The weekend effect in hospitals: Why we need evidence to underpin policy

The level of doctors’ working hours over weekends in hospitals is a subject of much current debate and controversy, with considerable attention being paid to the ‘weekend effect’ – evidence that patients who are admitted to hospital the weekends are at higher risk of death. The HiSLAC project is an independent study exploring the impact of specialist intensity in hospitals at weekends as compared to weekdays, on death rates and quality of care. The study is being led by Professor Bion, Professor of Intensive Care Medicine at the University of Birmingham, with collaboration from our team at Leicester. Although the government is pressing ahead with plans to implement 7-Day Services with similar levels of doctor staffing at weekends as weekdays, the project lead Prof Bion recently told a room full of national science and health journalists at the Science Media Centre that:

“Given the adverse effect on NHS finances of the 2015 spending review and Brexit, it would be challenging to implement comprehensive 7-Day Services, and could take as long as 20 years.  “That was why we need to prioritise the emergency care patient safety component of 7-Day Services.”

The following day these comments appeared under somewhat starker headlines:  ‘Seven-day NHS unachievable for 20 years, expert claims’  declared The Guardian. Well, yes and no.

Prof Bion argues “We can’t be certain of the future, but we know that to politicise the need and desire for 7-Day Services is a distraction. Once 7-Day Services became government policy, this is exactly what happened; the focus slipped from the original emphasis on improving emergency care and extended to elective care and creating opportunities for efficiencies, savings, more output per unit input. The weekend effect then became a political tool for getting doctors to ‘change behaviours’ to deliver more elective care at weekends, ignoring the fact that all consultants are obliged to provide emergency care at weekends anyway.”

Prof Bion has recently highlighted the importance of the HiSLAC study in relation to strong criticism of the way evidence about the weekend effect has been misrepresented in the government’s drive for 7-Day services.

The facts behind 7-Day Services and the weekend effect cannot easily be reduced to soundbites. So, in case the original messages got lost behind the headlines, here are the other points Professor Bion made to journalists:

• HiSLAC and other studies have shown that the weekend effect is a complex measure, and may not be measuring quality of care in hospital
• The weekend effect is probably a measure of changes in the type and volume of patients being admitted to hospital at weekends, and therefore we need to understand what is happening in the community as much as we do in hospital to ‘explain’ the many influencing factors
• In the HiSLAC study we have been unable to find a link between specialist intensity and weekend admission mortality, but this does not mean that care in hospitals or in the community at weekends is satisfactory.  Other evidence suggests that there are opportunities to improve care across all seven days
• To do that we need both professional commitment and leadership, and political commitment and funding, with more thought and less rhetoric
• It seems highly unlikely that 7-Day Services can be delivered without additional resource: no informed commentator thinks that this is possible.  Efficiency savings of £22bn by 2020 (as demanded in the 2015 spending review) are going to make it impossible to deliver more care at weekends within the same funding envelope.  And if the existing pool of consultants and junior doctors are to deliver more care at weekends, who will cover the weekday work?
• Brexit is universally regarded by economists as likely to cause short-term financial distress and this means there will be less money for the NHS, not more.

Prof Bion argues that, for these reasons, if there is any funding for 7-Day Services, we need to prioritise the acute care/patient safety aspects.  To offer a fully comprehensive service across the whole week is going to take a long time, and require more investment with new money.  It’s not clear whether this means 10 years, or 20, as the time is dependent on the economy and on political priorities. What we do know is the importance of using independent evidence to underpin these decisions; unless we have the answers, we won’t know how to invest what money we have to improve healthcare.

HiSLAC Project

This study aims to evaluate High-Intensity Specialist-Led Acute Care (HiSLAC) to improve the care of acutely ill medical patients admitted as emergencies to English hospitals at weekends. This research offers an opportunity to evaluate the impact of the transition to seven-day working, and to understand factors likely to impede or enhance the effectiveness of this change in practice.

Further details on the project can be found on the HiSLAC website.

Researchers from SAPPHIRE are conducting qualitative research to find out more about how hospitals organise systems for weekend care in the 20 case study hospitals. Researchers will explore: how care is organised on weekdays and weekends and how this impacts on staff and patients; the reasons for local variation between hospitals in the way weekend care is organised; and the barriers and facilitators to implementing high-intensity specialist-led acute care (HiSLAC).

Further information on the ethnographic component of the study can be found on the SAPPHIRE project page.

HiSLAC Publication

Aldridge, C., Bion, J., Boyal, A., Chen, Y. F., Clancy, M., Evans, T., … & Roseveare, C. (2016). Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. The Lancet. 2016 Jul 9;388(10040):178-86.