Variations in care quality occur across the whole week, not just at weekends.
The “weekend effect” is an oversimplification. Attempting to address it is a distraction; it’s answering the wrong question. This is because hospital mortality is not a good measure of quality of care and weekends are not the only times when quality is compromised by the way in which services are organised.
The questions ought to be, firstly are there variations in quality of care depending on the time of day or the day of the week that emergency patients are admitted? Secondly, are these variations clinically important? Thirdly, if they are important, what are the underlying causes and, fourthly, does the NHS want to make the changes and investment that are necessary to address the causes?
We think that we can answer the first and second questions, at least for some groups of patients, using data from national clinical audits. Stroke patients receive high quality care if admitted on most weekday mornings, but quality deteriorates on weekday afternoons, overnight and at weekends. Aspects of care related to patient flow and bed capacity are also worse on Monday mornings (1). These are clinically important deficiencies. Hip fracture patients are less likely to receive evidence based care the later in the day that they are admitted on weekdays, or on Fridays and Saturdays (National Hip Fracture Database, unpublished data). This is also likely to be clinically important. Most patients dying in English hospitals will not be able to see a palliative care specialist after 5pm on weekdays or at any time on weekends (2). We predict that similar patterns of diurnal and weekly variation in quality will emerge for other conditions.
The times of the day and week when there are delays to time-critical treatments will not be a surprise to any medical registrar, general physician or bed manager; very similar complex and overlapping patterns of temporal variation exist in bed availability, patient flow, access to investigations and access to specialist advice when demand for care exceeds the capacity of the system to supply it.
Hospital activity follows largely predictable patterns. Hospitals are busiest on Mondays and Tuesdays when emergency admissions, elective admissions and outpatients are all highest, numbers of discharges are low and the effects of a large excess of admissions over discharges at the weekend has produced a high bed occupancy (3). Pressure eases as the week progresses, as discharges begin to exceed admissions and when elective and outpatient activity drops significantly on Fridays. The weekly variation is compounded by a diurnal variation in emergency admissions with numbers low overnight and early in the day, building up after lunch time, peaking a couple of hours later and remaining high until late evening.
By contrast, most hospitals provide “routine” services (radiology, pharmacy, laboratories, outpatients, physiotherapy, most clerical and ancillary staff etc) following a very different pattern, Monday to Friday 9am to 5pm. Outside these hours services are reduced, restricted to emergencies or absent. Most “routine” services are closing down just at the times when the demand from emergency admissions is highest. On weekdays, medical teams, especially consultants, may have responsibility for inpatients, outpatients and elective activity as well as that day’s emergency admissions, so adding to delays. With rising demand many hospitals now operate near to full capacity so even minor delays for a small number of patients will have serious knock on effects on many others.
So, variations in care quality occur across the whole week, not just at weekends, and relate to the working practices of a whole range of staff, not just doctors. The solutions will almost certainly involve changes to routine weekday working, not just weekends working, for a whole range of staff, not just doctors. For example, extending routine working hours in support services like radiology and pharmacy into early evenings, providing additional resources on Mondays, Tuesdays and weekday afternoons to support the predictable surge in emergency admissions and shifting low risk elective work and outpatients from Mondays to Fridays all might help.
The real challenge for politicians and policymakers, once they recognise the complexity of these variations, will be to then recognise that none of the potential solutions are likely to occur without significant investment.
1. Bray et al. The Lancet. 10 May 2016. http://dx.doi.org/10.1016/S0140-6736(16)30443-3
2. End of life care audit; dying in hospitals. National report for England 2016. http://bit.ly/1qiS8ep
3. The weekly pulse. CHKS. June 2012.
Competing interests:
No competing interests
21 May 2016
Kevin Stewart
Clinical Director, Clinical Effectiveness & Evaluation Unit
Rapid Response:
Variations in care quality occur across the whole week, not just at weekends.
The “weekend effect” is an oversimplification. Attempting to address it is a distraction; it’s answering the wrong question. This is because hospital mortality is not a good measure of quality of care and weekends are not the only times when quality is compromised by the way in which services are organised.
The questions ought to be, firstly are there variations in quality of care depending on the time of day or the day of the week that emergency patients are admitted? Secondly, are these variations clinically important? Thirdly, if they are important, what are the underlying causes and, fourthly, does the NHS want to make the changes and investment that are necessary to address the causes?
We think that we can answer the first and second questions, at least for some groups of patients, using data from national clinical audits. Stroke patients receive high quality care if admitted on most weekday mornings, but quality deteriorates on weekday afternoons, overnight and at weekends. Aspects of care related to patient flow and bed capacity are also worse on Monday mornings (1). These are clinically important deficiencies. Hip fracture patients are less likely to receive evidence based care the later in the day that they are admitted on weekdays, or on Fridays and Saturdays (National Hip Fracture Database, unpublished data). This is also likely to be clinically important. Most patients dying in English hospitals will not be able to see a palliative care specialist after 5pm on weekdays or at any time on weekends (2). We predict that similar patterns of diurnal and weekly variation in quality will emerge for other conditions.
The times of the day and week when there are delays to time-critical treatments will not be a surprise to any medical registrar, general physician or bed manager; very similar complex and overlapping patterns of temporal variation exist in bed availability, patient flow, access to investigations and access to specialist advice when demand for care exceeds the capacity of the system to supply it.
Hospital activity follows largely predictable patterns. Hospitals are busiest on Mondays and Tuesdays when emergency admissions, elective admissions and outpatients are all highest, numbers of discharges are low and the effects of a large excess of admissions over discharges at the weekend has produced a high bed occupancy (3). Pressure eases as the week progresses, as discharges begin to exceed admissions and when elective and outpatient activity drops significantly on Fridays. The weekly variation is compounded by a diurnal variation in emergency admissions with numbers low overnight and early in the day, building up after lunch time, peaking a couple of hours later and remaining high until late evening.
By contrast, most hospitals provide “routine” services (radiology, pharmacy, laboratories, outpatients, physiotherapy, most clerical and ancillary staff etc) following a very different pattern, Monday to Friday 9am to 5pm. Outside these hours services are reduced, restricted to emergencies or absent. Most “routine” services are closing down just at the times when the demand from emergency admissions is highest. On weekdays, medical teams, especially consultants, may have responsibility for inpatients, outpatients and elective activity as well as that day’s emergency admissions, so adding to delays. With rising demand many hospitals now operate near to full capacity so even minor delays for a small number of patients will have serious knock on effects on many others.
So, variations in care quality occur across the whole week, not just at weekends, and relate to the working practices of a whole range of staff, not just doctors. The solutions will almost certainly involve changes to routine weekday working, not just weekends working, for a whole range of staff, not just doctors. For example, extending routine working hours in support services like radiology and pharmacy into early evenings, providing additional resources on Mondays, Tuesdays and weekday afternoons to support the predictable surge in emergency admissions and shifting low risk elective work and outpatients from Mondays to Fridays all might help.
The real challenge for politicians and policymakers, once they recognise the complexity of these variations, will be to then recognise that none of the potential solutions are likely to occur without significant investment.
1. Bray et al. The Lancet. 10 May 2016. http://dx.doi.org/10.1016/S0140-6736(16)30443-3
2. End of life care audit; dying in hospitals. National report for England 2016. http://bit.ly/1qiS8ep
3. The weekly pulse. CHKS. June 2012.
Competing interests: No competing interests