During an evening locum A&E shift recently, I referred a child for an orthopaedic opinion. An FY2 doctor discharged her home, after discussion with his registrar. The child was subsequently recalled to hospital the following morning following the morning consultant review of overnight X-rays, and underwent urgent surgery a few hours later.
I tell this story not to point fingers at the on-call orthopaedic team, who acted to the best of their considerable ability, but it brought to mind the thorny issue of senior clinical decision-making “out-of-hours.”
Various reports into maternity and child health, trauma care and others have demonstrated that mortality and morbidity is higher during weekends and nights (references on request). Reasons cited include excessive workload as a result of staff shortages, lack of available ancillary services like radiology support and, crucially, less experienced doctors being responsible for clinical decision-making.
Many "front end" services like A&E, maternity and intensive care have started moving towards a model of increasing both the volume and expertise of attending medical staff out-of-hours. But in most places, other services such as GP, radiology, surgery & general medicine (to name a few) have not followed suit.
We work to an outmoded model of healthcare when it comes to workforce planning. The workforce is concentrated during “working hours,” which does not reflect the workload of emergency and urgent care services. Out-of-hours, it is not knowledge or technical expertise that is lacking, but decision-making based on experience and clinical acumen.
There are huge difficulties with implementation of 24/7 care though. It does seem unfair to fundamentally change the working patterns of doctors’ midway through their career, when a lifetime of evenings and weekends wasn't on the original medical school brochure. There are still conflicting data on whether long-term shift working poses a threat to staff health and well-being. The standard "10 PA" consultant contract would also limit the number of shifts per consultant, and few trusts would be able to fund the substantial increases in consultant numbers needed to increase senior cover. And continuity of care is likely to suffer even more, if shift working becomes the norm not just for junior doctors, but also for medical staff at all levels.
Healthcare does not respect 9-5 limits, and we need to create a more balanced system where our services reflect the needs of patients, whilst protecting staff wellbeing. The question is, what is the best way to achieve that?
The on-call consultant of the future
The UK health service is near-unique in the West with a junior-led service model that sadly does not deliver round the clock high-quality care as best it should. There is no reason why a patient being seen at 3pm in A&E should have consultant input on their case, yet another at 3am does not.
Ensuring robust workforce planning that allows for greater senior input at all times necessitates proper investment in human resources as well as a willingness of current trainees to appreciate that our on-call commitments shall be rather different than those of our predecessors.