It’s good to talk – are the BMA playing into Hunt’s hands?

The junior doctor contract pantomime has now been running for a few months, without much progress in the plot.

The BMA calling a strike ballot polarised what is a complex issue. Of course I voted yes-yes, because to vote no would have been tacit agreement with Hunt’s plans.

But that’s not to say that I’m in awe of the BMA’s positioning. Quite the opposite. They have found themselves up against a master politician in Jeremy Hunt, and they’re being quietly maneuvered into an ever-weaker position.

In summary, they withdrew from negotiations many months ago and state that they will only return to the table if the threat of a contract being imposed is lifted.

This makes Hunt’s life easy.

Firstly, it’s an unreasonable demand. The BMA can’t honestly expect him to agree that a contract should only be implemented when both parties agree on all aspects of it. This would effectively give the BMA a veto on everything and a license to make unlimited demands. It’s the employer’s prerogative to implement contracts. The employee’s prerogative is to strike if they don’t agree with the content, but not to strike about the possibility of them being imposed.

Secondly, it leaves him an ultra-easy rebuttal. He can just smile sweetly, ask us again very nicely to come and talk it over like adults and such an enforcement probably won’t be necessary. But if we refuse to talk, he’s oh-so-sorry but the great British public voted for a 7-day-NHS, so changes will have to be made without our help.

All our other demands, the genuine contractual concerns, are totally neutralised by Hunt waxing lyrical about his (minor) concessions so far and the fact that ‘anything is up for negotiation’ if we talk.

We will end up looking like we’re striking against the possibility that a contract might be enforced at some point in the future, while refusing to talk to the man who will have to, as is his right and only option if we refuse to meet with him, do just that. Which is frankly weird. And the public will not understand it.

Wouldn’t it be a better tactic to find a reason to return to negotiations that saves face (perhaps a huge strike mandate?) then use those negotiations to push Hunt, again and again, for the changes we so reasonably want?

This would give us the upper hand. Instead of looking sulky and unreasonable, we’d be giving Hunt a good, solid chance to refuse fair contractual compromises. The public could understand this. Then and only then would it be fully effective to strike.

If Hunt imposes a contract, fine. We can strike about that. And keep striking while negotiating, watching the heat slowly build around him as he refuses again and again to make compromises fair to one of the most trusted professions in the land.

If the BMA could add in some proactive PR – some widely-accessible soundbites on how Hunt’s demands will cause the weak, sick and vulnerable irrevocable damage due to thousands of doctors burning out or flying off to Oz, then all the better. We need to hammer home the narrative that doctors are the NHS, we are all the NHS, and how dare Hunt, that outsider, pick on us when we’re trying to look after eachother. We have to make it look like striking is our last resort to desperately protect those we love from a vicious swindling.

But right now, I’d just settle for standing on a picket line knowing that my representatives were talking to the man able to make changes to my situation – even if just to continually prove that he won’t budge.


No beds in the whole country – mental health services hit a new low

Two years ago, I posted a tweet that a lot of people found very worrying.


I hadn’t been working in mental health for long, and had been shocked to discover that often the local area, even if it was the capital city, would have no available inpatient beds. Patients would have to be sent out-of-area, often hundreds of miles away, to be admitted.

The Guardian asked me to write about it in more detail, which I did. We were hopeful that with all the publicity occurring at the time, things would change.

And since then, things have changed.

Now, they’re even worse.


I don’t usually talk online about my individual professional experiences. But recently, I found it hard to contain my frustration and sheer disappointment. Presented with a patient who needed a bed, there were none in the local area, none in the surrounding areas, and none in the private sector nationwide. Patients like this, wherever they present in the country, have no option but to wait in A+E, or at home, or in a police cell, until appropriate, safe care can be provided. Which is a disgrace.

Minister for Health Alistair Burt MP was quick to reply that my statement ‘was found to be untrue‘ – by which I think he meant that there were some beds available in the country, but probably in random Trusts, hundreds of miles away. Trusts have no practicable way of contacting every other Trust in the country to seek out the last open bed in the land, and even if they could, that Trust would likely be trying to protect it for their own patients. So not a particularly constructive response from the Minister (what would’ve been wrong with ‘tell me more about the problem?’).

I don’t want to dwell on the minutiae of my own particular situation. My patients and my Trust deserve their privacy as they fight their own respective battles. But it wasn’t an unusual situation for a UK mental health service. Norfolk and Suffolk have been the only Trust that I know of who’ve been brave enough to say it publicly, but not being able to find a bed in the whole country is the new baseline for ‘tricky weekend’ in mental health.

It’s not hard to see how we got here.

The government has tried bloody hard to convince us that funding in mental health is rising, but the numbers aren’t exactly shouting out that conclusion. Some sources say there could actually have been cuts of up to 8%, with Trusts forecasting the same cuts again over the next few years.

Even if you believe the government line, that there has been investment (which they don’t seem to be sure about themselves), it pales into insignificance as part of the bigger picture.

Mental health was drastically underfunded to start with, accruing just 13% of NHS funding, despite accounting for 23% of the ‘illness burden’. But now with austerity in full flow, way more people are in contact with mental health services than ever before. Our sister services, public health and social care, have been decimated, leaving us to pick up their slack.

The end result? Carnage. We’ve lost 17% of our beds in the last 3 years (5% in the last year alone). The amount we pay private hospitals to takes care of our patients, because our own beds are full, has doubled in the last year alone to a very conservative estimate of £38m. Out-of-area admissions rose 23% in the same period. Bed occupancy is 94% on average, with some Trusts working at over 100%. And we used the Mental Health Act 10% more this year than the previous year, as patients spiral into crisis and need to be compulsorily detained more often, into beds hundreds of miles away that they’re less likely to go to willingly.

The interim report of the Crisp Commission has shown us that we technically may have enough beds, it’s just that so many of them are taken up by people who could be discharged but have nowhere to go. Good health doesn’t happen due to health services alone, so to say you’ve ‘ring fenced’ the health budget while cutting social care funding is willful idiocy.

In a way, I wish the solution to this problem was more complicated than it really is. It would reassure me that our politicians are working hard to fix the problem, but haven’t been able to. But that’s not the case.

We need real funding. Not just for isolated interventions like perinatal, liaison or early intervention services that have robust cost-effectiveness evidence bases and slightly-flashier-than-average selling points, but for general services too. Not just for humane reasons, but to stop our patients burning through funds in other services (police, A+E, ambulances) without it doing anyone any good. Spending money on mental health saves money, and not funding us adequately creates an inefficient, shameful shambles.

We need not just well-meant documents like the Crisis Care Concordat, but to stop cutting nursing staff numbers (down 3,300 over the last 5 years) so there’s someone left to provide actual care.

And besides all that, we need to be incredibly wary of slick rhetoric from politicians about how mental health services are a key issue, without them giving detailed assurances – including significant funding amounts – that big changes are about to be made. Their talk is cheap, and increasingly so, your mental health treatment is too.

24 hours of admin in mental health services

I recently had a Twitter conversation with Geraldine Strathdee, our National Clinical Director for Mental Health, about the administrative burden we face while practicing in our specialty. She asked me to write a blog detailing just how much paperwork (and electronic paperwork) I have to do over a set period, to shine a light on the issue. So this might not be my most scintillating blog, but I’m hoping that it’ll create some useful discussion nonetheless.

I’m writing about a typical day in my current job, but none of the content is specific to my team or Trust. I’ve done six other jobs in mental health and they’ve all carried roughly the same weight and type of admin.

The day shift

I’ve been away for a week (typical lazy junior doctor), so I get in early to check through my emails. I answer a few of the more pressing ones, which if at all vaguely important need to be copied and pasted into the electronic notes. I make a few phone calls to patients who left messages last week, typing the entirety of the conversations up too.

Then I move on to seeing some patients. Two full assessments in the morning. Not only do both need extensive clinic letters but an array of auxiliary electronic forms need to be filled out too. Each new patient needs a diagnosis under the ‘Outcomes’ tab of their electronic notes and a full risk assessment under the ‘Risk’ tab (the form has around 100 optional tick-boxes as well as free text space). Also, HONOS and clustering scores need to be calculated (two multiple choice forms which take 2-10 minutes each), so we can demonstrate that our patients are ill enough to need our help. These are all individually fairly easy forms to fill out, but when you have to do 5 for every patient, it suffocates you. I perpetually wonder why I was never weighed down by all this when I worked in general medicine (it’s because Acute Trusts pay coders to extract the information from the notes after discharge and don’t have such an unhealthy obsession with ‘risk’).

I make some more phone calls at lunch time, followed by seeing two more patients in the afternoon. It’s the same admin story as the morning’s patients. I also remember that every meeting we have with a patient needs to be confirmed on the electronic notes diary, so it gets logged as work that the team has done. This involves clicking on the appointment under the relevant tab in their notes, then laboriously copying every bit of information about the appointment (who is going to be there, what time and date it’ll be, where it’ll be, what it’s for) from the left hand side of the page into identical boxes on the right hand side of the page, to confirm it all actually happened. For every appointment. If we don’t do it, the computer doesn’t recognise that we did any work.

I stay late to finish (some of) my clinic letters and write covering letters to three other services (two within my own Trust) who I’m referring the patients to. I email all the letters to the admin team, who are wonderful. They’ll print off the letters and send them in the post (yes, including to other services in our own Trust), where the recipients will most of the time scan them right back onto their own computers. Welcome to our ‘paperless’ NHS. It’s been no different in any Trust I’ve worked in. Occasionally I find replies from these services in my pigeonhole, sent by post as well, already scanned on to our own computers by the wonderful admin ladies, who frankly must have better things to do.

God forbid you ever want anything from a GP. They have to fax it across to you, for it to be scanned and the hard copy shredded. Often they even ask for a faxed request to prove that you’re really who you say you are. It’s 2015. Email was invented before plenty of doctors were even born.

The night shift

I finally manage to get home, but I’m on call, and after grabbing some dinner I’m called into A+E to help see some new patients. Not a process which is easy on your typing fingers. Every time we see a patient in A+E, we have to:

  • write an entry in the handwritten A+E notes
  • if the patient is new, open an electronic account for them before you can do any of the above, entering their name, address, phone number, NHS numbers, and GP details at a minimum.
  • On the electronic system, fill in a brief clinical note…
  • do a risk assessment…
  • calculate the HONOS and cluster scores…
  • enter a diagnosis…
  • write an assessment letter…
  • and do a covering letter to the GP for the assessment letter.

Plus whatever extra paperwork you need to do for that individual patient, for example, a referral to social services, psychological services, or an employment support service. I have to admit, it’s so much paperwork that it’s sometimes very difficult to enjoy seeing patients. Which is a HUGE warning sign. How much paperwork do orthopaedic surgeons do when they see a patient in A+E? (not just the depth of detail on the forms, but the amount of forms?).

After quietly tiptoeing out of A+E, I make it home for a nap. But in the early hours of the next day, I’m called out again to assess someone who has been brought in on a Section 136 by the police. I see them, and they need to come into hospital. And as is absolutely usual, there are no beds.

The phone calls begin- to the consultant, to wards who might be able to spare a bed, and inevitably to the bed manager and anyone else who needs to give the green light to an out-of-area bed. Every phone call is accompanied by a note on the electronic system, in addition to the assessment entry (and risk entry, etc. etc.) and the handwritten section paperwork. Thankfully an SHO is around to do the drug chart and the blood test forms. I email the patient’s usual care team to tell them what’s happened. Eventually a bed is found, and the transfer paperwork needs to be readied – so you’ve guessed it, everything needs to be printed off, and either faxed to the accepting hospital or put in an envelope with the patient.

And with that done I go home, get some ice on my typing fingers, and catch a few hours of sleep before the emails start rolling in again.

Chaining doctors to their jobs is no fix for the NHS

I was unsettled to read Tom Tugendhat MP’s recent article in the Telegraph. He suggests that we could resolve the doctor recruitment crisis in the UK by forcing doctors to work for NHS for a set amount of years after they qualify, to ‘pay back their debt to society’ instead of having the option of emigrating.

This is a very short-sighted solution, with multiple flaws. I don’t know how much exposure Mr Tugendhat has had to medical professionals, but if he’s had only a little he must surely be aware of the following:

The most obvious drawback to his plan is that it doesn’t do anything to solve the root problems which are making our doctors leave in droves. Surely remedying the pressurised workplaces, cuts to services and insulting contract prospects which are driving emigration in the first place would be a more logical (and kinder) step? Without these improvements doctors will continue to leave even if it has to be at the end of a period of enforced working.

Then there’s the fact that it would destroy what’s left of our morale. Doctors will stoically grind out hour after hour of work on the deck of the proverbial Titanic as long as patients benefit, but handcuffing us to a railing will only make us lose faith in the captain.

Furthermore, those of us that struggle with the inevitable strains of medical work, as so many of us do, will feel compelled to carry on, burning themselves out so badly that they won’t be able to work again for years.

And those that want to leave for Australia, or New Zealand, or wherever, but have been forced to stay, aren’t exactly going to be employee of the month, are they?

Another reason – patients will wonder if their doctor has been forced to stay. They won’t trust doctor’s motives as much, which is hugely important to us.

But it doesn’t stop there. Sixth formers won’t look at the prospect of a few years enforced labour for a flagging NHS at the end of their degree as an incentive to apply for medicine, especially those from lower income families who are watching student loans and the cost of living rise, but doctor’s wages falling. They’ll rightly think that leaving university with over £75,000 of debt entitles them to choose what they do with their degree.

There’s a philosophical point behind all this too. We don’t educate the young people of this country so they will give us something back. If we did, we’d be forcing teachers, scientists, lawyers and nurses to work for the state after graduation. But we don’t. We educate young people because education is a right, not one half of a deal.

Mr Tugendhat draws a comparison with the armed forces, who fund some medical students through university in exchange for a period of service after graduation. But this comparison is poor. The armed forces, essentially a third party, simply offers students lots of money in exchange for later work. The choice is about personal gain and is all theirs. Whereas NHS services that help train medical students already get paid for it by the state. Students pay loans to their universities for the privilege, have no choice but to train on NHS premises and their only gain is learning. Entirely different systems of motive. Maybe if the NHS started paying medical students tens of thousands of pounds in lump sums during their training, instead of them accruing massive debts, then we might be justified in forcing them to work for the NHS later on.

We should build a system in which young people study medicine and work for the NHS for their whole lives because it’s a great place to work, not chain our doctors to a sinking ship and think we’ve plugged the leaks.

Why the new junior doctor contract is a slap in the face

NHS Employers have announced that they’ll be forcing an insulting new contract on junior doctors. The BMA Junior Doctor Committee did try to negotiate with them, but talks broke down and last month the BMA decided that it couldn’t come back to the table when what was on offer was so demeaning.

The reaction from medical staff (and the general public) has been visceral. They’ve made it very clear that this new contract would be nothing less than a danger to patients and staff alike and a despicable slap on the face for junior doctors. An unofficial petition calling for strike action has already topped 30,000 signatures.

So why all the anger? Here’s why.

  1. It’s a huge pay cut

From the limited data that NHS Employers have provided about the new rates of pay, most models, including my own, are predicting around a 10-15% pay cut. Although the new deal is supposed to be cost-neutral, we find it hard to trust a Health Secretary who denied nurses their 1% pay rise but then accepted a 10% pay rise himself, and who said that mental health funding had gone up despite mountains of stats that said that it had plummeted. Doctors don’t tend to be greedy people, but almost all of them have massive student loans, many of them have a family to support, and lots of them are trying, somehow, to afford a house. Seeing NHS Employers recently advertise for 200 ‘physician associates’, who only need two years training, for salaries of £50,000 a year, didn’t help our self-esteem.

2. It turns our evenings and weekends into ‘standard working time’

Currently, 7am to 7pm Monday to Friday is seen as standard working hours, and any work done outside of that is seen as worthy of extra pay. This seems reasonable. But the new contract extends these standard hours to 7am to 10pm on weekdays and Saturday, meaning that we’ll be paid the same for an hour of work on 9pm on Saturday compared to an hour of work at 9am on Tuesday. Only Sundays and nights are paid more. This means hospitals can rota us to work far more unsocial hours than we currently do at no extra cost, which is basically theft of our personal lives. Though doctors are frequently needed out of business hours, there’s no reason why we should submit to being paid the same for working at that time. We signed up to help people, not to sacrifice any semblance of a life outside of medicine as a favour.

3. There are no clear safeguards on monitoring our hours

Not so long ago, junior doctors were working over 100 hours a week. It was relentless, traumatic, and frankly dangerous. Then, after years of lobbying, the European Working Time Directive was passed into law and gradually the average number of weekly hours we were allowed to work started to shrink. It’s currently 48. A complex process of ‘banding’ occurs to add on a percentage amount to our basic salary (typically 40%) to recognise how hard we work out-of-hours and another complex process of hours monitoring occurs to make sure we don’t work too many hours. There are big incentives for employers not to overwork their doctors.

But with the new contract, there is no such system of monitoring. Doctors will be expected to go to their employers and ask for a ‘work review’ if they’re worried about their hours, which they won’t do because they’re too busy, which they’ll feel bad about doing, and which they’ll be quietly punished for doing. Back to the 1980s.

4. The reason for change – Cameron’s ‘7 day NHS’ – is deeply flawed

The whole point of this new contract is that David Cameron wants a ‘7 day NHS’. But he refuses to define what that means. He refuses to acknowledge that the NHS already works 7 days a week, and that forcing doctors to work more weekends and nights isn’t necessarily going to help improve services. Though Jeremy Hunt likes to spout about death rates being raised for patients admitted on the weekend, it’s still not clear if those patients just happen to be sicker or if more weekend doctors would save any of them, let alone be value for money.

I am seriously worried that doctors are going to be forced into rotas which schedule them for ever-increasing amounts of weekend and night work, with no clear rationale for what they’re meant to be doing, and no great means of doing it (as many other services are closed at the weekends). Some specialties like psychiatry don’t have a huge call for out-of-hours work, so pulling doctors from their Monday to Friday jobs to man the hospital on weekends would only be counterproductive. And we know that GP patients don’t necessarily love weekend appointments – pilots had to be stopped early as no one booked a slot!

5. Annual pay progression is being scrapped

In the clearest demonstration of how little NHS Emplyers and the DoH know about medical training, they’ve decided that instead of getting an annual pay rise, certain grades of doctor (SHOs, registrars etc.) should all earn the same amount within their grade, no matter how long they’ve been in that grade, as they all have the same responsibility. This is horseshit.

Every doctor knows that a first year SHO is going to be calling their seniors a lot, needing more help, and working slower. But a more senior SHO will be running more of the show for themselves, and helping out their less senior colleagues more, so deserving more money.

Also, pay progression encourages people to stay in their jobs, which at a time when GP recruitment is shockingly low, is a good thing.

6. It mistakes non-residential on call hours for lazing about

The new rate for non-residential on call hours (being at home, but available), is just 5% more than a standard hour’s work. As if doctors who have to rush in from home at 4am to do procedures that only they can do are of no use, when in fact, doing such on calls is often hectic, grueling and vital. And again, specialties who don’t have a huge demand for residential out-of-hours work, like my own, will suffer disproportionately.

7. It discriminates against women and men who want a family life

Currently, if a junior doctor changes specialty part-way through their training, effectively starting again, they stay on the same rung of the pay ladder to recognise their past service to the NHS. But under the new contract, pay will revert back to the lowest rate if the doctor decides to retrain in another specialty, or become an academic. Apart from being a harsh punishment for anyone who simply decides that they want to change their career direction (how dare they?), this is a flagrant swipe at women and men who want family lives, who often retrain in specialties more suited to that end, like GP or psychiatry. As if the fact that stopping annual pay progression will disproportionately hit women who work part time, as pay rises will come every 6 years instead of every 2, wasn’t bad enough.

I can’t emphasize enough how harmful this new contract will be for junior doctors and patients alike. Masses of my friends have already left for Australia, and they aren’t coming back. Why would they? The powers that be treat our NHS staff like dirt and unless we stop it soon, there won’t be anything left to protect.

I’m still undecided about strike action. If you could guarantee me that it would have a positive effect, then I’d be the first on the picket lines to fight for patient safety in the long-term. But the ignorance and deafness that NHS Employers and the DoH have shown is becoming legendary, so we may need another option. I’m open to suggestions. Help.

What the research on hospital death rates really says

There’s a been a big media splash today about research which shows an increase in the chance of death if you’re admitted to hospital over the weekend, compared to during the week.

Most of it has been reasonably accurate and clear, like the Guardian piece. But some has been misleading, like this Telegraph piece which states that you’re ‘twice as likely’ to die if admitted at the weekend, which seems to be nothing short of fictional.

The actual research paper can be found here [subscription required]. So what does it actually say, in simple terms?

The researchers looked at just under 15 million UK hospital admissions for 2013-14, of which around 280,000 led to death.

They worked out that the chances of a patient dying within 30 days of being admitted were 10% higher if they were admitted on a Saturday and 15% higher if they were admitted on a Sunday, compared to if they were admitted during the week. This sounds pretty damning, and frankly scary.

But it’s more complicated than that.

The first thing to note is that these numbers are what we call relative risks, i.e. the difference in risk compared to the same risk for another group of people. Relative risks can sound impressive, and they make for good headlines.

But the absolute risk of dying if admitted to hospital, i.e. the risk all by itself, is very small. Overall it was 1.8%, rising to roughly 1.98% for Saturday admissions and 2.07% for Sunday admissions. Not such a punchy headline anymore.

The researchers were also well aware that patients who are admitted over the weekend are sicker to start with. In fact, 50% of Saturday and 65% of Sunday admissions were emergencies, compared to 29% during the week.

The researchers did try to correct for this problem. They reanalysed their data after excluding all patients who died within 3 days of being admitted, to try to limit the impact that emergency admission had on the results. The relative risk of dying if admitted at the weekend dropped – to a 7% increase for Saturday admissions and a 10% increase for Sunday admissions.

As the study itself points out, we should be seriously cautious about interpreting these numbers, especially when it comes to blaming them on staff who prefer a ‘Monday to Friday’ working culture, as Jeremy Hunt is so keen to do.

Simply excluding everyone who dies within 3 days of admission isn’t a great way of excluding all emergencies. As any doctor (or friend, or relative) will tell you, many severely unwell patients don’t die as soon as they reach hospital. Modern medicine can support them for days if not weeks, so they could still be contributing to that increased weekend admission death rate.

Furthermore, during my days as a general medical doctor, it was routine to see patients admitted at the weekend not as critical emergencies, but as the result of deteriorating slowly over the previous few days, not being able to see a GP on a Friday, and eventually ending up in the option of last resort, an A+E bed on a Sunday, in worse shape than if their issue had started on a Monday. There’s a real case for poor access to other services being the real cause of increased weekend admission deaths, not a ‘Monday to Friday’ culture in hospitals.

This tallies with the fact that Saturday admissions do better than Sunday admissions – because they’ve only had to survive one day’s deterioration without their GP before coming into hospital, not two. If poor care in hospitals was really the problem, we’d expect Saturday admissions – who’d have to spend two whole days in hospital over the weekend – to do worse. But they don’t.

It’s important to note that no more deaths actually occurred on weekend days compared to weekdays. Weekend staff seem to be doing an amazing job of keeping people alive once they make it to hospital.

Another thing that any doctor will tell you is that care in the first few days of an admission isn’t likely to be much different if you’re admitted on a weekend compared to a weekday. A+Es and medical assessment units – the first two stops during most admissions – routinely have as many staff on at the weekends as during the week, and urgent tests and procedures still happen quickly. It’s only when a patient has been moved on to a general ward, maybe 2 or 3 days later, that they might feel the effects of the weekend slow-down, as routine investigations have to wait. This doesn’t tally with staffing factors being the cause of increased weekend admission deaths.

Don’t misunderstand me; doctors couldn’t be keener to ensure that patients get good care on every day of the week. Contrary to popular belief, only 1% of consultants opt out of weekend working. And I’d never deny that junior doctors can feel overworked and undersupported at the weekends, meaning that there is room for improvement in senior doctor hours.

But we have to understand what statistics really mean before using them as the basis for policy and contract changes which will profoundly affect our health service for decades to come. To assume that the increased death rate for weekend admissions is preventable, in the words on the researchers themselves, would be ‘rash and misleading’. Take note Mr Hunt.

We already have a 7-day NHS. Don’t believe the hype.

Seven-day psychiatrists

Unless you’ve spent the last few months in a cave, you’ll know that David Cameron is dead-set on turning our NHS into a ‘seven-day service’.

He hasn’t given much detail on what it’ll look like, or how it’ll differ from the current set-up (in which doctors already routinely work 7 days a week), but the current arm-twisting of doctors into a contract which would force them to work more weekend days for the same pay shows that he really wants it to happen. Whatever it is.

So how might psychiatrists adapt to working routinely at the weekend, instead of just being on-call for urgent jobs and emergency assessments? Despite the mean and unthinking way that the government have gone about their proposals, I do think that psychiatrists could make substantial changes to their practice to acknowledge that mental illness doesn’t just work 9 to 5, Monday to Friday. It depends on the setting though.

I see relatively little point in asking consultant psychiatrists on inpatient units to work routinely at weekends. If they work on a Saturday or a Sunday, it would only mean they’d have to make up their time off on a weekday at some point, so nothing would move quicker overall. Unless other staff were in work on the same weekend days, like junior doctors and OTs, there would be limited effect from a consultant presence anyway. There would also be substantial legal and practical issues to having a different consultant work routinely on the weekend on another consultant’s ward (for example, if all the inpatient consultants were on the rota to come in at the weekend). Patients under section are meant to be under the care of their responsible clinician, and they’re the only people who can give them leave or discharge them. This person shouldn’t be chopped and changed. Also, psychiatric care is like painting a picture – no matter how good the artists are, if too many of them help with the project, you’ll just end up with a confused mess.

Could psychiatrists work more routinely in A+Es? After all, we know that liaison psychiatry services are patchy, but would consultant presence at the weekend fix this? Well…possibly….but in many smaller A+Es a consultant psychiatrist would be sitting around drinking coffee all day. In the larger ones, their juniors would still be seeing patients first (or else how would they learn), limiting their workload. I don’t see why they couldn’t be at home, available for emergencies, as they already are.

What about community and crisis teams – could psychiatrists work more for these at the weekends? For me, this is the most likely setting in which psychiatrists could be seven-day beings. It seems entirely feasible for them to hold emergency clinics and do emergency home reviews, as well as follow-up on the more distressed patients that have arisen during the week. If they work in a team of many consultants, there would be relatively little stress in running a rota of weekend shifts, as the weekdays would still be covered by colleagues. But this too could meet with implementation problems. Weekend GP surgery pilots have had to be cancelled recently as no-one turned up; perhaps that might happen to consultant psychiatrists too.

Whatever the proposed plan, there needs to be recognition of the following:

  • Psychiatrists work hard at weekends already
  • We are chronically short of doctors (and other staff), seven-day working is not a fix for this
  • Psychiatry requires continuity of care, seven-day working should not jeopardise this
  • Working more at the weekends will leave staffing holes during weekdays
  • Doctors should be adequately compensated for working more at weekends. The current contract offer is a joke.

As always I’m keen to hear how things work (or don’t work) in your area, and your ideas for the way forward.


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