Outside the marginals

A commentary on the politics that followed the UK 2010, 2015 & 2017 elections

Lies, Damned lies and Simplistics

We seem to be suffering from a lack of appropriate figures to inform key debates and consequently protagonists seem to package up any data in to sound-bite grenades that then get lobbed into public debate. An example is the debate over the “seven-day” NHS.

There are not enough doctors to run a seven-day NHS in England, according to a leading doctor.

In a speech on Tuesday, Royal College of Physicians president Prof Jane Dacre will warn ministers the issue must be addressed if their policy is to work.

She will highlight research that shows vacant posts are not being filled and gaps in rotas are being seen.
BBC News Website, 15 March 2016 | Not enough doctors for 7-day NHS, says Royal College head

This news report suffers in a number of ways:

  • It is a “pre-announcement” – the actual news concerned has not happened yet so we cannot see the full context of the speech,
  • It conflates two issues; the seven-day NHS and the current shortage of doctors.

It is the latter that currently most concerns me.

The shortage of doctors (and nurses and ancillary skills) is a long-running issue particularly with a health service where demand seems to be rising uncontrollably.

Health tourism is often quoted as a cause of this increase in demand – but is dwarfed by longer-life spans, greater expectations of treatment and a greater ability to treat. We have not got our minds around these issues and how to address them.

An illustration: Prostate Cancer. This cancer used to be ignored – many men used to die unaware that they had this disease – and often they did not die directly of this disease. But,

  • men’s health, in general, is now being taken more seriously (why should men in the “age of equality” die earlier than women?); this increases demand.
  • Prostate Cancer is better understood and some of the symptoms are better understood and treatable (plus, not all those with symptoms have prostate cancer, they have other issues which are amenable to drug or minor surgical treatments); this increases demand.
  • Diagnostic techniques have improved from the low-tech “DRE” (Digital Rectal Examination – which is not some improvement from “analogue” – the “digital” refers to the doctor’s digit, the rectal refers to the patient!) through “TRUS” (Transrectal Ultrasound) guided biopsies, a relatively cheap means of taking biopsies, to the much more expensive high-tech MRI guided transperineal biopsies – which means that more cancers are picked up and the aggressiveness can be judged; this increases demand.
  • Surgical techniques have improved – again involving higher costs but bringing the possibility of better outcomes; this increases demand.

And yet there is little evidence that there is significantly more Prostate Cancer – just more cost – but better outcomes.

We as a nation are unwilling to deny our fellow citizens the benefits of improving health care – particularly in areas like cancer. We need to be equally willing to will the resources and that usually means cost.

So we probably have a systemic need for more doctors, nurses, MRI technicians, pathologists, health care assistants, porters, caterers, cleaners, etc. etc.

But does the “seven-day NHS” make this problem worse? Does the current “non seven-day NHS” only have 5 days of demand a week, whilst the introduction of the “seven-day NHS” means an immediate jump from 5 days of demand to 7 days of demand – a 40% increase?

I cannot clearly see how changing “opening hours” can increase demand so dramatically. It may be that greater accessibility means that some more people will come forward with their symptoms but this may also mean that people get treated earlier. Earlier treatment often works out cheaper because of the possibility of less aggressive treatment and the avoidance of complications.

So if demand is not substantially changed by seven-day a week accessibility, will it require more resources to overcome in-efficiencies brought about by seven-day working? If seven-day working means a more even flow of work you would expect greater efficiencies.

There is however a “configuration” issue. If your general hospital is not “full seven-day working” it is possible that some departments may only be available on week-days – and even only “9 to 5”. So for instance an out-patient department may so small that it has only one receptionist (with arrangements for holiday and sickness cover); with seven-day working one receptionist will not be sufficient. Likewise if that department is open seven days a week rather than the previous five either you have a specialist working seven days a week (!) or you have to arrange seven-day cover with extra specialists. But you find that with five days demand spread over seven days the specialists are twiddling their thumbs for much of the time.

There is however a move to concentrating treatments into larger hospitals¹. In these cases you may have, say, seven people of a particular type etc. on duty each day covering a big five-day a week department; re-rostering the same resource so that you have five people on duty each day covering seven-day a week working may be possible. There is an expectation that working less social hours deserves some form of pay premium; but this should be at least partly (if not wholly) fundable by the asset utilisation benefits arising from seven-day working (fewer assets – buildings, machines & equipment – working seven days a week can handle the work of more assets working five days a week).

To claim that you can’t introduce seven-day working because we don’t have enough doctors is simplifying the issue to the point of distortion. Seven-day working is pretty much an irrelevant factor when faced with staff shortages unable to meet demand.



¹. Such a move is not always popular. For instance I have serious concerns about the concentration of A&E services (a 24 hour, 7 day a week service) into more distant “super hospitals” due to the extra load on the ambulance service and the often critical delay in treatment cause by the need to transport people over greater distances. A classic case of trying to balance geographical accessibility against time accessibility. Ultimately more cost may have to be accepted as the means to tolerate the lower utilisation brought about by trying to have time and geographical accessibility.


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