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

BMJ 2015; 351 doi: (Published 05 September 2015) Cite this as: BMJ 2015;351:h4596

Rapid Response:

Results of the Hunt effect surveys in response to “Increased mortality associated with weekend hospital admission: a case for expanded seven day services?”

Dear BMJ,

Few other studies since Andrew Wakefield’s MMR vaccine publication in the Lancet in 1998 have attracted such controversy and media attention such as that of Freemantle et al. (2012 (1), 2015 (2)). Unfortunately, misinterpretation and public statements by various members of the government including the Secretary of State for Health, the Rt. Hon. Jeremy Hunt, blaming the “weekend effect” firstly on a lack of consultants (3,4), then junior doctors (5) has been associated with a significant number of patients delaying their presentations to frontline services such as A&E and out-of-hours GP surgeries, based on the misconstrued belief that there is a lack of doctors over the weekend and they are more likely to die as a result of this.

We present here the results of a 2-week national survey conducted between 6-20 October 2015 aimed at determining the overall impact of what has been termed colloquially as the “Hunt effect” – patients presenting, usually early in the week, despite having had symptoms over the weekend due to concerns that “there are no doctors” during this period. Two surveys were conducted in parallel – one epidemiological, aiming to collect data on the day of presentation in relation to symptoms and the severity of the resultant clinical impact ( and the other clinical, aiming to collect basic demographic data, the specialties affected and short- and long-term patient outcomes (

Cases were defined as patients who should have presented immediately to either acute primary or secondary services, but instead delayed their presentation after having developed symptoms just before or over the weekend (Saturday and Sunday) due to concerns about a lack of doctors covering emergency services and/ or an increased risk of mortality or harm over this period. Doctors were clearly asked to complete these surveys only if the primary reason for the delayed presentation had been due these concerns; cases were excluded if the root cause of delay in seeking medical attention was not clearly cited as being due to these misconceptions.

For reasons of patient confidentiality these two databases were not linked; instead doctors were asked to enter data anonymously into both surveys in parallel. The surveys were publicised through various social media outlets – including the Junior Doctors Contract and Junior Doctors – Our Lives in Your Hands forums on Facebook (>57 000 and >15 000 members respectively) and Twitter.

Within two weeks, the surveys collected a total of 40 cases. Of these, data on day of symptom onset and day of presentation were available for 33 cases. The vast majority of patients had symptoms beginning just prior to or over the weekend (Thursday (9.1%), Friday (39.4%), Saturday (39.4%), Sunday (3.0%)) with most patients presenting either to A&E or their GP on Monday (75.8%) or Tuesday (9.1%) (Figure 1). Worryingly, the majority of doctors reported the impact of the delayed presentation as being major (39.4%), significant (30.3%) or life-/ limb-threatening (15.2%).

Indeed, analysis of the clinical database revealed similar trends in the severity of these presentations. Two deaths were reported as a result of delayed presentation, whilst 31.7% of cases suffered long-term, irreversible morbidity (Figure 2). Overall, 82.4% were deemed to have had a worse outcome as a result of their delayed presentation and 90% were reported as having the potential to be life-threatening. Of the cases reported, 2.5% involved children, with other patients being admitted under adult medicine (45%), adult surgery (12.5%), obstetrics & gynaecology (5%) and psychiatry (2.5%). Worryingly, 10% were admitted for high dependency or intensive care. 56.1% reported that patients would have needed shorter hospital admissions had they presented earlier and 29.3% reported that no admission would have been needed at all if prompt medical attention had been sought.

Although this study, like the study by Freemantle et al. cannot definitively prove causality, it is concerning that there is an association between Mr. Hunt’s comments in July and October 2015 about the apparent lack of a 24/7 NHS and an increasing number of patients not presenting to frontline services in a timely manner, thereby affecting their clinical outcomes and ultimately jeopardising their safety. Voluntarily reported surveys will by nature under-report cases, but extrapolation of this data would already indicate that at least 1000 patients could potentially come to harm as a result of this misconception per year, and this is based on our estimates before the peak winter season.

No previous studies exist in the literature reporting the incidence and clinical impact of delayed presentations secondary to a fear of lack of weekend healthcare services. Indeed, it would appear that this phenomenon has now become unique to the UK, and would suggest even a partial reversal of the so-called “weekend effect”. It is particularly concerning that two deaths were possibly attributed to the delayed presentation, that the vast majority of patients were at risk of significant harm as a result, and that nearly 30% of patients could have avoided hospital admission altogether.

We terminated this study early because we did not feel it would be ethically possible to continue in the face of such data. A public clarification by Mr. Hunt and the authors of this study is urgently needed regarding the fact that emergency NHS care is available 24/7 and that patients should access these appropriately in order to avoid further episodes of patients coming to harm.

1. Freemantle N et al. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 2012; 105(2):74-84.
2. Freemantle N et al. Increased mortality associated with weekend hospital admission: a case for expanded seven day services?. BMJ 2015; 351:h4596.
3. Department of Health. Health secretary Jeremy Hunt sets out the direction of reform for the future NHS. Jul 16 2015 (
4. HC Deb 16 July 2015, vol 598, col 1101
5. HC Deb 13 October 2015, vol 600, col 151.

Competing interests: No competing interests

04 November 2015
Hoong-Wei Gan
Clinical Research Fellow / Paediatric Endocrinology Subspecialty Trainee
Constantinos Kanaris, Paediatric Intensive Care Subspecialty Trainee/ Doctorate Student in Bioethics & Medical Jurispudence, Royal Manchester Children's Hospital
UCL Institute of Child Health/ Great Ormond Street Hospital for Children
30 Guilford Street, London WC1N 1EH