Intended for healthcare professionals

Analysis

Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4596 (Published 05 September 2015) Cite this as: BMJ 2015;351:h4596

Re: Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

Rapid Response

Dear BMJ

On the 18th of May 2015 the Prime Minister gave a speech setting out his plans for "a 7-day NHS, safe in our hands - for every generation to come". In this he stated that “It’s a shocking fact, but mortality rates for patients admitted to hospital on a Sunday can be 16% higher than on a Wednesday, while the biggest numbers of seriously ill patients arrive at the weekend when hospitals are least well equipped to handle them. So 7-day care isn’t just about a better service – it’s about saving lives.” (1) The statistic of 16% corresponds to that in a paper published in 2012 (2).

Two months later on the 16th July 2015 the Secretary of State for Health gave a speech setting out his “25 year vision for the NHS” (3). In this he stated that “You are 15% more likely to die if you are admitted on a Sunday compared to being admitted on a Wednesday.” The statistic of 15% corresponds to that in a paper published in 2015 (4). Indeed a BBC reporter wishing to check the source of this statistic published on social media that they had been informed by the DoH Press Office that it “relates to analysis of 13/14 HES data being published in the BMJ soon” (5). However it came about, the existence of a new BMJ analysis, with specific details, was made public on that day.

One month later on August 19th the BMJ accepted a paper for publication entitled “Increased mortality associated with weekend hospital admission: a case for expanded seven day services ?” This was then published on 5th September 2015. In this it states that “This article arose from a request by BK” a co-author and National Medical Director based within NHS England. Subsequently there has been prominent political use of this paper to seek to justify expanded seven day services - despite the authors disclaimer that “It is not possible to ascertain the extent to which these deaths may be preventable; to assume they are avoidable would be rash and misleading.”

As others have commented in this forum there continue to be a number of unanswered questions regarding how it was possible to indicate that this paper would be coming out in the BMJ – 1 month before it had actually been accepted for publication. Also how data within it were made available for prominent political use – 1 month before it was accepted for publication and 2 months ahead of actual publication. Also given the importance of this issue illustrated by David Cameron’s speech 4 months prior to publication, it seems relevant to ask about any role that politicians had in commissioning and interpreting this analysis in the first place.

Many have commented here about the relevance and validity of the methods used in this paper. High among these concerns was the decision to classify Friday and Monday as part of the weekend in contrast with the 2012 publication on which most other methods are based. The pattern of crude unadjusted deaths by day of occurrence (see attached figure) makes one wonder whether such a decision might have been data-driven rather than based on a prior hypothesis – thereby introducing significant bias into the analysis, its conclusions and subsequent high profile political statements concerning 11,000 deaths being preventable in the event of extended seven day services .

Alistair S Hall
Consultant in Cardiology / Professor of Cardiovascular Epidemiology
Leeds Teaching Hospitals NHS Trust / Leeds School of Medicine

1. https://www.gov.uk/government/speeches/pm-on-plans-for-a-seven-day-nhs
2. Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 2012;105:74-84
3. https://www.gov.uk/government/speeches/pm-on-plans-for-a-seven-day-nhs
4. Freemantle N, Ray D, McNulty D, et al. increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351: h4596
5. Dreaper J. July 16th 2015 Tweet. https://twitter.com/janedreaper/status/621698323473399808

Competing interests: Father of two Junior Doctors Mentor to many other Junior Doctors Consultant who delivers weekend patient care

11 October 2015
Alistair S. HALL
Doctor / Professor
Leeds Teaching Hospitals NHS Trust / Leeds School of Medicine
Cardiology Department, General Infirmary at leeds, Great george Street, Leeds