Thursday, 22 October 2015

It's not the doctors: it's the beds...

People admitted to hospital are more likely to die if the admission happens at the weekend. The government thinks this is because hospitals don't really work 7-days a week. So they are engaged in an attempt to rewrite doctors contracts so they can't opt-out of weekend work. This is the wrong focus.

People don't stop getting sick at the weekend. So hospitals really shouldn't provide a worse service then. But the evidence suggests they do (though it should be admitted that working out the weekend mortality is both hard and controversial). The government thinks this is because consultants can opt-out of weekend working (though how many actually do this is unclear and a subject of significant controversy).

While it is obvious in activity statistics that hospitals function very differently at the weekend, it is a lot less obvious that the doctors are to blame. And focusing on them may be a mistake. A recent study (reported in the BMJ here) casts some new light on the problem that suggests the focus of government policy may be wrong.

The study reported a clear reduction in mortality in a hospital when bed occupancy was reduced. The text below is a version of what I said in a BMJ rapid response and on LinkedIn when I first saw the study.

I'm puzzled that more commentary has not noted the relationship between this study and the current topic of weekend mortality in NHS hospitals.

The government has focussed on trying to force changes to medical contracts to eliminate the ability for doctors to opt-out of weekend work in the hope that this will fix the problem of excess mortality at weekends. But, by focussing on the doctors, they miss the more general point that just having more doctors won't fix broken operational processes at the weekend. This study points to a much broader problem that links mortality to those processes.

The missing link is the fact that the processes for discharging patients and therefore keeping bed occupancy down are widely broken at the weekend. While admissions are lower as few elective patients are admitted, discharges are muchlower. Emergencies, of course, continue to arrive. So the beds fill up as the overall process for discharging patients is usually dysfunctional at the weekend. This leads to very clear patterns (easily observable in activity statistics and for length of stay). In many hospitals beds fill up at the weekend.

The presence of doctors at the weekend isn't (or shouldn't be) the critical factor here. Most of the discharges that should happen are probably routine and could happen automatically without medical supervision. But they often don't because the process for discharge has been poorly designed (this is sometimes because it has an unnecessary requirement for consultant sign off).

We have known for some time that the dysfunctionality of processes associated with the flow through beds is the dominant cause of delays in A&E (which are bad for patients). And we know that A&E delays are bad for mortality and outcomes. Monitor's recent report adds further weight to this hypothesis. This study now reports a direct link to mortality when beds are crowded.

The high bed occupancy is directly bad for patients and is caused by poor operational management of discharge processes. Those processes are much poorer at weekends than they are during the week. This alone may explain the weekend mortality effect.

The weekend mortality problem is not primarily a medical problem, it is a management problem. The lesson for policy is that a focus on medical contracts is a distraction. If we really want to fix weekend mortality we should focus on improving the way hospitals manage the flow through their beds, especially at weekends. As a bonus, this would also lead to major improvements in hospitals' ability to treat patients quickly in A&E. This should be a double win for patient outcomes.

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