in order to refuse being part of extended hours working.
Therefore, it may not have been wise for Hunt to link weekend mortality so closely with the consultant contract, implying that changes to the contract alone will serve to address the disparity between weekend and weekday mortality. The fact is that mortality measures continue to demonstrate a difference in outcomes for patients over the weekend but if urgent, emergency, high-risk or life support care is already provided by consultants 24/7 then where is the problem? Perhaps it is happening outside of the acute areas where patients who stay in hospital for weeks at a time can and do deteriorate rapidly with only a scant medical workforce to respond to them.
Interestingly, the majority of the social media backlash against Hunt – either calling for his removal or via #ImInWorkJeremy– comes from junior doctors or those consultants already providing care 24/7. While negotiations for the junior contract stalled at the same time as for consultants last year, there is already provision for juniors to work out of hours, financially recognised within their pay scales. The main difference for junior doctors at weekends is they can often double, triple or quadruple the number of patients they are responsible for at these times and are expected to respond and make life-changing decisions, often without on-site senior support in many of the non-urgent general medical specialties when the patients are frail and elderly with multiple complex medical problems.
So is it the speed of appropriate response to an unwell patient, a lack of on-site senior medical decision making and experienced support or a lack of weekend diagnostics and support services that contribute to the reduction in mortality out of hours? “All of the above” would seem the appropriate box to tick in this case.
We are already working 24/7
It is the junior medical workforce who are working on site tirelessly at the weekend, responding to deteriorating patients with little on-site support from senior colleagues, so you might think they would welcome a change that could bring about an increase in consultant presence out of hours. But, it is these same juniors who might soon become consultants who feel they hold the NHS together out of hours and are affronted by the words of Hunt and his implication that vocation and professionalism have been lost.
Perhaps the cynic might say that juniors don’t want removal of the consultant opt-out clause as they look forward to their post-training days when weekends and nights are no longer so onerous.
The bigger problem
Removing the out of hours working clause from consultants’ contracts is one step towards equitable services seven days a week but significant investment is required to protect Monday-Friday cover and elective services as consultants are spread through the week. However, add this cost to the required additional support services and one has to wonder if equitable services seven days a week is affordable – a much bigger problem for Hunt altogether.
Dr Jenny Harrop - Medical workforce specialist
Please note that the views expressed in this blog do not necessarily represent the views of Skills for Health.