Weekend Mortality and the 7-day NHS

“If you are admitted to hospital on a Sunday, you are 15% more likely to die than on a Wednesday”.

This is Jeremy Hunt- quoting a paper without atribution from the Journal of the Royal Society of Medicine, conducted in 2010 by Freemantle et al [1] amongst nearly 15 million admissions.

Here is the actual paper:
Here are the ACTUAL conclusions
  1. Patients admitted on a Sunday were more likely to die over the next thirty days than a similar cohort of admissions on Wednesday- the ratio was 1.16 and the result significant, suggesting a true result of increased deaths by 16%
  2. 94% of these ‘admissions’ were emergencies
  3. 34% of deaths occurred within three days of admission
  4. You are actually less likely to die if you are IN hospital on the weekend – the Sunday to Wednesday ratio here is 0.92, or 8% LESS likely. As the authors also conclude, this likely reflects the fact that high-risk, non-urgent procedures are performed during the week.
  5. For elective (non-emergency) admissions, the ratio was 1.62 for Sunday to Wednesday, suggesting a 62% increased chance of death. This, as the authors conclude, is likely biased by the fact that high-risk elective patients are brought in early in general for exactly this reason, therefore this is unlikely to be significant.
  6. Of 10 conditions specifically looked at, only 7 were found to show the same increased risk: sepsis, acute renal failure, cancer of the bronchus or lung, myocardial infarction, acute stroke, and congestive heart failure.
  7. The authors also conclude: “7-day access to ALL ASPECTS of care” could improve such figures, but further ‘economic evaluation’ is required to ensure efficiency with ‘scant resources’ [para]
  8. A further third of patients in this study died after discharge
So to summarise, you are 16% more likely to die, over the next thirty days, if you come into hospital on a Sunday- 30% will die within three days (Mon-Tues), and a further 30% will die after discharge. This only applies to emergency admissions, and a list of medical emergency conditions.
One major criticism, published by the authors themselves, is the fact that any conclusion completely ignores the reason for admission and the route of admission- there are no routine GP services on the weekend, and the impetus to admit on a weekend has to be higher than the week when most people would hold out for the GP unless they were very unwell. This immediately selects out a group of sicker patients than might routinely come in on a Wednesday.
Now we will play a game called ‘Jeremy Hunt spectacles’.
I look at this paper with ‘Jeremy Hunt Spectacles’ and read the abstract ‘admissions on a Sunday…16% more likely to die vs a wednesday’ and then completely stop reading and decide that a) 15% is a rounder, more soundbite-friendly number b) this must be the consultants fault c) I should go and tell them, loudly and with contract renegotiations for the entire consultant body. Or more realistically d) this would be excellent to further my agenda of privatising the NHS (despite that later in the paper the private US system shows the exact same pattern).
Now I take off the spectacles and look again.
The paper shows that patients admitted on Sunday, overwhelmingly emergencies, do worse during the entire course of their illness episode than those on Wednesday, but they deteriorate during the next three days (30%) over the weekdays, or even after discharge (34%) ie all on weekdays or even weeks of admission. Of the commonest conditions they are all medical emergencies.
Therefore, the suggestion is there is a decreased level of care on a Sunday admission, assuming that the patients are not genuinely sicker on average as suggested above, and that exarcebates or worsens an illness episode greater than a Wednesday admission. This extra initial insult, in 16% of patients, is not survivable. The ward patients however, appear generally unaffected weekend or weekday.
So what do the Wednesday patients get, that the Sunday patients don’t get? Consultants? In every hospital I have worked in that is simply not the case. Think about the admission process; in A&E there is always a consultant, on a 7-day 24-hour basis. Most have 3 or 4 at a time. For this set of patients they go to acute medicine where the standard is a daily consultant ward round, some twice or even thrice daily. So that is not going to help Mrs Sunday.*
What is not there? Only limited access to their GP, which in turn increases the workload in A&E, limited radiographer and lab techs, echocardiogram technicians, reduced pharmacy cover, and the hordes of office hours staff – secretaries for vital notes from other hospitals, semi-urgent referrals to other teams, the list goes on. In other words the missing £20 billion from the £100 billion budget that has already been cut away.
So, looking at the same problem, where emergency admissions are the chief cause of the 15% bump in mortality, what is the rational response? To increase funding and GP resources, to staff and fund A&E and acute medicine and other acute specialties and to support community services.
Has this been done? No.
Instead- GPs have been pushed on to duties they didn’t want in the form of the wholly rejected Health and Social Care Act, at a conservative estimated cost of £1.5 billion [2], and instead of funding and supporting emergency admissions A&Es have been closed and the specialty chronically under recruited, despite warnings. In other words, the areas designed to prevent this exact problem, identified in 2010, have been systematically underfunded and cut by the current Government for the last 5 years.
So, is an attack on consultant contracts, who are already working weekends and nights in vital areas, going to save 6100 lives? Clearly not. The system needs to extend through the multidisciplinary teams and out of the hospital and into GP land and social care- this needs to focus on emergency admissions. So while there is a neat political capital in claiming 7-day NHS services is good for patients- it’s an appeal to convenience, not safety, and no regard to resource. If you want all the staff and equipment and resources available 24 hours a day, you will need another two 8 hour shift equivalents- another 300,000 doctors, 800,000 nurses, 310,000 multi-discplinary team members. If you have a spare annual £200 billion, this would be a good time to speak up.
And in the meantime Lord Prior, the parliamentary under-secretary of state for NHS productivity, quietly announces an inquiry into private charges and insurance to fund the NHS. I.e to move the system from tax-funded to full charge-based private healthcare. [3]
So, Jeremy Hunt, is not stupid. He isn’t ignorant- he is inflammatory. He is not incompetent he is corrupt. There is an agenda here far wider than doctor-bashing.
While myself and my colleagues post #ImInWorkJeremy tweets in solidarity against changes to our contract, the political conversation is focused on us, while behind the scenes one of the greatest healthcare systems in the world is quietly dismantled by politicians and Lords with no democratic mandate to do so.
All doctors would like a 7-day NHS- we would like all the resources we have at the weekdays to do the best for our patients. Just come and witness the frustrated arguments with midnight radiographers and rushing to on call pharmacy at 11.55 am on a Saturday. But you learn to prioritise as well- that’s why you want to be the patient kept waiting, because the patient we are running to is usually the one in a hurry to die.
Perhaps Jeremy Hunt needs a lesson on prioritisation. Or perhaps he, Lord Prior and the rest of the Conservative government are not prioritising patients at all.
*In fact this is exactly the changes made at Northumbria hospital, mentioned in the same breath in the same speech by Mr Hunt as an example 7-day service, to increase acute medicine and A&E Services, NOT the entire hospital.
**. And for what’s it’s worth: this is day 6 of my 12 day shift. Lazy old me.
[1] J R Soc Med. 2012 Feb;105(2):74-84 doi: 10.1258/jrsm.2012.120009. Epub 2012 Feb 2. Weekend Hospitalization and additional risk of death: an analysis of inpatient data. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, Roche WR, Stephens I, Keogh B, Pagano D.
[3]http://www.independent.co.uk/news/uk/politics/the-principle-of-a-free-taxpayerfunded-nhs-must-be-questioned-says-tory-health-minister-10395991.html
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30 Comments

  1. * and as for the Northumbria model, it would be useful if someone could do a FOI Act request as to how many elective sessions have been lost and how many increased pa’s have been given to cope with the extra workload. I suspect they will fudge it but it needs to be pursued.

  2. Dr,

    I really don’t know how use are managing to keep going and do the fantastic work use do under such difficult circumstances. As targets, for the most recent vile and disgusting sustained attacks from our conservative and the previous coalition governments, are a long way short of the praise and admiration all our NHS staff deserve. Use do an excellent job under impossible conditions and as a member of the public you serve, I want to acknowledge that and say thank you.

    The attacks on our NHS by successive governments have been sustained, deliberate and calculated, with the ultimate goal of privatisation of our NHS. I cannot fathom why more of the general public are not enraged about the governments clear agenda. Perhaps it is that they don’t understand what it will actually mean. World class healthcare will still be available, but only to those who can afford it. For everyone else there will be little healthcare available if any.

    I am disgusted, enraged, fuming, angry, upset, disappointed and worried, not only for the future of our NHS, but what effect a privatised health service will have on society as a whole. Our NHS belongs to and is paid for by all of us and I passionately believe that it is not for any of us to give away what was so freely given to us.

    Therefore I am setting up a group for concerned citizens. The purpose of the group will be to provide a forum for people to get together to discuss, debate, design & build a better, fairer, more democratic UK society which will include a publicly owned & funded NHS.

    Group meetings will take place as webinars and it is hoped that the first meeting will take place during the last week in July. Anyone who is UK resiedent may join by sending an email to redesigndemocracy@yahoo.co.uk in order to be added to the list of invitees.

  3. Excellent critique!
    Another observation I would add is that if poor or inadequate doctoring by consultants were indeed the cause for increased mortality, one would expect an increasing hike in mortality from Fri to Sun, in line with increasing periods of being thus ‘undertreated’.
    Not only does this not happen, Sunday (the day with the *shortest* such period) has the *highest* relative mortality. This just does not make sense!

  4. Surely those admitted at weekends are likely to be more critical cases and hence more likely to die whatever day of the week they are admitted. But on weekdays the less critical cases are also admitted lowering the overall death rate for those days.

  5. I really hope you are a member of the National Health Action Party. Their analysis is the same as yours as is the conclusion. Too many people, in addition, including, I have to say, the BMA, are going along as ‘partners’ staying ‘in the tent’ and ‘influencing the debate’ whilst actually doing F all about changing the direction of travel or putting a halt to the destruction of the NHS. Devolution is a catastrophic next step in the process.

  6. Very good study, does it make an analysis of the mortality amongst admissions thru A&E during the wk days vs weekends. They are likely to be more similar.and the data of general cases during the weekdays will not dilute the figures.

  7. Great article! More should be done to ensure your voices are heard. It is an absolute shame that your views are simply not considered to the level that they should be or ignored completely.

  8. I would suggest that patient admitted to hospital on a Sunday (via Emergency Dept) are more sick than those elective admissions on a wednesday. Also, if as stated in this paper, 60% of all people admitted to hospital on a sunday DIED within 30 days, I would question the validity of the study population cohort. I do not think this reflects the average outcome for the average NHS hospital. In fact I would question the validity of this study overall

    1. Dear Dr Ainsley, apologies for the confusion. The elective admissions figure, 62% increased deaths, comes from the fact the probability of death, expressed as a ratio of the event rate between Sunday admissions and Wednesday, was 1.62. This means there is a 62% increased probability of death, not 60% absolute death rate. The death rate reported was around 1.3% I believe.
      BW,
      Juniordoctorblog

  9. Absolutely spot on. I’m so pleased our hospital colleagues are fighting back with such vigour. Sadly, we’ve had ten years of this media/govt abuse in primary care.

  10. What a great blog post. As an NHS clinician (not a dr) I am fed up with hearing that the NHS isn’t a 7 day/24hrs service. Ours is ‘fully’ staffed monday to Friday, but during out of hours we do offer a crisis sevice including access to an on call consultant if necessary which includes weekends and evenings. Many of our staff are now working flexible hours to offer services after 5pm as we want to be as inclusive as we can. The tosh that Jeremy Hunt spouts is untrue, unfair and demoralising for all of us who do above and beyond. I counted up my unpaid overtime and over a week I am probably doing over 10-15 hrs more than I should. We want to do out best, but until additional staffing and funding is put in place then we will just continue to firefight. In our service for over 6 mths we have been running our service with 4 wte fewer than we should. The government needs to stop bashing the nhs and support us instead.

  11. I think the article is written from a very low level of thinking complexity. IF you are sincere about changing the NHS then you need to look at the NHS as a SYSTEM. What tests the system? What breaks the system? How do you (as a consultant) function within the system? What prevents you from functioning? Money won’t help – but changing how you THINK about the problem will set you on a better course than simply whining about not having enough funds. There is so much waste within the NHS that extra funding is irrelevant. As a system then, how can you eliminate wasted expenditure?

  12. Reblogged this on Red Youth and commented:
    Thoughtful article from a young doctor pointing out that Jeremy Hunt, Lord Prior, and the whole gang in government are not stupid, and not being incompetent, but are assiduously following the line of privatising the NHS:

    “Lord Prior, the parliamentary under-secretary of state for NHS productivity, quietly announces an inquiry into private charges and insurance to fund the NHS. I.e to move the system from tax-funded to full charge-based private healthcare.”

    Not untypically, the emphasis is put on the ideological line of the Tory government, rather than on the entire economic interest of capitalism, which is remained constant, in the face of dwindling working class organisation and political will, for decades, irrespective of the hand at the tiller (Labor, Liberal or Tory).

    The real message of all of this: there is no such thing as Capitalism with a friendly face. Imperialism in its death throes is a viscous enough beast to take humanity down with it, unless we gain focus and courage and end this heartless, blood thirsty warmongering and profiteering system.

    #iminworkjeremy must become #EndImperiaism

  13. The day I can have 24 hour access to my MP (analogous to a junior doctor?), as well as a consultant politician (a cabinet minister?) on call to handle my queries on the off chance that the MP isn’t skilled enough to help me, and a phone call to his or her boss won’t suffice, and David Cameron (Medical Director?!) on call in case I feel I need him at the weekend too, then I’ll withdraw my objection to renegotiate my contract.

    What’s this I hear, politicians frequently work all weekend already without us knowing? Silly me; I thought they were all at home watching telly. Never mind; but let’s change their contract anyway, to make the service they give to the country “more professional”

    James Naughtie was highly prescient when he mis-introduced Jeremy Hunt that day on the Today programme wasn’t he…

  14. Also worth noting from original paper that Friday admissions are at no increased risk of death – meaning the plausibility of Hunt’s line is non existent. After all if weekend care were poorer then one would expect friday admissions to have higher mortality as many would be neglected over weekend by Hunt’s logic.

    As you say the reason for the higher mortality of weekend admissions is patient selection bias – HES data is poor and often inaccurate/incomplete – meaning that the study cannot adequately adjust mortality for known confounders like co-morbidity. It is just confounding.

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