A Day in the life of an F1

By Zana Martin

As a newly qualified FY1, typically each day has something new to offer. I’m currently based in care of the elderly, spending my time with a fantastic team of people and facing new challenges daily…

Each day starts with a full board round of every patient, where we discuss recent results and more importantly discuss discharge plans. As the FY1 my role usually entails shouting out the significant blood results and chipping in with and titbits of information I have managed to glean from family members. From there, we divide and conquer, each taking a handful of patients, for which we are responsible that day (being on a well-staffed ward makes all the difference!). 

As the clinician responsible for those patients, it is our job to ensure jobs are done and discharged letters prepared in advance, with TTO’s written early to avoid delays. Often this means you have 4 or 5 letters to prep in a day, which seems a lot but makes your life easier in the future! We are also responsible for updating families and the nearest and dearest, and asking the difficult questions when there is no clear plan surrounding resuscitation. While it was daunting initially, being able to have these conversations early on does allow for a good rapport to be formed between patients and staff and makes the journey a lot more pleasant for everyone involved. Believe me, the difference it makes when you remember a relatives name is amazing. 

One of the biggest challenges I’m sure every FY1 faces is learning to trust your clinical judgement and having the courage to implement a plan for a patient. Things like prescribing laxatives will induce panic, as will the thought of being around a patient with a EWS of anything more than one. Despite feeling like you will never be able to do it, the confidence and competence will grow exponentially in those first few weeks and suddenly you will find yourself wondering why you worried in the first place. For example being called to an unwell patient on the ward with an increasing oxygen demand and tachycardia (that was just me, not the patient) and feeling like a fish out of water, I managed to call on the 5 years of training and issue some basic management until senior help arrived. Thankfully the patient survived. That is certainly a personal highlight. 

But the most enjoyable part of FY1 so far? (And no it’s not the wage, though that is glorious) Is being part of a team and being able to make a difference to real lives, even if it’s something as minor as holding a patient’s hand while you speak to them, or helping to make a bed when there’s a lull in the day. Those small interventions that we don’t consider to be of value are often the most valuable to patients and their families, and are what make the job special. 

The Significant Seven: An Exploration Of The Counter-Evidence For A '7-Day NHS'

Posted on 11th May by JuniorDoctorBlog

The Department of Health’s favourite line is “There are 8 independent studies showing a ‘weekend effect'”. I’ve been through these 8 before, and the terms “independent” and even “studies” are used fairly loosely. This has been the stick Jeremy Hunt and co have used to justify their unfunded and unmodelled 7-day NHS plans, and to beat the junior doctors with. This week the stick broke.

To borrow the Ministry of Truth’s own language: “There are now 7 independent studies showing that the 7-Day NHS plan is a bad idea”.
Juniordoctorblog explores the counter-evidence against the 7-day NHS spin.

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The ‘Weekend Effect’

Three separate studies this week came out against the established narrative of ‘poor care’ at weekends creating excess deaths.

“Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission” by Meacock et al in 2016

All previous research has shown increased rates of dying amongst patients who are admitted to hospital at weekends, but not those already in hospital or attending A&E. Meacock et al used the same data from the original Freemantle paper that Jeremy Hunt was quoting his ‘11,000’ excess deaths figure from, which covered 12,000,000 admissions to all 140 hospitals between 2013-14. They found for patients attending A&E on the weekend, far fewer were being admitted to hospital vs a weekday. When you look at all patients attending A&E, as opposed to those being admitted, there is no weekend effect. The authors attributed this to the differential admission threshold – well patients are less likely to be admitted on a weekend, so this makes the group admitted on weekends sicker on average, thus increasing mortality rates slightly.

Bottom line: the ‘weekend effect’ appears to be about how patients are counted, not how they are looked after.

Professor Rothwell, Oxford University, interview on Radio 4
– so far, unpublished study

Now the purists amongst you will claim this is unpublished, and therefore not available to scrutiny. I agree. However, we are using the DoH definition of ‘study’, which includes all manner of reports, audits, and human resources documents. So it’s in the Seven.

Prof Rothwell group based from Oxford Univeristy found similar problems with the ‘weekend effect’ amongst stroke patients. Looking at patients in Oxford, they found those labelled ‘strokes’ weren’t strokes at all, but were admitted for other things, like urgent investigations, or rehabilitation. These admissions happened primarily on weekdays- meaning only truly sick stroke patients came on weekends, but weekdays had a mix of very well patients and unwell patients. Once these was corrected, the weekend effect disappeared. Prof Rothwell said “nobody had done… the basic due diligence” on these studies to look at this.

Bottom line: the weekend effect again was found to be a statistical artifact, based on how patients are counted, not how they are cared for.

“Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care” by Bray, 2016

There were a lot of statements about stroke care, and a huge backlash from stroke experts who had already spent 10 years improving the urgent care of stroke. Now a new study from Bray that used national data between 2013-14 on 74,000 patients with stroke found no association with weekend vs weekday admission. No weekend effect. It did find variation across many variables in different patterns, including a small increase in mortality in weekday night admissions. The study called the weekend effect ‘an oversimplification’.

Bottom line: Again, no weekend effect, small changes on weekday nights, and further work needed. Oversimplification not helpful.

“What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions?” by Meacock in 2015

Put aside the fact for a moment that the ‘weekend effect’ probably doesn’t exist. Don’t get bogged down in methodology, as Jeremy Hunt doesn’t. This paper by Meacock in 2015 looked at the actual size of the supposed ‘weekend effect’ and then worked out the cost to address it. It found the cost, £1-£1.5 billion, was far higher for the small supposed benefit than any medication or treatment recommended in the NHS.

Bottom line: even if the ‘effect’ existed, the money would be spent better elsewhere for greater patient benefit.

“The 7-Day NHS”

So despite the evidence being weak, the government has plowed forward in making their “7-day NHS” plans. Except they haven’t.

“Managing the supply of NHS clinical staff in England”

Public Accounts Committee 2016 

The PAC is a group of MPs that examine public policy and hold public departments to account for their decisions. This report found that the Department of Health had made ‘no coherent attempt’ to work out how much a 7-day NHS would actually cost, or the doctors or nurses needed to staff it. They were told they were ‘flying blind’ on this issue. A leaked report suggested they needed £1 billion a year, 4000 more doctors, and it ‘probably wouldn’t alter’ the supposed weekend effect anyway.

Bottom line: close scrutiny of policy for 7-day working found it to be woefully lacking. 

While the 7-day policy seems to be a shambles, a further report shows the existing NHS  heading to disaster;

“Sustainability and financial performance of acute hospital trusts”
Public Accounts Committee 2015-16

This second public accounts committee focuses on hospitals and funding. It revealed that No. 10 created “unrealistic” and “unsustainable” budget cuts to hospitals. As in the report above, hospitals had to cut regular staff but many refused to cut quality in favour of cost- hiring back temporary staff at a higher rate. The committee were clear that the excess cost running the NHS into a deficit of £2.8 billion was 80% due to the gaps created, not the fees themselves. The report also found dodgy accounting practices – which came from a whistleblowing hospital accountant who requested anonymity for fear of losing his job. It would seem a lot of ‘creative accountancy’ was going on to make hospital budgets look healthier than they are, to cover up the extent of the ‘black hole’ in NHS finances.

Bottom line: NHS hospitals are currently in a budget and staffing crisis created by No. 10 who then attempted to cover it up. 

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Still with us?

So far we’ve established that the 7-day NHS is an unfunded and unmodelled solution to a non-existent problem, which probably isn’t fixable itself, but even if it was, isn’t cost effective to do so. Meanwhile the real problems of the NHS are not only being unaddressed they are being actively covered up.

So what’s it all about then?

Throughout this drive for seven days services has been this narrative that there aren’t enough doctors at weekends, and this leads to harm; the ‘weekend effect’.
So having already discussed there is no weekend effect, we should probably still address this ‘lack of doctors’.
Firstly, no study has ever looked at junior doctor staffing levels. Full stop. So we actually cannot possibly say that is associated. One study from the Hateful Eight actually showed that medical cover is 100% across seven days, and this is true, all hospitals have junior doctors Monday to Sunday, midnight to midnight. Despite this Jeremy Hunt embarked on a damaging junior contract fight anyway, despite all the evidence to the contrary.

What’s surprising is that the Department of Health themselves don’t even know how many juniors are already working weekends.

Freedom of Information Request to Department of Health 2016 and Commons Question, 2016

In two unrelated freedom of information releases NHS England first revealed they had no idea how many junior doctors typically work on a Saturday or bank holiday nationally, and then in a written question from MP Norman Lamb it transpired that the only research into this that had been done was a ‘snapshot’ of 14 hospital rotas, in January 2016 (well after the contract had already been ‘imposed’, I might add).

Bottom line: despite no evidence to show a link to junior doctors and weekend mortality issues, a new contract was ‘imposed’ anyway, without anyone actually studying the problem they were trying to ‘fix’.

Confronted with this last week, the Department of Health shifted the goalposts once again– now saying the ‘weekend effect’ is about consultant presence and diagnostics. Except it isn’t.

“Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study” by Aldridge in 2016

This is a study looking at a snapshot of weekday to weekend cover of consultant specialists attending hospital admissions. It found that consultant specialist presence varied between weekend and weekdays, but found no link to any change in mortality.

This follows from another study by Bray in 2014 looking in stroke units specifically whether the presence of a consultant on weekends and weekdays made a difference to mortality. In that study consultant presence made no difference, but the number of nurses had a direct link to survival.

Bottom line: in the only study that looked at weekend and weekday mortality in NHS hospitals there is no link to consultant presence. 

Nursing numbers are much more important but this government cut training places in 2011 and cut the bursary in 2016- the PAC recognised this would continue the shortage for at least another three years. 

Wrong again.

 The Significant Seven are a damning group of ‘studies’ that highlight how ill thought out and potentially dangerous both the 7-Day initiative and the current NHS management is. Is this incompetence or something else?

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Let’s change the perspective.

Imagine you are in government. You made a back of the envelope promise of a ‘7-Day’ NHS without defining anything for voters, but you’re also ideologically against increasing funds to a socialist medical system.

You can’t be seen to cut costs to a beloved and vital national institution, so you announce ‘efficiency’ drives and streamlining of services, a ‘pay freeze’ which cuts pay by 25% against inflation. You get wind of new NHS contracts, and decide to make some subtle changes- increase basic pension contribution, reduce junior doctors pay and remove financial penalties for hospitals that make doctors work illegal and unsafe hours.

Obviously you can’t be seen to want to attack doctors to cut costs, you need a PR message that will travel. You find an already running plan to improve urgent 7-day Care, and in the words of Fiona Godlee, editor of the BMJ, derail it.

You never really believed hospitals needed that much money, or that costs really do rise at that rate, so when hospitals started to report crisis level failings, you didn’t listen. When junior doctors protested and demonstrated and even sat outside your office for three weeks, you still didn’t listen.

I am a doctor- I want a 7-day health service more than anyone, because I know what that would really mean. I also know that we need more funds just to keep the staff and the hospitals we have already going, and if we want to ever improve our health service, Mr Hunt, we must use the evidence properly.

Now the evidence is knocking on your door.

It’s The Significant Seven, and behind them 68 million people. We’d all like a word about our national health service. It’s time to listen.

Juniordoctorblog.com

 

Jeremy. Let's Make This Simple.

Posted on 7th May by JuniorDoctorBlog

“Everything should be made as simple as possible but not simpler.”

Albert Einstein

There’s a great book called Thing Explainer by Randall Munroe that explains lots of complex stuff in the simplest terms possible, using only the thousand commonest words in the English language. The dispute over the new junior doctor contract has become increasingly confusing, so let’s keep this really simple.

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Jeremy Hunt said this new deal for doctors was meant to make ‘7 Day hospitals‘. He said ‘more people die on Sunday compared with Wednesday‘ and this is because of poor care and less doctors. He called this a ‘weekend effect’. The papers where we read about new events said this too, many times.
But new findings show there is no ‘weekend effect’. People sick at weekends go to hospital, but fewer people actually stay in hospital at weekends, and less people die, not more, on Saturday or Sunday. Only very sick people stay in hospital on weekends, while slightly less unwell people go home and come back during the week.

It is easier to explain if you use a story.

Here is a story.

Ten people go to hospital on Wednesday, two are very sick and will soon die, two are well but need urgent advice. All ten stay in hospital, and the two who need advice are seen by a special doctor who gives it to them. For that Wednesday ten people stayed in hospital, two people died, so the ‘risk’ of death is 2 in 10, which is 20%.

The same ten people go to hospital on Sunday. Two are very sick and will shortly die, two are very well but need urgent advice. The two who need advice see a general doctor, who arranges a special doctor to see them on Monday. They go home. The eight left stay in hospital. For that Sunday eight people stayed in hospital, two people still died, so the ‘risk’ of death is 2 in 8, which is 25%.

So because two well patients waited at home for advice, instead of staying in hospital, the ‘risk’ of dying on Sunday seemed to go up, by 5%, because of how they were counted, not because of how they were looked after.

So Jeremy Hunt said we need to make 7 day hospitals. We have ‘7 day emergency hospitals’ and we know now that those 7-days look after emergencies the same, every day.

Doctors don’t like the ‘new deal’ because it’s unfair to women, reduces pay, and spreads five days worth of doctors across seven days, for what we now know is no good reason. It also takes away the rules that stopped hospitals making doctors work unsafe hours. 

Doctors told Jeremy Hunt this was a bad idea, but he forced the deal on them anyway. Jeremy Hunt told doctors they were killing patients by not agreeing to the new deal. This was a lie, and it made doctors sad. Many have now left.

Now Jeremy Hunt wants to talk again, but only about Saturday pay. Doctors know this was never about Saturdays, and now so do you. Jeremy Hunt told everyone that the new deal wouldn’t cost any more money than the old deal. So without a reason to change things, what does Jeremy want?

I’ll tell you what I want. I want to go back to looking after people again. I want to go to work and have enough doctors to look after everyone properly, every day. I want hospitals to have enough money to help us do that. I want the people in charge to only want that too. I simply want hospitals that continue to look after everyone based on need, not on how rich they are.

Now that you’re up to speed, what do you want?

Juniordoctorblog.com

How To Solve The Health Crisis. Leave Us Alone.

Posted on 12th April by JuniorDoctorBlog

Dear Messrs Cameron, Osbourne and Hunt,

You may have noticed the NHS is doing pretty badly lately; funding is at a record low,waiting times are at a record high, and morale across the service is at rock bottom.

You all made some silly promises about money- that’s okay, we all say things we don’t mean sometimes. You perhaps got a little confused and said that you were committing “half a trillion” pounds to the NHS over this parliament- which is simply the current flat yearly budget (~£100 billion) x 5 years. You said this was ‘the most amount of money ever given to the NHS’, but you might remember every successive government since 1948 could have said the same- it’s called health inflation.

You may have forgotten about that when you said you were ‘committing 10 billion‘ pounds ‘extra’ to the NHS, to fund the NHS ‘own’ plan. Except it wasn’t the NHS own plan– it was yours, and it’s not nearly enough even to keep the lights on.

Everyone’s a critic eh? It’s not nice when people say you’ve done a bad job, so I can fully appreciate why you asked hospital accountants to hide the debts under their carpets, and told hospital managers to pay for less nurses and doctors last year. I can feel your annoyance when hospitals decided that wasn’t safe, and had to hire lots more agency staff to fill the gaps. You said some silly things blaming this on agency fees, but that’s okay, 80% of the cost of this was the gaps themselves, and you won’t make that mistake again next time will you? Will you?!

You’ve said some funny things about the health service. You’ve said you want it to be the ‘safest health care system in the world‘, but I think you also want it to be the cheapest in the industrialized world? I picked up a few bits for you to read- might help. This one shows increased funding improved outcomes in healthcare. This one shows big reorganizations in healthcare don’t work at all.

You’ve said some things which, I think, aren’t true. I do hope I’m wrong. You said you were committed to keeping the NHS public – but Virgin just bought huge swathes of services, and private company contracts increased 500% this year. You have neglected to mention this, but that’s okay – government is busy work, and not everything can be in every speech. Some people might not mind NHS privatisation, but I do think you should let them know.

You’ve handled the junior doctor contract rather badly. I don’t think it’s unfair to say so. 98% of ballotted doctors voting for strike action, the first doctors strike since 1970, the first ever emergency walk out in NHS history, record levels of dispersal, record low morale. Can I make some suggestions? Have you thought about just leaving them alone?

Since 2006 they have had a £6000 one off pay cut, then a further cumulative 25% pay loss while working in the busiest and least funded decade in NHS history. But no one really complained, bar a half-hearted effort in 2012. I don’t think this is about money, but understand the context.

Doctors conditions are already poor and retention is already a problem. Record levels of doctors leave training after two years, vacancies and rota gaps have increased 60% in two years, and 1/3 GP training posts and  50% of year 3/4 A&E registrars resigning.

So what’s the hurry? Do correct me if I’m wrong, but if contract changes are cost neutral, but could threaten recruitment and retention of staff at a time when the NHS is under incredible pressure, and doctors say is categorically less safe than current conditions, one has to ask, why bother? Why not talk for another year, rather than strikes and strikes, and resignations. Not to mention the reversal of all equality workplace gains in the last decade. Mr Hunt wanted ‘certainty’ in the health service- but I cannot imagine a more uncertain time.

Why not just leave us alone? It’s not too wild an idea. You might say the BMA asked for contract negotiations and therefore the contract must change. This is like inviting your friend for tea, punching them in the face repeatedly and then wondering why they wanted to leave. You can’t force them to keep having tea at your house, and if tea isn’t essential, then why would you?

It might hurt your feelings a little bit, but that’s okay. We all have little tiffs, we all make mistakes. No need to be too proud about it. After all, why would you want to wreck a whole health service just to save face?

It must be a tricky job, being in charge of everything. Why don’t we just sit and talk for a bit, about how we might all make the NHS better?

Unless of course that’s not what you want at all. Unless you have decided that with four years of government, a weak opposition, and deep pockets controlling >50% media and the BBC, you might decide to ram through as much toxic and undemocratic policy as you possibly can. Kamikaze politics, with a hope some strong PR spin at the end will still save the next election? So why not ram through massive NHS-reorganisation and sell off, privatise the schools and the land registry, cut disability benefits and cut corporate tax, cut funding to the opposing party and turn the BBC into state-run television. Why not in fact trample the entire fabric of democracy, safe in the knowledge that the public are too apathetic to offer any significant opposition?

You are leaving them few choices Messrs Cameron, Osbourne and Hunt. Strike or resign. Perhaps it’s #timetolisten? Or better yet, just leave them alone.
Juniordoctorblog.com