The Fallacy of Hunt

Posted on October 29th 2015 by Gagan Bhatnagar on the clinioncdoc.

“Sorry, this is quite complex for early in the morning” – Jeremy Hunt

The time: 07.15 on the 29th of October 2015 on the BBC.

What Mr. Hunt was trying to explain was how junior doctors working “within the legal limit” will not see any reduction in their pay.

By comparison, thousands of junior doctors have been up all night caring for patients. They would be expected to make life-saving, high-pressure decisions at 07.15 after being awake for 10 hours without so much as a bathroom break. The kicker – this time is classed as ‘social hours’ or ‘plain time’.

Fallacy 01: If Mr. Hunt can not manage simple arithmetic at 07.15 because it is too early in the morning, should he be peddling ‘sociable’ working hours of 0700-2200 Monday to Saturday for doctors? – Where doctors receive no additional remuneration for working outside of the standard 9-5 time bracket.

Given that Mr. Hunt is not particularly strong in arithmetic, we may want to delve deeper into what he is promising for the hard-working junior doctor workforce. He proposes the following: 

• A reduction in maximum working hours from 91 hours/week to 72 hours/week
• A pay envelope that is cost neutral – that is to say, no money is being put in or taken out from the pot of money used to pay junior doctors.
• Extending services by 40% to  include Saturday and Sunday
• No additional doctors will magically appear to fill in for these extended services.

Let’s provide an example with some estimated rounded figures

• Let’s say, for any given week, a hospital requires 100,000 junior doctor man hours (JDMH).
• Let’s say there are 1000 doctors in the hospital each working 100 hours/week to achieve this.
• By extending services by an extra 2 days – the hospital now needs 140,000 JDMH.
• However, there are still only 1000 doctors (a deficit of 400 doctors).
• The hospital now requires 140 JDMH per week per junior doctor.
• However, there is no additional money being inserted into the system. So, that’s 40% extra for no additional cost.
• But now the maximum number of hours a doctor can legally work is reduced to 50 hours / week so the hospital needs 2800 doctors to cover the 140,000 JDMH.
• Again, there are no more doctors, there is no more money – the solution: to make doctors’ labour cheaper and make them work ‘off the books’.
• Alternatively, this could be done at the expense of closing services on, say, a Wednesday to reduce the number of JDMH required by the trust.

Fallacy 02: If there are no more doctors, and there is no more money, extending services by 40% will mean the same doctors are doing this from the same pay envelope. That is, more work for no extra cost. His intentions were made clear by increasing plain time from 60 hours/week to 90 hours/week.

Mr Hunt has reduced the maximum number of hours that a doctor can ‘legally’ work. Doctors already go far beyond their contracted hours and don’t ask for a penny more. Doctors DO NOT work 91 hour weeks because of perverse monetary gain. They work these hours because there are simply not enough doctors, because there is a NECESSITY to work these hours.

Fallacy 03: By reducing the maximum hours but not increasing the number of doctors in the pool, he is advocating an increase in unpaid ‘off the books’ labour of the current doctor workforce. This is confirmed by the removal of financial penalties to trusts for over working doctors and the removal of regular hours monitoring – both of which acted as safeguards to prevent a fatigued workforce.

Mr Hunt keeps mentioning patient safety on weekends. The rhetoric of 15% higher mortality at the weekend. The dreaded ‘weekend effect’.

Let us be clear, Mr Hunt keeps quoting a research paper by Freemantle et al (2015). Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

The ‘weekend effect’ describes Friday to Monday (4 days) where a patient is up to 15% more likely to have died 30 days after admission. That’s right…1 month after admission to hospital.

Courtesy of Freemantle et al 2015 – 30 day mortality, relative risk by day compared to wednesday

To simplify this image – if an unwell patient is admitted on a Friday you have a 2% increased chance of not being alive 1 month later compared to a wednesday. Saturday 10%, Sunday 15% and Monday 5%.

The same study showed that an inpatient had a 1% LOWER chance of dying if they were in hospital on a Sunday compared to a Wednesday (although this value was not statistically significant) and a 2% LOWER chance of dying as an inpatient on a Saturday compared to a Wednesday (this was statistically significant).

Courtesy of Freemantle et al 2015 – In hospital mortality in comparison to wednesday

In fact, your risk of dying IN HOSPITAL is LESS on Saturday and Sunday than a Wednesday as Freemantle demonstrated in 2012. Weekend hospitalization and additional risk of death: An analysis of inpatient data.

Courtesy of Freemantle et al 2012 – mortality divided by day

Fallacy 04: Doctors do not deny a ‘weekend effect’. However, the cause of this effect is unknown. It has been observed that globally, more acute / unwell patients are admitted on the weekends and it is speculated that this is a major contributing factor to increased 30-day mortality. It is unlikely to be related to junior doctor staffing on Saturday and Sunday as indeed, mortality on those days actually DECREASES compared to when the hospital is more fully staffed.

The authors of the paper Mr Hunt so readily quotes have stated quite clearly:

“It is not possible to ascertain the extent to which these excess deaths may be preventable; to assume that they are avoidable would be rash and misleading.”

Fallacy 05: So why is Hunt being “rash and misleading”? His motivations are unclear. If this were truly about patient safety, Mr Hunt would promote more research into the actual cause of the weekend effect. Is it that patients are genuinely more unwell towards the latter half of week? Why is this? Is it the lack of social care facilities available at the weekend? Is it our weekend habits of excess alcohol, smoking and generally unhealthy lifestyles? Is it truly the lack of junior doctors or nursing staff? Is the lack of access to community GPs on the weekend? Is there a decrease in compliance when taking medications at the weekend?

There are no answers yet, only questions.

To steamroll through changes to try to fix an unknown is haphazard and foolhardy. Or perhaps he has an ulterior political agenda? Why else would the health secretary ignore the pleas and calls from the ENTIRE health workforce (including all the Royal Colleges) who have unparalleled insight into the workings of the NHS?

I am no politician.

Mr Hunt’s weakness with numbers is apparent. I, however, am trained to interpret scientific research. To analyse and critique data for the sole purpose of improving outcomes for my patients.

Patient safety is my calling. Is it truly yours Mr Hunt?

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See Gagan Bhatnagar's blog on the clinioncdoc.

An Apolitical Creature

Posted on October 27th 2015 by Gagan Bhatnagar on the clinioncdoc.

I am not a political creature.

I’m a doctor. I’ve spent the last 12 years of my life rigorously training to be able to look after the public. My training continues even now, as a clinical oncology specialist registrar (cancer specialist), and I look forward to many more years as a junior doctor. Up until now I did not worry myself with politics, perhaps naively assuming the UK government had the peoples’ best interests at heart. 

Why is this important? Why is this relevant? Because today I am no longer that person. Today I am angry, I am frustrated, I am genuinely worried. 

20,000 doctors turned up in London to protest contract imposition

The NHS is under attack and it WILL NOT survive without public support.

The Health Secretary,Jeremy Hunt, and the government are in the process of undermining and attacking doctors throughout the nation with the imposition of an unsafe and unfair contract. The details of this contract have been covered extensively in the media but, put simply, will lead to:

1. The removal of safeguards protecting junior doctors from overworking by removing financial penalties on hospitals for scheduling work-heavy rotas.
2. Removal of pay progression if doctors go into clinical research (yes…including cancer research) or decide to work part time to have a family – essentially penalising doctors for doing research or having a family.
3. Extending ‘plain time’ by 50% from 60 hours/week to 90 hours/week. (By comparison the average 9-5 job has plain time of only 40 hours) 
4. This will lead to a pay cut of up to 30% which will hit the acute specialties who do the most antisocial hours (Accident & Emergency, Intesive Care, Obstetrics, Acute medicine) that are already struggling to recruit doctors.
5. Recommended 20 minute break every 6 hours. That’s right…if I do an 11 hour shift, I am afforded only 20 minutes (including my time for lunch)

These are amongst the few of the recommendations from the Doctors’ and Dentists’ Review Body (DDRB) which, suspiciously, lacks either a doctor or dentist on the panel. In fact, not a single front line health worker was on the panel to provide insight into what happens on the shop floor.

The government are suggesting these proposals are to provide a 7 day NHS while maintaining cost-neutrality. Let’s be very clear about this:

The NHS is a 24 hours/day, 7 days/week, 365 days/year service

 

Proof of a 7 day NHS. Thousands of placards held for doctors unable to attend as working on a saturday.

Distinctions between emergencies and routine care is something our Health Secretary has been unable to do. 

Emergency care is always covered, round the clock. 

However, if you would like that routine operation to remove a bunion, it may not be available on a Saturday or Sunday. The simple reason for this is that there just aren’t enough doctors, nurses, radiographers, healthcare assistants, porters, pharmacists, secretaries, cleaners on the weekend to achieve this. 

Herein lies the problem. The NHS is cash-strapped. Long term underfunding from the government has left the NHS on the brink of collapse. At present it is struggling to hold together a 5 day service and indeed may only be being held up by the good will of the staff who work an insurmountable number of unpaid hours for the benefit of the patient. 

The government are imposing an increase in productivity of 40% (2 extra days) without providing any more money or more staff. It has been suggested that for there to be such an increase, the NHS would need to recruit over 30000 more doctors(currently there are 53000 junior doctors). It does not take an economist to tell you this is fool hardy and short sighted. 

The proposals suggest same number of doctors will cover an additional 40% of the service. This will stretch the regular 5 days in the working week even thinner. At a time when staff are at breaking point, this will be the anvil that breaks the camel’s back.

Surveys have shown, if these contracts are unilaterally imposed by the government, up to 70% of junior doctors would move abroad or give up medicine entirely. Even if only a small fraction of this number leave the workforce due to unreasonable working conditions, this would have catastrophic implications for a stretched service.

So why? Why go against the advice of 53000 junior doctors and all the Royal Colleges who have unparalleled insight into how the NHS functions?

To paraphrase Noam Chomsky: Underfund,  Villify, Demoralise, Privatise.

In the long run, doctors would benefit from a privatised healthcare system (case in point The United States Of America). It will be the patients that suffer. So it should be ringing alarm bells when as a workforce we are fighting desperately to avoid it. The reason is simple…patients will suffer.

From day one, we are indoctrinated with one mantra – Do No Harm. As a workforce we go above and beyond for patients, we dedicate our lives to serve the public.We are not perfect and we make mistakes – we are after all human, but our goal remains singular.

Our previous health secretary, Mr Andrew Lansley, now sits on the board for a firm promoting privatisation of the NHS. There is no reason the current health secretary will not follow suit.

The imposition of these contracts would only be the beginning of the downfall. Nurses would be next, then pharmacists, then radiographers.  Then the reality of paying thousands of pounds for surgery for your burst appendix or for your grandmother’s hip operation, or hundreds of thousands of pounds for your cancer treatment may become a reality. Once the system is broken, there will be no going back. But those that have made the decisions on your behalf will already have lined their pockets.

So what can you do? Write to your MP. Voice your concerns. Join the debate. Support your junior doctors should they reluctantly ballot to strike. Start telling people. If you don’t stick up for the NHS when it needs you, it won’t be here much longer to stick up for you.

While it may not seem it now…this is everyone’s fight. 

I am not a political creature.

 I am a doctor.

#juniorcontract #notsafenotfair #saveourNHS 

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See Gagan Bhatnagar's blog on the clinioncdoc.

Avoidable Hospital Deaths - Who is Really to Blame?

Posted on October 22nd 2015 by Steve Smith on Big Up The NHS.

So Fiona Godlee, editor of the British Medical Journal, has at last written to Jeremy Hunt accusing him of “publicly misrepresent(ing) an academic article printed in the BMJ”.  She referred to theFreemantle paper which clearly demonstrated a statistical excess of deaths in patients admitted to hospitals over the weekends but which did not conclusively identify the cause.  She said that “Despite the authors’ very clear statements (that the data did not indicate a the cause) in the paper and elsewhere, you (Jeremy Hunt) have repeatedly told MPs and the public via media interviews that these deaths were due to poor staffing at weekends, with particular emphasis on medical staffing. This clearly implies that you believe that these excess deaths are avoidable”.Godlee is not the first to point out his overegging of the evidence. There are dozens of rapid responses printed alongside the paper in the BMJ (including my own) which say pretty much the same thing. Causality cannot be determined from this study and to imply that it can for political purposed is dishonest and potentially harmful.

Earlier this week two academic doctors wrote to the cabinet office asking it to investigate Hunt’s claim that the 11,000 deaths were due to too few doctors being on duty. They alleged that that he had breached the ministerial code of conduct by misrepresenting official statistics. The letter was signed by thousands of fellow doctors.

I know from personal contacts in the Department of Health and elsewhere that Mr Hunt has been briefed, is well aware of these concerns and understands the issues completely, yet he has continued to make the same unfounded claims.

So it appears highly likely that Mr Hunt has indeed deliberately attempted to mislead the public about weekend death rates, which begs a crucial question. Why has he felt it necessary to do this?

The wider context

This question should be considered with reference the wider context of what has happened to the NHS in recent months.

The NHS is under considerable pressure at the moment. Staff morale is low, finances are stretched to breaking point and demand for services is increasing. Disgruntled doctors have taken to the streets. More than 30 acute trusts have not been able to recruit a permanent CEO. Many have predicted a very difficult winter ahead with the potential for significant service failures.

In these circumstances one might expect a responsible government to take a lead on emergency contingency planning, identifying and plugging funding gaps and taking actions to encourage recruitment and retention of staff.

This has not happened. There is no central winter emergency plan – that has been delegated to the regions. (I know about the Cold Weather Plan which is about wearing a thicker pullover and is different). There is no attempt to help or financially bail out “failing” trusts, despite the fact thatmoney is available. Putting trusts into special measures and walking away is unlikely to help the situation.

Picking public fights with junior and senior medical staff by threatening to unilaterally impose Draconian changes in terms and conditions is deeply unhelpful. Promising the public an elective 7 day service when there is clearly insufficient money to operate the current system, threatening todeport overseas nurses,  capping spend on agency nurses regardless of whether they are essential for safety, going back on safe ward staffing level recommendations, the list goes on.

So why has Jeremy Hunt found it necessary to try to deceive parliament and the public about weekend mortality?

When taken in the wider context one can only speculate on his motives for doing these things.

• It could be that he is just ham fisted and does not understand how the NHS works
• It could be that he deliberately wants to break the NHS in order to facilitate a change toward a more commercial model
• It could be that he has become so focused on his spat with hospital doctors that he prepared to generate fear in the general public as a political device to get his own way regardless of the consequences
• It could be that he does not have the insight to realise that these scare stories cause real distress for real patients and staff and does not appreciate the harm he is doing.

Only he can say why he has done what he has done and perhaps he should be asked formally. In a sense the reason for his actions is unimportant – it is the consequences of his actions that matter.

When there is a major disaster such as a train crash and people are killed the investigation quite rightly looks at the senior management in charge of the service and if they are found lacking they may be vulnerable to prosecution on charges of corporate manslaughter.

If acute front door services in a major trust fail completely this winter it will be just as serious and potentially just as deadly as a major train crash. I don’t know if the law on corporate manslaughter applies in the NHS or indeed even if such a catastrophe would trigger an independent investigation. We all accept that it is so likely to happen that it will probably not even make the news headlines.

When emergency services are starved of funds and staff, stretched to the limit, abused and abandoned then mistakes are likely to occur and patients are likely to come to harm. Perhaps now is the right time to have a grown up, rational debate on avoidable deaths, their root causes, and the potential effective solutions – and to identify who is really to blame.

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See Big Up The NHS blog here.