The Department of Health’s favourite line is “There are 8 independent studies showing a ‘weekend effect'”. I’ve been through these 8 before, and the terms “independent” and even “studies” are used fairly loosely. This has been the stick Jeremy Hunt and co have used to justify their unfunded and unmodelled 7-day NHS plans, and to beat the junior doctors with. This week the stick broke.
To borrow the Ministry of Truth’s own language: “There are now 7 independent studies showing that the 7-Day NHS plan is a bad idea”.
Juniordoctorblog explores the counter-evidence against the 7-day NHS spin.
The ‘Weekend Effect’
Three separate studies this week came out against the established narrative of ‘poor care’ at weekends creating excess deaths.
“Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission” by Meacock et al in 2016
All previous research has shown increased rates of dying amongst patients who are admitted to hospital at weekends, but not those already in hospital or attending A&E. Meacock et al used the same data from the original Freemantle paper that Jeremy Hunt was quoting his ‘11,000’ excess deaths figure from, which covered 12,000,000 admissions to all 140 hospitals between 2013-14. They found for patients attending A&E on the weekend, far fewer were being admitted to hospital vs a weekday. When you look at all patients attending A&E, as opposed to those being admitted, there is no weekend effect. The authors attributed this to the differential admission threshold – well patients are less likely to be admitted on a weekend, so this makes the group admitted on weekends sicker on average, thus increasing mortality rates slightly.
Bottom line: the ‘weekend effect’ appears to be about how patients are counted, not how they are looked after.
Professor Rothwell, Oxford University, interview on Radio 4
– so far, unpublished study
Now the purists amongst you will claim this is unpublished, and therefore not available to scrutiny. I agree. However, we are using the DoH definition of ‘study’, which includes all manner of reports, audits, and human resources documents. So it’s in the Seven.
Prof Rothwell group based from Oxford Univeristy found similar problems with the ‘weekend effect’ amongst stroke patients. Looking at patients in Oxford, they found those labelled ‘strokes’ weren’t strokes at all, but were admitted for other things, like urgent investigations, or rehabilitation. These admissions happened primarily on weekdays- meaning only truly sick stroke patients came on weekends, but weekdays had a mix of very well patients and unwell patients. Once these was corrected, the weekend effect disappeared. Prof Rothwell said “nobody had done… the basic due diligence” on these studies to look at this.
Bottom line: the weekend effect again was found to be a statistical artifact, based on how patients are counted, not how they are cared for.
“Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care” by Bray, 2016
There were a lot of statements about stroke care, and a huge backlash from stroke experts who had already spent 10 years improving the urgent care of stroke. Now a new study from Bray that used national data between 2013-14 on 74,000 patients with stroke found no association with weekend vs weekday admission. No weekend effect. It did find variation across many variables in different patterns, including a small increase in mortality in weekday night admissions. The study called the weekend effect ‘an oversimplification’.
Bottom line: Again, no weekend effect, small changes on weekday nights, and further work needed. Oversimplification not helpful.
“What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions?” by Meacock in 2015
Put aside the fact for a moment that the ‘weekend effect’ probably doesn’t exist. Don’t get bogged down in methodology, as Jeremy Hunt doesn’t. This paper by Meacock in 2015 looked at the actual size of the supposed ‘weekend effect’ and then worked out the cost to address it. It found the cost, £1-£1.5 billion, was far higher for the small supposed benefit than any medication or treatment recommended in the NHS.
Bottom line: even if the ‘effect’ existed, the money would be spent better elsewhere for greater patient benefit.
“The 7-Day NHS”
So despite the evidence being weak, the government has plowed forward in making their “7-day NHS” plans. Except they haven’t.
“Managing the supply of NHS clinical staff in England”
Public Accounts Committee 2016
The PAC is a group of MPs that examine public policy and hold public departments to account for their decisions. This report found that the Department of Health had made ‘no coherent attempt’ to work out how much a 7-day NHS would actually cost, or the doctors or nurses needed to staff it. They were told they were ‘flying blind’ on this issue. A leaked report suggested they needed £1 billion a year, 4000 more doctors, and it ‘probably wouldn’t alter’ the supposed weekend effect anyway. They also found that the NHS has been cut by 50,000 clinical staff.
Bottom line: close scrutiny of policy for 7-day working found it to be woefully lacking.
While the 7-day policy seems to be a shambles, a further report shows the existing NHS heading to disaster;
“Sustainability and financial performance of acute hospital trusts”
Public Accounts Committee 2015-16
This second public accounts committee focuses on hospitals and funding. It revealed that No. 10 created “unrealistic” and “unsustainable” budget cuts to hospitals. As in the report above, hospitals had to cut regular staff but many refused to cut quality in favour of cost- hiring back temporary staff at a higher rate. The committee were clear that the excess cost running the NHS into a deficit of £2.8 billion was 80% due to the gaps created, not the fees themselves. The report also found dodgy accounting practices – which came from a whistleblowing hospital accountant who requested anonymity for fear of losing his job. It would seem a lot of ‘creative accountancy’ was going on to make hospital budgets look healthier than they are, to cover up the extent of the ‘black hole’ in NHS finances.
Bottom line: NHS hospitals are currently in a budget and staffing crisis created by No. 10 who then attempted to cover it up.
Still with us?
So far we’ve established that the 7-day NHS is an unfunded and unmodelled solution to a non-existent problem, which probably isn’t fixable itself, but even if it was, isn’t cost effective to do so. Meanwhile the real problems of the NHS are not only being unaddressed they are being actively covered up.
So what’s it all about then?
Throughout this drive for seven days services has been this narrative that their aren’t enough doctors at weekends, and this leads to harm; the ‘weekend effect’.
So having already discussed there is no weekend effect, we should probably still address this ‘lack of doctors’.
Firstly, no study has ever looked at junior doctor staffing levels. Full stop. So we actually cannot possibly say that is associated. One study from the Hateful Eight actually showed that medical cover is 100% across seven days, and this is true, all hospitals have junior doctors Monday to Sunday, midnight to midnight. Despite this Jeremy Hunt embarked on a damaging junior contract fight anyway, despite all the evidence to the contrary.
What’s surprising is that the Department of Health themselves don’t even know how many juniors are already working weekends.
Freedom of Information Request to Department of Health 2016 and Commons Question, 2016
In two unrelated freedom of information releases NHS England first revealed they had no idea how many junior doctors typically work on a Saturday or bank holiday nationally, and then in a written question from MP Norman Lamb it transpired that the only research into this that had been done was a ‘snapshot’ of 14 hospital rotas, in January 2016 (well after the contract had already been ‘imposed’, I might add).
Bottom line: despite no evidence to show a link to junior doctors and weekend mortality issues, a new contract was ‘imposed’ anyway, without anyone actually studying the problem they were trying to ‘fix’.
Confronted with this last week, the Department of Health shifted the goalposts once again– now saying the ‘weekend effect’ is about consultant presence and diagnostics. Except it isn’t.
“Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study” by Aldridge in 2016
This is a study looking at a snapshot of weekday to weekend cover of consultant specialists attending hospital admissions. It found that consultant specialist presence varied between weekend and weekdays, but found no link to any change in mortality.
This follows from another study by Bray in 2014 looking in stroke units specifically whether the presence of a consultant on weekends and weekdays made a difference to mortality. In that study consultant presence made no difference, but the number of nurses had a direct link to survival.
Bottom line: in the only study that looked at weekend and weekday mortality in NHS hospitals there is no link to consultant presence.
Nursing numbers are much more important but this government cut training places in 2011 and cut the bursary in 2016- the PAC recognised this would continue the shortage for at least another three years.
The Significant Seven are a damning group of ‘studies’ that highlight how ill thought out and potentially dangerous both the 7-Day initiative and the current NHS management is. Is this incompetence or something else?
Let’s change the perspective.
Imagine you are in government. You made a back of the envelope promise of a ‘7-Day’ NHS without defining anything for voters, but you’re also ideologically against increasing funds to a socialist medical system.
You can’t be seen to cut costs to a beloved and vital national institution, so you announce ‘efficiency’ drives and streamlining of services, a ‘pay freeze’ which cuts pay by 25% against inflation. You get wind of new NHS contracts, and decide to make some subtle changes- increase basic pension contribution, reduce junior doctors pay and remove financial penalties for hospitals that make doctors work illegal and unsafe hours.
Obviously you can’t be seen to want to attack doctors to cut costs, you need a PR message that will travel. You find an already running plan to improve urgent 7-day Care, and in the words of Fiona Godlee, editor of the BMJ, derail it.
You never really believed hospitals needed that much money, or that costs really do rise at that rate, so when hospitals started to report crisis level failings, you didn’t listen. When junior doctors protested and demonstrated and even sat outside your office for three weeks, you still didn’t listen.
I am a doctor- I want a 7-day health service more than anyone, because I know what that would really mean. I also know that we need more funds just to keep the staff and the hospitals we have already going, and if we want to ever improve our health service, Mr Hunt, we must use the evidence properly.
Now the evidence is knocking on your door.
It’s The Significant Seven , and behind them 68 million people. We’d all like a word about our national health service. It’s time to listen.