30 March 2007
The latest strategy to get NHS waiting lists down is 24 hours a day surgery. But critics say it might endanger patient welfare, and boosting resources elsewhere would be more effective. Noel Plumridge reports
Back in the 1940s Jackson Pollock, the American painter and notorious 'wild man' of abstract impressionism, moved from New York City to rural Long Island in search of rest, inspiration and maybe even the occasional alcohol-free night. It wasn't long before Pollock's new neighbours beat a path to his neatly painted white door.
But they weren't complaining about the noise from parties, or even wanting to be photographed beside the famous man. No, they were concerned for his welfare. Was everything all right? 'You see', one gently explained, 'we keep seeing lights on at night in your house. And generally no-one round here stays up after 9:30.'
That was 60 years ago. Nowadays, we can shop at the supermarket at 3am, buy petrol for the car at 4am or ring a call centre at 5am to sort out a bank account query. Technology enables us to work very different hours than did our predecessors. When you send a business e-mail from home at 10pm on Sunday, it's surprising how often you get an immediate reply. The term '24/7' has become a fixture of our language.
But how 24/7 is society when it comes to a hernia operation or a hip replacement? When Tony Blair last month suggested introducing 24-hour surgery to help meet the government's NHS target of a maximum 18 weeks from referral to treatment, was he serious? Was this anything more than a soundbite from a prime minister trying to generate a headline containing the word 'NHS' without the accompanying 'deficit'? Doesn't he recall the fiasco of night court sittings?
Imagine what it might be like as a patient. After an evening spent on the ward trying but failing to sleep because of the heat, the lighting and the noise from two competing televisions, not to mention your own anxiety, you fall into a fitful doze.
A bleary nurse wakes you at 1:30am. After your pre-medication you are wheeled out to the lifts on a gurney by a jaded porter. The private portering firm has difficulty staffing night shifts and your porter doesn't yet know his way round the hospital that well. But he eventually finds the theatre suite.
Here another nurse welcomes you but can't quite suppress a yawn. And then you meet the anaesthetist and the surgeon, who both seem tolerably awake. But then, staying awake all night always was a central part of their medical training – it was bound to come in useful again.
It is unclear who would opt for a non-emergency operation in the wee small hours – even a minor one. And, with waiting lists falling, what is the problem that the prime minister is intending to fix? Yet the message of all-hours access runs through NHS policy, from Agenda for Change (staff flexibility) to this month's NHS policy review and pharmacy access.
To put it in context, the 2007/08 operating framework for the NHS in England includes four key targets (see below). Much has been written about the realism of target four, achieving financial health, and more about the challenge of reducing rates of MRSA and other hospital-acquired infections. But it's the target of a maximum wait of 18 weeks from GP referral to start of treatment by next March that still seems the most ambitious.
Before every PCT finance director in England asserts that the financial target is really the toughest, let's acknowledge that purely financial targets usually offer some scope for negotiation and manipulation. When Health Secretary Patricia Hewitt last summer reportedly staked her Cabinet career on NHS financial balance by this March, we looked first at the small print and the definitions, and then wondered what else would have to go to make breakeven possible.
If the NHS financial outturn for 2006/07 is indeed a small surplus, it will have been achieved at a high price in restricted patient care and deferred costs, especially in public health and in training. But the maximum wait target has two specific sub-targets: that by the end of March 2008:
- 85% of pathways where patients are admitted for hospital treatment should be completed within 18 weeks; and
- 90% of pathways that do not end in an admission should be completed within 18 weeks.
These leave very little wiggle room for NHS managers, although some might yet be created around the definition of where a pathway starts. Is it at the point of GP referral, or is it when the increasingly common referral centre or peer review process deems the referral appropriate? So how far does the solution lie in hospitals using their key capital assets, such as operating theatres, more intensively?
Traditionally, hospital wards at weekends have been sleepy places, with numerous patients marking time until Monday, consultants' rounds and discharge. But the modernisation movement dreams of transforming wards, and their supporting clinical processes, into what is, if not a 24/7 service, then certainly into a seven-days-a-week service. The 'Ten high impact changes' published by the NHS Modernisation Agency in 2004 estimated that discharging patients seven days a week, instead of the usual five days per week, could release 10% of all hospital bed capacity. Parallel changes on access to diagnostics could save 25 million weeks of unnecessary patient waiting time each year.
In some places this is moving from theory into practice. At the huge Cardiff and Vale NHS Trust in south Wales, medical ward staffing has recently been redesigned to accommodate seven-day working, and six additional physiotherapists are employed to avoid unnecessary admissions and prepare patients for earlier discharge. The average length of stay has fallen from 15 to seven days and projected savings have been assessed at more than 9,000 bed days a year: that is, near enough an entire ward.
Meanwhile, the NHS has succeeded in getting staff to work at weekends. Some see, in recent embarrassment at junior doctors without jobs, a cynical tactic to force this issue. 'Having 30,000 junior doctors compete for 22,000 jobs creates sufficient anxiety and insecurity for those with a job to work illegal hours covering holes in the NHS without whistle-blowing,' according to one medical commentator this month. Others maintain that clinicians, especially surgeons, will happily undertake more work if properly motivated. It's what they enjoy doing.
Blair's emphasis on theatre usage was repeated forcefully in management guru Gerry Robinson's recent BBC TV series (Can Gerry Robinson fix the NHS?), and all agree that we should get the maximum use from costly capital assets. However, the constraint on achieving the 18-week target is neither theatre time nor availability of surgeons. In recent years, the NHS has invested extensively in extra capacity, including considerable volumes bought in at above-average prices from the new independent sector treatment centres. In reality, there is probably little need for 24/7 surgery. The real bottlenecks in the system lie elsewhere.
Typically they are in diagnostics, where chronic skills shortages are still to be found. Without a radiographer to operate an x-ray machine there can be no x-ray image for the surgeon to use. This is one reason why diagnostics are at the forefront of the Department of Health's pressure on commissioners to 'unbundle' the payment-by-results tariff: a clear price is a prerequisite for major independent sector entry into the market.
More generally, bottlenecks occur when the hospital pathway encounters a wider world that isn't yet living and working the 24/7 lifestyle. For example, discharge from hospital is crucial to making beds available for new admission. If social care staff and NHS community nurses work Monday to Friday, this limits the smoothness of the slickest surgical production line. The Cardiff and Vale physiotherapists found that they could prepare patients for discharge, but discharge itself requires a broader co-operation.
There is an inherent tension between consumerism – the value underpinning the 24/7 culture – and the professional work ethos. In today's society many of us are both consumers and professionals. As consumers we expect, and enjoy, much freer access to all manner of facilities. Why shouldn't we be able to shop on Sundays, drink after 11pm and enjoy leisure pursuits when we choose? But this often depends upon other people working – therein lies the conflict. As professionals we increasingly value our work/life balance and increasingly would like to choose our working hours. Quite a few of us go part-time.
For a service that claims to aspire to 24/7, hospital car parks can be remarkably empty on a Friday afternoon, and during half-term week. Far from opening all hours, the NHS has become much more of a four-day week service.
This takes us full circle to the questions of who actually wants genuine 24 hours a day elective surgery and who is going to staff it? We might claim to be creatures of the 24/7 age, and de-industrialisation has released many of us from the bonds of the Monday-to-Friday factory shift system, but most of us still like to sleep in our own beds at night.
What people say they want isn't necessarily what they do want. One major London teaching hospital recently introduced 8am–8pm outpatient clinics in one specialism from Monday to Friday. But the early evening clinics are undersubscribed. Individuals might claim the option of a 7pm appointment is attractive – allowing greater flexibility, not taking time out of busy schedules and so on – but their behaviour tells a different story. The suspicion is that London office workers prefer to take time out of the working day.
Another little-explored issue is patient safety. Orthopaedic surgeons point to the correlation between more intensive bed use and higher MRSA rates. But this is not just about cross-infection, although squeezing NHS assets still further to get more patients through beds and theatres will probably not help with that particular target.
It is also about the human body's internal clock, which responds to the time of the day and seasons of the year. Many people suffer from seasonal affective disorder, for example. More pertinently, the time of day we are generally more likely to die is reckoned to be around 4am – there are specific patterns associated with some conditions, for instance, heart attacks occurring in the morning. Hence, wherever possible, operations on patients deemed to be at high risk are not carried out at night. Patients need to be at their physical best for anaesthesia and night surgery presents potential hazards to patient safety.
But our body clock doesn't recognise the days of the week, and Saturday and Sunday are now, for many of us, just normal days. So why not attempt something less ambitious than round-the-clock surgery? If there are problems with 24/7 theatre usage, maybe 16/7 would be a worthwhile start. Turning the NHS into a genuine seven-days-a-week organisation might be less of a headline-grabber, but it's possible, practicable and would make much better use of the assets we have.
Priorities for the NHS in England 2007/08
Priority one: 18 weeks maximum wait
'The key milestones to be achieved as a minimum by all PCTs and all providers by the end of March 2008 are:
- 85% of pathways where patients are admitted for hospital treatment should be completed within 18 weeks;
- 90% of pathways that do not end in an admission should be completed within 18 weeks.'
Priority two: reducing rates of MRSA and other healthcare associated infections
'We must do more to reduce the rate of health care associated infections in order, ultimately, to reduce the number of avoidable deaths… PCTs and providers have signed up to local targets for year-on-year reductions in MRSA infections … we expect PCTs and providers to engage with clinicians and agree local targets for a significant reduction in clostridium difficile infections.'
Priority three: reducing health inequalities and promoting health and wellbeing
'For 2007/08, PCTs need to focus on the interventions that evidence shows can have the biggest impact on reducing health inequalities. This builds on the recommendations in a review of the life expectancy target.'
Priority four: financial health
'By the end of this financial year we expect the NHS to return to net financial balance. 2007/08 will be a further year of financial recovery and we will require the NHS to make a net surplus of at least £250m across NHS trusts, PCTs and SHAs. We are also planning on the basis of a 2.5% efficiency improvement across the NHS.'
Source: The NHS in England: the operating framework for 2007/08 (DH, 2006)
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