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Excess deaths at weekends 'a statistical artefact', finds major new study

Fewer patients die after being admitted to hospital at the weekend, say researchers, who claim the Government’s push for a seven-day service is ‘fixing a perceived problem that doesn’t exist’.

The study, by researchers from the University of Manchester, looked at data on 12,670,788 A&E attendances and 4,656,586 emergency admissions in greater detail than ever before, and found that mortality rates of patients admitted at the weekend were higher than those admitted during the week.

But they said this was because 'hospitals apply a higher severity threshold' at the weekend, and that the overall number of patients dying within 30 days of being admitted on a weekend day was lower than on a week day.

Pulse has also learnt that despite the size of the study it was rejected by the BMJ after it was peer reviewed by the author of a previous analysis used by health secretary Jeremy Hunt to justify his imposition of a new junior doctor contract.

The previous study in the BMJ led by Professor Nick Freemantle, chair of clinical epidemiology and biostatistics at University College London claimed that 6,000 lives could be saved by increasing the workforce in hospitals at the weekend. Another study published in the BMJ claimed that there were also higher risks for babies born at the weekend.

But Pulse understands this latest study was rejected by the BMJ after being reviewed by Professor Freemantle and was subsequently published today in the Journal of Health Services Research and Policy.

The study concludes that the ‘so-called “weekend effect” is a statistical artefact and extending services will not reduce the number of deaths’. The lead author told Pulse that routine GP seven-day access was likely to lead to more admissions, but this would not necessarily lead to better health outcomes, only extra costs for secondary care.

The new study - published in the Journal of Health Services Research and Policy - found that there was an average of 378 deaths within 30 days of patients who attended A&E on an average weekend day compared with 388 on an average weekday, which the authors said was significantly fewer.

It added that attending A&E at the weekend was not associated with a higher probability of death either.

Rachel Meacock, lead author of the study and research fellow in health economics at the University of Manchester, said: ‘The so-called “weekend effect” is a statistical artefact and extending services will not reduce the number of deaths.’

She told Pulse: ’I think the plan for seven-day services has got a bit ahead of the evidence. People looked at the mortality rates for the admitted population and tried to fix a problem they didn’t really understand. Our study shows that higher mortality rates are not a reason to extend services at the weekend because no lives are likely to be saved.’

’It seems that more availability of GP services would increase admissions at weekend… It will probably just push up hospital costs.’

The study only looked at mortality rates and not overall health benefits, she added, but said: ‘The issue is that there is no evidence around it.’

Professor Matt Sutton, professor of health economics at the University of Manchester, who led the research, said: 'Hospitals apply a higher severity threshold when choosing which patients to admit to hospital at weekends – patients with non-serious illnesses are not admitted, so those who are admitted at the weekend are on average sicker than during the week and more likely to die regardless of the quality of care they receive.

’As a result, the figures comparing death rates at weekends and weekdays are skewed. The NHS has rushed to fix a perceived problem that further research shows does not exist.’

A Department of Health spokesperson said: 'Disputes about precise methodology risk obscuring the established consensus of a weekend effect. Of course, we’ve always been clear that death rates are higher following admission at the weekends - this is in part because some patients are sicker, but even adjusting for that experts have been clear that other factors including staffing levels and diagnostic availability are part of the problem.

'Eight studies in the last five years show clear evidence of the weekend effect and the Government makes no apology for tackling the problem to create a safer seven day NHS.'

A BMJ spokesperson said: 'We are unable to comment in detail on a specific article, even to confirm whether it was submitted to the journal as this is a confidential matter. However, we can say that in general articles are considered on matters of methodology, potential importance, interest to our broad readership and on what they add to the established literature.' 

Pulse approached Professor Freemantle for comment, but he did not respond in time for publication.

The row over the ‘weekend effect’

Jeremy Hunt - online

Jeremy Hunt - online

Health secretary Jeremy Hunt has imposed a contract on junior doctors removing extra pay for working Saturdays in a bid to increase the workforce at weekends in a cost-neutral way.

The Government justified the push for seven-day services by using a study in the BMJ led by Professor Nick Freemantle, chair of clinical epidemiology and biostatistics at University College London.

The study concluded: ‘Patients admitted on Saturday or Sunday face an increased likelihood of death even when severity of illness is accounted for.’

Mr Hunt claimed that the study revealed there were 6,000 preventable deaths due to fewer staff working at weekends – although the BMJ editor Fiona Godlee said he was ‘misrepresenting’ the data.

But this latest study has found that although mortality rates are higher, this is down to fewer patients being admitted to hospital – refuting the basis of the whole policy.

Please BMJ, no more studies on the ‘weekend effect’

 

Readers' comments (40)

  • Lies,dammed lies and statistics.Arcane navel gazing by academics is irrelevant (much as we would like decisions to be based on evidence ). The NHS is a public service and we are public servants. The man in the pub, whose taxes pay our salaries understands a simple concept :"If my Nan has a stroke on Sunday morning, I want her to get exactly the same care as she would do if she had the stroke on Monday "
    The corollary (I'm sorry, Man-in-the-Pub, but we are clever people and will tell you what is good for you")is the sort of patronising attitude I thought we had consigned to history.

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  • '..the Government makes no apology for tackling the problem to create a safer seven day NHS.'

    Government makes no apology! Shards of democracy anyone? Fu@king Conservatives. Go on cardigans, get offended.

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  • 06 May 2016 10:45am

    fine - but man in pub will have to pay for it.

    it may be a public service but it still has to be funded

    nan may want her own room, sky tv, china tea set and 5 course meal? you either want a gold plated service so therefore fund it or you make do with what you are willing to pay for.

    politicians have been disingenuous and are promising a lot without wanting to pay for it. they have then encouraged the public to blame the staff for failing to deliver what they have promised.

    they need to be held to account.

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  • I have just read this very interesting paper all the way through, which sheds a lot more light on the so-called weekend effect. From my reading, the weekend effect mainly arises because during the week we GPs have a tendency to refer more of the less sick patients to hospitals for assessment and likewise hospitals tend to admit them – I suppose these are the “just in case” patients (which are increasing year on year because of our concerns over receiving complaints and/or being sued for missing something significant and/or because we are trying to follow condition based guidelines more closely to the letter). These less sick patients admitted on weekdays cause a statistical skew in the 30 day mortality rates and make weekday admissions look safer than at weekends. We could go along with the rhetoric of increasing more routine community and hospital care at weekends. And yes, this would certainly help drive up hospital admissions of this cohort of less sick patients at weekends and thereby help dilute out the so called weekend effect and give mortality rates that are similar over every day of the week. Or, and my preferred solution to the weekend effect problem, we could all work less hard during the week, see less patients (study after study seems to show that a not insignificant amount of our work could be done by others anyway), admit less of the patients that probably don’t need to be in hospital anyway and even up the weekend to weekday mortality rates that way. Government and patients happy – hospital mortality rates same across all the days, so hospital care must be “safer”. GPs happy – working less hard during the week and managing to have some sort of work-life balance. (This solution is somewhat tongue in cheek, clearly there is much more behind the data which needs explanation and a proper planned response, but it is no more insensible or illogical than the government’s current obsessional drive to increase more routine medical services at the weekend to make patient care and hospitals “safer”.)

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  • If ever there was a chance for Hunt to save his face and make a U turn on the imposition of seven day services -- This is it.

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  • The debate about mortality rates at weekends is interesting and could run for ever. But this risks missing the key point - which is that one of the few remaining ways for the NHS to improve its productivity is to make full use of its investment in plant, expensive technology and equipment that frequently lies idle at weekend periods.

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  • medicine tastes awful

    This policy of 7 day week is flawed - mr Hunt - you having delusions.

    This study could put the Juniors contract to rest. Or will this man listen?

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  • Not sure I agree that we have differing thresholds of admission at weekends. From the community I tend to send more, less ill patients as the services are not there to support them. Sounds like it is too complex and big for anyone to work it out.

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  • I absolutely agree with earlier comments regarding 'the man in the pub'
    If you want something you' have to pay for it
    Democracy is great and yes the NHS is publically funded but the tendency for politicians to tell the electorate they can have stuff they can't afford just to get elected is the problem

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