Ken Taylor: Dr Foster on inpatient hospital mortality

On the Today programme on Radio 4 on Monday morning there was a feature on these recently released data. Two areas were discussed. Hospital mortality is higher out of hours ie nights and weekends. The other item discussed was the smaller number of senior doctors in the hospital out of hours.

John Humphrys interviewed a spokesman for Dr Foster and one for the NHS Confederation. Unfortunately nobody who knows anything about the working of a hospital was interviewed. There is nothing unusual about this state of affairs.

John Humphrys in his usual bombastic style naively concluded that this must be a case of cause and effect. He may be right, but could there be other possibilities?

It is important for the world at large to realise that these days people tend to be admitted to hospital to die when they are seriously ill and nearing the end of life. Hospital is a place of last resort for the dying as well as a place for the seriously ill but potentially recoverable to be treated. Now these seriously ill irrecoverable cases may well be admitted when out of hours care in the community ceases to exist after 5pm. They are admitted out of hours and then die. Are these figures included in Dr Foster’s report? I very much doubt it.

Indeed could the seriously ill in the community be getting to hospital late and then dying out of hours because intervention has taken too long to occur? Do these data reflect a major defect in care in the community?

Mr Humphrys seems painfully unaware of the European Working Time Directive on doctors hours. Junior doctors now have to comply with a 48 hour week. The reduction from 56 hours to 48 hours has been the last straw. Never mind senior hospital doctors there are very few junior doctors around at night. Hospitals have had to resort to the Hospital at Night scheme whereby a senior nurse has to assess a patient before a junior doctor is called. Obviously this is a bad system. Doctors should know more than nurses about what patients need. If a patient is seriously unwell, the junior doctor should be called first and be adequately supervised. How many patients dying out of hours in hospital had actually seen a doctor? How many had seen a nurse?

Mr Humphrys’ solution to the problem is more senior hospital doctors’ time. There are two ways to increase senior input. One is to make the existing consultants work longer hours. However the seniors are on time sensitive contracts. It will cost money. More seniors could be employed but that would cost money. We could employ more juniors but that would also cost more money.

Mr Humphrys may have missed the news when NHS cost cutting was announced, sorry I meant to say efficiency savings. What a time worn euphemism. My trust has got to save £20,000,000 pounds. Where is the money for anything? The nursing budgets across the country are being cut so if Dr Foster had looked at the number of nurses I think they would have found that there are less nurses in the hospital at night. Could that also play a part? Indeed there will be less staff in every department as a result of these so-called efficiency savings that “will not affect front-line services” ministers reassure us. What utter rubbish.

Data from America show that more people either arrive dead in A&E or are admitted and die in hospital over the Christmas period than at any other time. Dr Foster should investigate further.

Ken  Taylor  is  now  a  teaching  consultant  for  medical  students  and  junior  doctors.  He  worked  as  an  NHS  consultant  physician  for  about  25  years  in  general  medicine,  diabetes  and  endocrinology.  He  chaired  the  hospital  management  board  for  some  five  years  and  was  clinical  director  of  medicine  for  four  years.