Weekend admissions

It seems amazing to me but I’ve been in medicine now, as student and doctor for 30 years. During that time I’ve seen time and again the routine of patient admitted to a specialist service, seen by a junior doctor, reviewed by a less junior doctor, tests organised, decisions made as far as safety and knowledge allows and then a final review by the consultant with the timing of that review based on how ill the patient is (within minutes of admission if needed). When scientific papers that suggested a higher death rate at the weekend (which is a world wide phenomenon) it led me to a bout of professional soul searching. While the politicians and clinicians associated with them were quick to jump to causation (not enough consultants available at the weekend) this just didn’t feel right to me.

This deserves its own paragraph: Correlation is not causation.

It’s probably worth looking at the real world difference, the absolute increased risk of death if admitted at the weekend as an emergency is 0.3% so for every 1000 deaths within 30 days of a weekday admission 1003 people might die within 30 days of a weekend admission. As you can imagine only a small change would be needed to cause this effect.

Is there evidence that patients are sicker at the weekend. One of the earliest papers to look at this was a paper from Dublin http://www.ncbi.nlm.nih.gov/pubmed/22111090 this looked at nearly 50,000 episodes and carefully took into account not just medical co-morbidities (in other words multiple illnesses) but also biochemical (blood test) markers of illness severity. They found once patients were matched in terms of these other factors there was no difference in outcome. So weekend patients were likely sicker on admission.

A new paper http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html looking at 17 million UK attendances and admissions found that the weekend increased mortality could be described by the difference in proportion of patients who were admitted at the weekend. Most patients are of course treated and sent back home. So the proportion of just in case admissions was lower, thereby skewing the results. Again, the patients admitted at the weekend are sicker.

So far there aren’t papers that show evidence that the problem is due to lack of senior input at the weekend. There are papers which show that the patients who are admitted are different between weekdays and weekends.

In a hospital with good working relationships and doctors who know when to escalate problems appropriately lack of senior cover is unlikely to be the issue. From a practical point of view most doctors will tell you that they have worked in jobs where there are simply not enough pairs of hands, not enough doctors on the rota, not enough support workers to help with tasks like ECGs, echocardiographs etc, not enough emergency theatre space, or recovery, or ITU beds. These are all real and addressing them would cost more money. This is not a matter of doctors having the wrong contracts but not enough staff or resources.

Maybe we should just try out 7 day services and see if it works? The NHS has a body to look at the cost effectiveness of medical interventions. Its called NICE, it looks at the cost of a medicine or operation and declares whether it is cost effective enough to be available on the NHS. This paper http://onlinelibrary.wiley.com/doi/10.1002/hec.3207/abstract takes the NHS calculated costs of an NHS 7 day service of £1 billion and looks at whether 7 day services would be cost effective if it really did produce a reduction in deaths (as we have seen very unlikely). The answer is that if it were a new treatment NICE would rule it as not cost effective and would not allow its use within the NHS.
Many would argue that the cost of taking the NHS from a 7 day emergency and 5 day routine service to a 7 day emergency and routine service would cost more than an extra £1 billion on the overall budget of £115 billion so the true NICE calculation would likely be worse. That's not to say that doctors wouldn't welcome improvements in the support services we get at the weekends we'd love it.

All hospital doctors in the UK have contracts which specify that they must provide emergency services on a 24/7 365 basis. There is no opt out for any group for this work. Consultants just like everyone else are in hospitals out of hours providing care.

It looks like we have mounting evidence that the push for contract negotiations for doctors based around ‘7 day services’ is much more about politics than evidence or science. Meanwhile consultants, juniors and specialty doctors are happy to work to improve care at all times of the week and day. It must be recognised however that this will have resource implications which need to be properly calculated and funded.

One of the abilities that we work hard on in medicine is to take in fresh information, blood test results, comments from colleagues regarding a patients diagnosis or management and change our direction if it's in the patients interest. Don’t hold on to fixed ideas but practice flexibility of thought. Sir Bruce Keogh of course has a professional duty to do this and I would urge the Secretary of State Jeremy Hunt to do the same. Healthcare should not be about political dogma. Changing contracts to save money dressed up as improving safety is being economical with the truth at best.