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Helen Macdonald: Dangerous weekends – more complicated than just a lack of consultants

29 Nov, 11 | by BMJ Group

Why are patients in English hospitals more likely to die at the weekend? A good question, put to Dr Mark Porter, head of the BMA’s consultants’ committee by John Humphrys on the Today programme on Radio 4 yesterday morning.

It was a difficult question for him to answer in a couple of sound bites. The question emerged (or perhaps re-emerged) in light of annual figures from the research company Dr Foster which show a 10% spike in weekend deaths, compared with weekdays.

Dr Porter’s reply was all about the lack of consultants around out of hours for complicated patients. That’s a bit one-dimensional, I thought. And it’s unfair on the consultants too. What about the lack of pretty much everyone else at the weekend?

The shortage of imaging services and inexperienced juniors were implicated in online stories about the report. While inexperience might be a fair criticism, I don’t think it is the whole story, and I take considerable issue with this statement; “The junior doctors, they’re always around, but they’re not the ones making a difference here,” the BBC quotes the director of the Dr Foster research group as saying.

Perhaps he would like to sweat through a long day on-call with a junior doctor. In my experience, there are considerable reductions in the number of junior staff around at the weekend, particularly those caring for existing patients – so although we might “always” be around it is certainly not the same. And I find it difficult to believe that the decisions we make or influence (right or wrong) make “no difference.” 

At the weekend juniors are fire fighting, and must triage bleeps from inpatient and outpatient areas, from medical and nursing staff, and from patients and their families (who are often around in force at the weekend). Incessant bleeps and demands mean it is a considerable achievement to maintain a train of thought. 

Juniors move between admissions areas and the wards of existing patients. When they review existing patients, it can be difficult to glean sufficient information to make timely decisions about what to do next. There may be poorly formed or documented clinical plans regarding what to do if the patient is ready to go home, or becomes unwell. It’s true that this is harder when you have less experience of patients, or are new to a specialty. And at the weekend it is harder still, because juniors can cover many wards of unfamiliar patients, sometimes from specialties they have never experienced. 

As well as assessing patients, juniors might perform extra tasks at the weekend, such as phlebotomy or putting in cannulas, which are sometimes done by allied professionals during the week. Even these seemingly simple tasks can take a long time at the weekend, when trying to locate needles on an unfamiliar ward, or one that has not been stocked for several days. 

The issue of weekend care is about more than just consultants, and it is more than junior staff too. If you read the bottom of the news articles on this story which litter the press, it is clear that when you scratch the surface there are inklings of a whole system under strain, which health professionals and patients do their best to negotiate and survive each weekend.

Helen Macdonald is assistant editor, BMJ

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  • Richard Drake

    I think the point that the team at Dr Foster were making is that the thing that predicts the excess mortality is the number of consultants and specialist registrars present in the hospital at the weekend per 100 beds, not the number of other juniors.

    Despite somewhat missing this point, this comment might explain why: even if there are lots of FY1s about, if they're faffing about looking for needles their presence has little effect on mortality. So for these grades, it's not just about their numbers, it's what they're doing too. More senior doctors tend to concentrate on patient care for difficult cases, even in inefficient hospitals that use their juniors as phlebotomists.

    The implication from Dr Foster was a different one: that even poor hospitals manage to have enough juniors. They're not saying juniors have no influence, just that differences in their numbers appear not to influence differences in death rates.

    In any case, one can criticise their methodology or conclusions in various ways, but not on the basis of this cri de coeur.

  • John

    So if there were no FY1s then the consultant would put in cannulas on the weekend?

  • Guest

    How did they differentiate between the effect of reduced numbers of registrars and consultants and the effect of reduced numbers of juniors?

    Considering most consultants have a team of doctors, then the whole of that team is also off that weekend too, hence proportionally reducing the numbers of doctors on weekends, but keeping the makeup relatively the same.

    Even if the consultant is on call and off site, there is at least a registrar on site for most large specialties who are likely to be suffering the deaths-how is the effect of the registrar and the SHO distinguished?

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