Jeremy Hunt, secretary of state for health, and Philippa Whitford, a Scottish surgeon and MP, had a row about seven-day services during Hunt’s appearance before the Health Select Committee on May 9. The issue has also featured in the acrimonious dispute about the junior doctors’ contract negotiations which reopened on the same day.
Hunt and Whitford tussled about the quality and interpretation of evidence about weekend mortality rates and whether we need a seven-day hospital service to set things right. Hunt referred to evidence compiled by the Department of Health. It comprises eight studies, of which only four are peer-reviewed articles, the others being reports. Hunt claims that these studies prove that hospital mortality rates are higher for those admitted over the weekend than during the week. Other studies have also found a “weekend effect”. But the effect is smaller when accounting for how sick patients are and it isn’t evident for all conditions. For instance, there is no weekend effect for stroke care.
Whitford didn’t dispute the existence of a weekend effect, but said the higher weekend mortality rate is not because more people are dying. Rather the rate is higher because fewer people are admitted at the weekend and they tend to be sicker. This was the conclusion drawn by authors of a study published a few days before the committee hearing. Unlike other studies, this made use of both accident and emergency and hospital data. It found a weekend effect only among those admitted to hospital, and it was mainly because they are sicker. The authors conclude that expanding services to seven days a week may cause the mortality rate to fall, but most likely because admissions will increase, not because fewer people will die.
Hunt brought out a different message from the same study, saying that more stringent admission criteria shouldn’t be applied at the weekend. He wants four priority clinical standards to be met every day for all patients requiring urgent and emergency care. All emergency admissions should have a thorough assessment by a consultant within 14 hours of arrival at hospital; everyone in hospital should have access to consultant-directed diagnostic tests, and to consultant-directed interventions; and high dependency patients must be seen and reviewed by a consultant twice daily, and once a day after transfer to a general ward.
Notably, these standards all relate to the presence of consultants (senior doctors). But, to meet them, a whole range of diagnostic and support services must be made available as well as clinical cover provided by junior doctors. Junior doctors, however, object to plans to consider Saturday a normal working day for calculating their pay.
The four standards were chosen as priorities by NHS England and the Academy of Medical Royal colleges set out by NHS England’s Seven Days a Week Forum. These are being rolled out across the country, the aim being that they will have been adopted by all hospitals by March 2020.
The standards have already been implemented in some hospitals. The day after the Hunt-Whitford debate, a study was published in The Lancet comparing hospitals that have implemented the standards with those that have not. This found that patients admitted on Sundays get less than half the attention from consultants than those admitted on Wednesdays. But it also found that variation across hospitals in how much time consultants spend with patients is not associated with the hospital’s mortality rate. So it cannot be said that mortality rates can be reduced simply by increasing consultant cover.
Where does this leave us?
Clearly, more evidence is required. First, it remains unclear whether the weekend effect is just a statistical artefact or whether there is a real problem with a clear cause.
Second, studies should capture a broader array of outcomes than just mortality. Even if seven-day services don’t reduce mortality rates, patients may still be better off.
Third, we need to know the costs of the policy. On May 11, the Public Accounts Committee offered harsh criticism, saying:
no coherent attempt has been made to assess the headcount implications of major policy initiatives such as the seven-day NHS … It beggars belief that such a major policy should be advanced with so flimsy a notion of how it will be funded…
Finally, implementation of seven-day services was a manifesto commitment. But mortality rates for patients admitted overnight are higher than for those admitted during the day; and they are higher for poorer than richer patients. If we want to reduce hospital mortality, perhaps policy could be directed at correcting these differences as well.