Acting to stop harm: the FCA and Appointed Representatives
A recent study has produced findings which suggest that patients are more likely to die if admitted to hospital on a weekend.
The study, authored by researchers from University Hospital Birmingham NHS Foundation Trust and University College London and published in the Journal of the Royal Society of Medicine, examined the effect of hospital admission day on death rates across NHS England hospitals for 2013-2014. The results confirm findings from an analysis they undertook for 2009-2010.
Researchers looked at risk of patients dying from any cause within 30 days of admission taking into account various other factors that could influence the risk, such as age, reason for admission, and other medical illnesses.
During the year, 187,337 deaths occurred within 30 days of admission, equating to 1.3% of all those hospitalised. When they looked at factors associated with risk they found a person admitted on a Sunday had 16% increased risk of dying following admission compared to a person admitted on a Wednesday. Similarly, those admitted on a Saturday had a 10% increased risk of death. Overall, that amounts to an extra 11,000 deaths a year among those admitted between Friday and Monday.
According to the research, appropriate support services in hospitals are usually reduced from late Friday through the weekend, leading to disruption on Monday morning. This could go some way towards explaining what was referred to in the report as the ‘weekend effect’.
The researchers claim to have shown a clear association between weekend admission and worse patient outcomes, “Our analyses show that an increased proportion of higher risk patients are admitted on Saturday and Sunday, when services inside and outside the hospital are reduced”. It is also claimed that there is evidence of junior hospital doctors feeling clinically exposed during the weekend and that hospital chief executives are concerned about levels of weekend cover.
Professor Sir Bruce Keogh, NHS medical director and one of the authors of the landmark study, said it revealed an “inconvenient truth” that could no longer be ignored and required an overhaul in the way services are run. “The idea that patients are being harmed because of the way we organise our services is quite simply beyond what any of us can regard as acceptable. The moral and social case for action is simply unassailable” said Sir Keogh “I’m not offering people whatever they want, whenever they want it. The priority is to reduce mortality by concentrating on improving the way we design and deliver urgent care for our sickest patients.”
Organisations representing hospital doctors and surgeons said the findings underlined the need to move to a seven-day NHS in order to improve care at weekends and save lives. The Royal College of Surgeons said that “in many hospitals, the levels of staffing and access to diagnostics are worse for all patients, including those requiring emergency treatment over the weekend”.
The debate on seven day working was reignited following health secretary Jeremy Hunt's recent call for hospital doctors to work at weekends to improve quality of care and reduce deaths. But an accompanying feature article by Helen Crump at the Nuffield Trust says it is not clear how or to what extent investment in seven day services will reduce weekend deaths, and that the costs may outweigh any benefits. She also warns that, unless overall staffing levels increase, ramping up services at the weekend “will leave a gap in the hospital’s weekday rota, with potentially serious consequences across other services.”
While the researchers’ models adjusted for a variety of important factors, it is difficult to see from the report how they did this, making it difficult to decide whether all relevant factors have been appropriately adjusted for. Most importantly, this study has not examined the reasons why there may be increased risk of death with weekend admission, so no assumptions should be drawn about staffing levels or the availability of senior staff.
So how seriously should we take this most recent study? The authors caution that it is not possible to show that this excess number of deaths could have been prevented, adding that to do so would be “rash and misleading”.
Nevertheless, they say the number is “not otherwise ignorable” and “we need to determine exactly which services need to be improved at the weekend to tackle the increased risk of mortality”.
In a linked editorial, Paul Aylin, from Imperial College London, suggests more research is needed to determine the “complex” relation between staffing levels and services, and patient safety. He says promised changes to how the NHS provides weekend and out of hours care “will be an ideal opportunity to evaluate their impact on the weekend effect.”
Seven day working has also been a central part of negotiations between the government and doctors about proposed changes to the standard contract for NHS consultants. Jeremy Hunt recently announced that the government would remove a clause in the contract which allowed doctors to opt out of non-emergency work at weekends. But figures obtained from freedom of information requests by BMJ Careers show that just 1% of consultants have opted out of non-emergency weekend work.
From a medico-legal perspective, the re-organisation of services to provide multi-disciplinary, coordinated care out of hours and at weekends can only be a good thing. It is hoped that this will, amongst other things:
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