Dangers of fatigue

时间：2017-11-16

发布：Fiona Godlee, editor in chief，The BMJ

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Health systems in the northern hemisphere are gearing up for winter. In the UK this brings traditional prognostications of doom, which were heightened last week by an unprecedented public call for more money from NHS England’s chief executive (doi:10.1136/bmj.j5251). Our own veteran reporter of winter crises, Nigel Hawkes, wonders whether this time the NHS really will fall over, not from sudden collapse but from slow strangulation (doi:10.1136/bmj.j5203). With “winter” pressures now apparent all year round, the cause is not more patients arriving at hospitals, he says, but fewer patients leaving. Until 2013 lengths of stay were falling, but this trend has reversed in the past four years, with the finger being pointed at growing problems in social care.

“We face winter better prepared than we have ever been but more scared than we have ever been,” says NHS England’s chair, Malcolm Grant. Scared for patients, whose safety will be put at risk. Scared too, I would suggest, for doctors and others working in healthcare, who may themselves be put in harm’s way because of fatigue and lack of support. As Paul Grieg and Rosamund Snow explain (doi:10.1136/bmj.j5107), needlestick injuries and road traffic crashes are more common when doctors are tired. And when mistakes are made, doctors suffer as well as their patients.

Other safety critical industries, such as air and road transport, now have clear rules to safeguard against fatigue. Staff can’t opt out, and the rules take account of not only hours worked but the cumulative effect of patterns of work. Schedules and budgets have to take them into account. Not so in medicine. Grieg and Snow question the assumption that doctors’ training makes them better able to overcome fatigue or to make their own judgments about risk. They find no evidence that doctors can evade the limitations of human physiology. At an individual level, they call on doctors to look for warning signs in themselves and their colleagues as part of their professional duty. “If you would not let a colleague work under the influence of alcohol, the same should apply to fatigue,” they say.

At an organisational level, they make an equally strong plea for tighter oversight of working patterns at all levels of seniority, including how working hours are clustered, whether proper breaks are taken, and how much fatigue someone may be accumulating. Shorter shifts need not mean reduced safety if training includes how to do safe handovers. Some of us may be looking forward to a post-Brexit health service freed from the constraints of the European Working Time Directive. If we want to survive winter’s pressures, perhaps we should think again.

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5294 (Published 16 November 2017)
Cite this as: BMJ 2017;359:j5294

Renaissance or requiem?

时间：2017-11-02

发布：Kamran Abbasi, executive editor

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Fifteen years ago Martin Marshall and Martin Roland asked whether the Quality and Outcomes Framework (QOF) would bring a renaissance or requiem for general practice in England.1 The mood is sombre, if not quite a requiem, but it’s hard to pin the blame entirely on QOF. The pay for performance scheme contributed by burdening general practitioners with administrative demands, diverting attention from interpersonal elements of care to financial incentives, and favouring poorly evidence based or managerial (over clinical) agendas. However, QOF delivered some “modest improvements in some aspects of clinical care,” Marshall and Roland now say in The BMJ (doi:10.1136/bmj.j4681). That isn’t a ringing endorsement. Indeed, QOF has produced no clear effect on overall mortality. But while there is little sign of benefit, there isn’t much to suggest a negative effect on care or patients’ experience either.

QOF was one of the most ambitious experiments in general practice, and though it hasn’t entirely failed it’s time for a rethink. The question now is how to replace it Some of QOF’s indicators might be retained, Marshall and Roland propose, but only those with a clear relation to beneficial health outcomes. Any replacement must harness the goodwill and professionalism of general practitioners. Also, a process of continuous improvement in care is preferable to standard setting. These components would value better the complexities of general practice, which require attention to managing uncertainty, social determinants of health, and shared decision making.

Twelve clinical commissioning groups in the north east of England decided to make shared decision making a central feature of one of their policies. In a disruptive innovation, described by Deborah Cohen’s investigation this week (doi:10.1136/bmj.j5016), the commissioning groups are offering bevacizumab (Avastin) to patients with wet age-related macular degeneration. Bevacizumab is not licensed for this indication, but it is cheaper and just as safe and effective as the alternatives. This move is against General Medical Council and National Institute for Health and Care Excellence guidance—both of which The BMJ questions—and faces legal threats from drug companies. In a Commentary David Hambleton, chief officer of South Tyneside Clinical Commissioning Group, estimates that the switch will save the region’s NHS £13.5m (€15m; $18m) a year. “In a financially stretched NHS,” he argues, “the alternative for CCGs is that we may have to make less evidence based savings” (doi:10.1136/bmj.j5013).

Just as with QOF and macular degeneration, in cancer care too what matters to patients doesn’t seem to be a sufficiently high priority. Tessa Richards, The BMJ’s pioneering editor for patient partnerships, describes her personal experience as a cancer patient on the receiving end of care that offered bewildering options and limited her involvement in discussions about treatments (doi:10.1136/bmj.j4956). What patients seek, she maintains, is “a doctor we know and trust and who knows and understands us, and who helps us to weather the storms, including the final one.”

References
01. Marshall M, Roland M. The new contract: renaissance or requiem for general practice?Br J Gen Pract2002;359:531-2.pmid:12120720.

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5045 (Published 02 November 2017)
Cite this as: BMJ 2017;359:j5045

When targets miss the mark

时间：2017-10-26

发布：Richard Hurley, features and debates editor

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Warnings of a looming winter crisis in the NHS are coming thicker and faster, with another just last week (doi:10.1136/bmj.j4885). It’s appropriate, then, that our latest Head to Head debate considers emergency care, a barometer of NHS performance in the cold season, and whether the “four hour wait” target has had its day.

Since 2004 this target has stipulated that emergency departments in England should see, treat, and admit or discharge most patients within that time.

“Before the target was introduced, being a sick patient in an emergency department was pretty awful,” Adrian Boyle and Ian Higginson remind us (doi:10.1136/bmj.j4857). “Emergency departments were often full, waiting times were long, and care was poor.” The target has focused resources, improved urgent care as a whole, and may have reduced deaths, they say. But their opponent, Peter Campbell, remains unconvinced. He notes that the target is not being consistently met despite its longevity. In fact, he dislikes targets altogether, pointing out that they inevitably distort care and encourage gaming. “Masterful managers manipulate,” he says. Real and sustainable improvement in A&E is more likely if payments are not linked to targets.

The effect of a different kind of target is worrying doctors and patients. The UK government promised to create a “hostile environment” for foreigners, including in the NHS, and this year it committed itself to cut net immigration to 100 000 people a year.

Clinicians now find themselves at the sharp end of policy to fulfil these promises. Starting last Monday, patients must be assessed for immigration and residency status before they receive NHS treatment in England, as our editorialists Lucinda Hiam and Martin McKee explain (doi:10.1136/bmj.j4713).

Patients deemed ineligible may have to pay upfront at 150% of the tariff—or go without care for themselves and their children. The policy also applies in services provided in the community and by charities that receive NHS funding. The Department of Health warns that doctors who treat a patient it deems ineligible could face prosecution.1 The likely result is that patients most in need will be refused care or will be deterred from presenting to health services, say Hiam and McKee.

The campaigning group Docs Not Cops set up a mock immigration checkpoint outside the Department of Health headquarters in Whitehall in protest (doi:10.1136/bmj.j4924). The policy is unfair, contradicts the NHS’s founding principle to treat people on the basis of need rather than ability to pay, and reduces doctors to border guards, the group says.

Footnotes
Follow Richard on Twitter, @rich_hurley

References
01. Department of Health. Guidance on implementing the overseas visitor charging regulations. Aug 2017. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/639277/Guidance_to_Charging_Regulations_post_21_August_final__Master_version_.pdf.

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4934 (Published 26 October 2017)
Cite this as: BMJ 2017;359:j4934