It was a fairly typical Sunday afternoon in 2011. The emergency department was experiencing its usual surge of ambulance arrivals: every cubicle in ‘majors’ was occupied and a queue of patients on trolleys was slowing growing in the corridor. The nurse in charge seemed as calm as ever: I asked what I could best do to help. ‘Have a look at the queue – see if there are any you can get home’, she suggested – more in hope than expectation.
‘My husband is dying…’
John was second in the queue and didn’t look like he was going home, but judging by his reduced conscious level, he appeared to need urgent attention. I asked a passing nurse if there was any space in resus – ‘all full’, she replied as she sped to the assistance of another patient. John’s wife was reading to him – she put down the prayer book when I introduced myself and asked her the problem. She had been crying, but spoke clearly ‘My husband is dying and needs to go to the hospice – please can you help us?’
John was 52. He had pancreatic cancer with cerebral metastases and had exhausted all therapeutic options. He had seen the palliative care team the previous week and a bed had been arranged at the hospice for his admission on Monday; his wish to avoid hospital and not to be resuscitated in the event of a cardiopulmonary arrest had been documented. While eating his lunch he had experienced a brief grand-mal seizure; this had happened before, but this time he had not regained consciousness and his breathing now appeared laboured and noisy. His wife thought he had probably aspirated, and had phoned the hospice to see if they could take him one day early.
‘He will have to go to A&E…’
The hospice nurse had confirmed that his bed was available, but weekend admission would require referral from a doctor, and he would have to arrive before 5pm. She advised his wife to phone the GP, but the Out-of-Hours operator explained that a doctor could not attend for several hours – ‘I am afraid he will have to go to A&E’, she said: it appeared to be the only realistic option. An ambulance had arrived, and here he was – on a trolley in a corridor, seemingly within his last few hours of life, while his wife tried to offer whatever comfort she could. ‘I know John wouldn’t want this; it’s all my fault that he is here – I wish I had never phoned’. Five o’clock had come and gone.
Guidelines, toolkits and standards…
Much has happened since 2011: 7 day guidelines, toolkits and standards have been produced by various Royal Colleges, the Academy of Medical Royal Colleges and NHS England. I have attended and spoken at many meetings, conferences, summits and working groups. Sir Bruce Keogh has indicated that developing 7 day services is a key priority for the NHS in England, and has set a timescale for delivery by 2018. There is international evidence from the UK, USA, Spain and Australia that patients admitted to hospital at weekends have a higher chance of dying during their hospital stay than those admitted during weekdays; a large NIHR-funded research project (the HiSLAC study) is underway to investigate whether increased levels of consultant staffing could influence this.
The need for the current situation to change has been clearly, and repeatedly stated, and yet at ‘ground level’ the signs of real change seem to be relatively small.
Must do’s, should do’s and could do’s
Unfortunately the messages get confused. Government ministers talk of providing a service that is more convenient for patients: a GP appointment on a Saturday or Sunday to avoid taking a day off work; a scan at a weekend when the equipment is lying idle. Shops are open at weekends, so why shouldn’t the same be true of GP surgeries and hospital outpatient clinics? It is important to inject a modicum of reality into such discussions. At present we are many miles from being able to deliver an elective service which looks the same on a Sunday as it does on a Tuesday. This is a ‘could do’ for the future, but not the key priority for 2014.
At the other end of the spectrum, clinicians regularly remind us that they are already providing a 7 day emergency service: general practitioners are always available via the ‘out of hours service’ and hospitals provide 24/7 care, often consultant delivered, for those who are severely unwell and deteriorating. The fact that the ‘must do’s’ are being delivered does not change the fact that there is a group of patients who fall between these groups. The ‘Should do’s’: Patients in hospital who are not unwell enough to go to intensive care, and are unlikely to die before Monday, but who are not well enough to go home; community patients who don’t need to be in A&E, but whose urgent care needs can’t be met by the out-of-hours service. Large numbers of patients fall through huge cracks in the system at weekends, and the knock on effect on Mondays is felt both in primary and secondary care.
Solutions cannot be cost-neutral…
The responses from senior clinicians are predictable: ‘not enough money’, ‘not enough staff’, ‘can’t sacrifice my weekday service’, ‘a recipe for burnout’. We have to be clear that attempting to deliver radical change on a ‘cost neutral’ basis is a recipe for disaster; you cannot provide more care at weekends with the same number of people without impacting on weekday services. There will be some efficiency savings if we can smooth out the variability of emergency care across seven days, but this will probably not offset the increased cost of staffing an improved weekend service.
It’s time to change…
There will need to be investment, but significant change will not occur unless the clinicians want to make this happen. It is easy to put up barriers, to find reasons why it cannot be done, or to blame others for not sharing the burden; but we cannot allow the status quo to continue, year-on-year. As we head into 2015, all clinicians need to ask themselves the following question:
‘If a member of my family became unwell at a weekend, would I be confident that my service would be able to deliver the care that they needed?’
If the answer is ‘no’, then the time has come to change this.
It would have been easy to have allowed John to join the weekend hospital mortality statistics: to move him to a ward and wait for his final moment to come, or hope that he survived long enough to arrange a Monday morning transfer. His wife would have accepted this, but her grief would have been compounded by guilt. On a busy Sunday evening there were many things I could have done with the 45 minutes which it took to undertake 3 phone calls and negotiate transfer with an ambulance crew on the ED forecourt; but this was undoubtedly the most worthwhile thing I did that day. The hospice nurse even agreed to waive the ‘not after 5pm’ rule following my telephone conversation with the on-call Palliative Care consultant. John died, peacefully, later that night, with his wife at his hospice bedside.
Footnote: Although ‘John’s’ wife agreed that I could share details of his case, his name, age and some clinical details have been changed to protect his anonymity.