Huntonomics

There is no urgent need to change the junior doctors’ contract. It probably could be improved, but the complexities are such that it’s impossible to tell whether a new contract would be better without a proper comparative trial. Both the government and the BMA have put forward new contract proposals. They need to be properly tested in a variety of hospitals against the existing contract. Bad science is at the heart of the junior doctors’ dispute with health secretary Jeremy Hunt. His unsubstantiated conclusions about weekend mortality rates were inflamed by the fact that he appeared to have privileged access to this data before it was published in a peer reviewed journal. This may sound trivial but the scientific process is very clear that data should not be made public before it has been peer-reviewed. It made junior doctors very suspicious that NHS England was ganging up against them too. Hunt then quoted outdated data on variation in stroke care to justify imposing the new contract as part of the Tory election pledge of ‘a truly 7 day NHS.’

This uncosted pledge may yet undo the government. A ‘truly 7 day NHS’ has the same high quality routine and emergency care – 7 days a week – in hospitals, community care and general practice. In most cases this would require a 40% increase in routine care at weekends. Staff can’t be spread more thinly than they are at the moment. Clearly it needs more staff and ‘truly 7 day funding’ to match.

The fact that the government has made this pledge without identifying any resources to implement it is absurd. The junior doctors too are right to be suspicious of a contract offer which will apparently see most of them get a pay rise and work fewer hours whilst somehow extending weekend cover for no extra funding or staffing. As one junior doctor put it: ‘This is pure Huntenomics.’ The dispute, was predicated on an astonishing 98% vote in favour of industrial action, which is a very loud smoke alarm about the current state of the NHS. In the midst of 10 years of flat-line funding, rising demand and big cuts in social care, NHS staff are struggling to provide 5 day routine treatments and 24/7 emergency care as it is. No-one currently provides routine services 7 days a week, although hospitals such as Salford Royal NHS Foundation Trust have managed to improve the quality of urgent and emergency care across 7 days using the existing junior doctors’ contract. This suggests the junior doctors contract has very little to do with 7 day services and the battle over Saturdays makes no sense when – at least according to Hunt’s figures – the highest number of excess deaths are on Sundays (see letters). The most likely agenda is simply to get junior doctors to work at weekends for less, and then roll this out right across health and social care.

The government’s biggest error would be to impose the contract. The fragile goodwill the NHS relies on would vanish, and resentment and resignation would follow. Likewise, junior doctors must be wary of an all-out strike which risks harming patients particularly in those hospitals that are already unsafe and perilously short-staffed. The government has cleverly manipulated the argument to be about ‘Saturday pay’ but for doctors it’s ensuring that there are financial disincentives to protect them from abuse. Contracts on paper are often very different from contracts in real life, which is why a proper trial in a variety of hospitals is essential to see if it really is – in Hunt’s words – ‘better for doctors and better for patients.’

Hunt may or may not turn out to be right that his reforms will reduce mortality rates, but the evidence is against him. An excellent study of all the political reforms of the NHS since 1974 concluded ‘centrally led NHS reorganisation has never had any detectable effect on either male or female mortality and must be considered ineffective for this purpose. But some evidence that increased funding improves outcomes is found.’¹ Ultimately doctors will leave the NHS if they feel it is too stressful and unsafe for patients and their own mental health. The government has also promised to make the NHS the safest service in the world, but again it hasn’t promised the money to do it. Unrealistic expectations, inadequate funding and bad science are a truly dangerous mixture. But whatever happens, junior doctors will refuse to be silenced, even if they pay a heavy price.       1 Has NHS reorganisation saved lives? JRSM 2016 Jan;109(1):18-26

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

Sepsis, and spotting serious illness

The NHS England report into the tragic death of one-year-old William Mead from sepsis shows how disjointed and dangerous the NHS frontline can be. Sepsis is a hard enough diagnosis to make in ideal conditions but UK general practice is now so threadbare and splintered that continuity of care has been lost and patients are seen and assessed in disparate ten minute blocks without anyone having time to join up the evidence. The pressure on GPs not to prescribe antibiotics and not to refer patients to busy emergency departments doesn’t help, and research by the Commonwealth Fund recently found that UK GPs are the most stressed in the western world. Under such circumstances, difficult diagnoses are more likely to be missed.

The failure of NHS 111 call-handlers is equally understandable when people with no medical training and limited experience are using simplistic and imperfect algorithms (Eyes passim). Even if William had made it to hospital there is no guarantee his sepsis would have been quickly picked up. The excellent Sepsis Trust highlights the 44,000 deaths that occur each year in the UK including a thousand children, when the body mounts an extreme reaction to infection and injures its own tissues and organs. The infection that leads to the sepsis may appear minor, and many of these deaths occur because the sepsis wasn’t spotted quickly enough while the patient was already in hospital. And even when a diagnosis is made, delays in giving urgent IV antibiotics, fluids and oxygen can occur while a patient is shunted form the emergency department to a ward. Again, continuity of care is lost.

The Sepsis Trust (www.sepsitrust.org) is hoping to educate parents and carers not just to spot the signs of sepsis but to mention to the health professionals they contact that they think sepsis might be the diagnosis. It issues very useful toolkits for NHS staff and the public to help spot when a child or adult might be seriously ill and takes the line that the public should have easy access to all the information even if it is complex. The NHS and NICE websites in contrast are so vast that it’s hard to find the information you need quickly.

MD has collected all the information he can find from the sepsis trust, NHS and NICE websites to list the ‘red flag’ symptoms and signs that require an urgent medical opinion for a sick child. They might not be a sign of serious illness and they might lead to even more over-crowding in emergency departments but here they are:

Pale/mottled/ashen/blue skin, lips or tongue. No response to your voice and play. Just looking really ill to you. Does not wake, or if roused does not stay awake. Weak, high-pitched or continuous cry. Grunting. Passing no urine in the day. Breathing rate greater than sixty breaths per minute in a child aged up to five months; greater than fifty breaths per minute, age six to twelve months; greater than forty breaths per minute if older than twelve months. Sucking in of the muscles in between the ribs as your child breathes (in-drawing), showing it is working really hard to breath. Reduced skin turgor – when you’re well, your skin returns quickly to its normal shape if you (gently) squeeze it. If it doesn’t, that’s a sign of dehydration. Skin mottled or discoloured. Extreme shivering. Bulging fontanelle – feel your baby’s soft spot between the skull bones when he or she is well. If it bulges out during illness, that’s a red flag sign. Children younger than three months with a temperature of 38°C or higher. Children aged three to six months with a temperature of 39°C or higher. A fever lasting more than five days. Children with a high heart rate (you have to look up what’s normal). Cold arms and limbs, and a low temperature (36°C or less). A weak pulse. A non-blanching rash (a rash that does not disappear with pressure). Your child has a fit or seizure.

Most parents don’t want to be doctors to their children but surviving serious illness generally requires parents to spot it first and act on their instincts, NHS staff to listen, make the correct diagnosis and start the right care quickly. It needs adequate numbers of properly trained staff on help lines, in general practice, in ambulance services, emergency departments and on the wards. Not all sepsis deaths are avoidable but to stop those that are requires not raised awareness but a properly funded, safely staffed, joined up NHS. The government should put seven day routine services on hold, and get round the clock urgent and emergency care right. People most want the NHS to be there for them when they really need it, not to have chiropody on a Sunday afternoon.

Diagnosing diagnosis

Sir,

Helpful as it is of MD to provide PE readership with the basic warning signs for sepsis in children (Medicine Balls, Eye 1411) sadly, this particular disease accounts for only one of many diagnostic failures in the NHS or any other healthcare system.

In the US it is estimated that up to 80,000 hospital deaths occur annually due to preventable diagnostic failure i.e. they could have been saved if the premortem diagnosis had been known. The number is clearly higher if out of hospital deaths are included. Doing the maths, this would translate into about 16,000 preventable deaths in the UK each year.

Diagnostic failure has always been medicine’s elephant in the living room. The US Institute of Medicine recently tackled it head on and issued their report Improving Diagnosis in Health Care last September with appropriate apologies for not having picked up on the problem sooner: http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx

The report proposes a variety of solutions to the problem of making a correct diagnosis but chief among them is that we start coaching doctors and other healthcare providers how to think critically. The simple acquisition of medical knowledge in training is not enough; we need to know how to use it.

PAT CROSKERRY

Halifax, Canada

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To: Strobes <strobes@private-eye.co.uk>

Subject: MEDICINE BALLS – SEPSIS

I am sure that the article on sepsis has produced many letters.

44,000 deaths – 120 PER DAY!

In children – ALMOST 3 PER DAY!

MD has obviously gone to a great deal of trouble in collating as much information on sepsis from various courses.

His short but revealing paragraphs on how to recognise the condition should be published to the public at large ASAP.

It might help if EYE could reproduce the symptoms A4/large case size so that readers could copy and pin up in their medicine cabinets as well as copying and sending to friends.

If it saves but one childs’ death it will have been worthwhile.

If the death rates are so high in this country one can only imagine the death rates world wide especially in undeveloped countries.

It also leads me to suggest that our major pharmaceutical countries might work on inventing a quick and simple test such as now exists in many other conditions.

Don Roberts

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Sir

I was unimaginably depressed at your Medicine Balls: Sepsis, a Spotter’s guide not because its content was not entirely accurate but that you have to write it down in your organ almost as a guide to doctors. All the features you describe are first year clinical medicine student stuff and so as a comparative dinosaur hospital paediatrician I despair.

As a junior doctor in the 80s doing my stints in casualty at a now sadly closed children’s hospital in the north of England I was taught a single (German) word – gestalt meaning form or face or overall impression as the single most useful quality to have. At that time, after football on Sunday ITV was over the entire surrounding population seemed to descend on the hospital ER at 5pm. So one would walk round saying to families 3 hours 3 hours 3 hours but I want to see you , you and especially you right now just because there was something instantly obviously not right about them. MD’s long and correct list can all be encapsulated by the word gestalt and all these guides and endless policy books make it more complicated not less. I know of a certain district general hospital paediatric department in the south east who has thankfully gone back to the old rules of admit almost all under 1s who present after dark and all under 3s who have returned a second time to casualty – and it works. In paediatrics the mnemonic KISS (keep it simple stupid) works remarkably well.

A Consultant

Royal Brompton Hospital London