Mergers, 24/7 working and ratings – mind the gaps

The queasily thin amount of experienced medical cover in some hospitals at nights and weekends was the subject of BBC Radio 4's File on 4 last week. Juniors missing key symptoms and signs, not wanting to bother a consultant out of hours, with occasional tragic results or at best near misses.

Suggestions for remedy included making consultants work 24/7 rotas. I sympathised with the experienced paediatrician who predicted that would be the last straw for many who have given their all for the NHS over many years.

The person in question was probably my age, brought up as I was on one-in-three rotas. That 90 hour a week marathon saw your twenties disappear into fug, the only bits in focus being the drama, grim humour and memory of iconic patients.

Not ideal from the patient's point of view either and having 'done time' like this, which consultant would want to return to the night and weekend shift?

Remedy number two was...increase the number of consultants! Here the estimates from selected Royal Colleges ventured into several thousand, with a budget to match. In the scheme of things, not a huge sum, but given current budget projections, somewhat unlikely.

Remedy number three was to merge hospitals to provide more consultant cover on fewer sites.

Possibly. Leave to one side the difficulties of achieving this politically (big and small p). Instead focus on the possible gains. 'Is bigger better?' and 'is bigger cheaper?' was the subject of a recent seminar here at the Trust on mergers, chaired and subsequently blogged by Ernst & Young’s Richard Lewis.

The answer to both questions from currently available evidence seemed to range from 'not necessarily' to 'no', perhaps because institutional 'merger' is a different activity to planned and purposeful service concentration (e.g. stroke).

The key to that last sentence is 'currently available evidence', particularly on the quality and outcomes of medical and nursing care. As time goes by, more data are becoming available nationally to make comparisons between institutions and to track pathways of care using data linkage.

Individual hospitals may have rich data used for internal review and clinical governance, but those with very good systems are still in a minority.

Data from clinical audits help to shine a light on quality of services for people with specific conditions, but beyond a few areas such as cardiac stroke and diabetes, this still needs development and much more analysis.

For other clinical services there are accreditation processes, such as for endoscopy, but apart from that nowhere near all services are covered across the country. Greater scrutiny of patient experience will help, as there is a link with quality of care, and more hospitals and other providers collect real time patient feedback.

So while there is welcome progress, there is a way to go before we can confidently answer questions such as ‘what is the quality of geriatric care in hospital X?’ or ‘paediatric care in hospital Y?’, using objective evidence say in three domains: effectiveness, safety and patient experience.

And we have even further to go to assess pathways of care for patients across providers – say preventing avoidable admissions. The amount of comparable data on quality outside hospitals is very limited.

So poor care may go undetected. This is a challenge for any system of aggregate rating of providers – find out about our work in this area and have your say via the online consultation. It is also an uncomfortable thought as the Francis Report hits the streets next week.

There are big benefits of having a single payer health system – time now to use them.