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Editor's Choice

What to do about the “weekend effect”

BMJ 2015; 351 doi: (Published 10 September 2015) Cite this as: BMJ 2015;351:h4840
  1. Fiona Godlee, editor in chief, The BMJ
  1. fgodlee{at}

Does being admitted to hospital at the weekend increase your risk of dying in the next 30 days compared with admission during the week? If so, is your death avoidable, and would a fully operational seven day service prevent it? A new Analysis article by Nick Freemantle and colleagues sheds some light on these questions but leaves many more to be answered (doi:10.1136/bmj.h4596).

The findings confirm these authors’ previous work published in 2012 (doi:10.1258/jrsm.2012.120009). They find that patients admitted on Saturdays and Sundays have an increased relative risk of death of 10% and 15%, respectively. They also find a smaller increased risk of death for patients admitted on Mondays and Fridays, extending the “weekend effect” to those days. They conclude that around 11 000 more patients die each year within 30 days if they are admitted between Friday and Monday than if they’re admitted on other days of the week. When adjustments are made for the fact that patients admitted at weekends are sicker, the increased risk of death within 30 days is less but still present and, in the authors’ words, not ignorable.

What these figures actually mean is now hotly debated. The secretary of state for health seized on them before they were published to support his call for more senior consultants to work at weekends. This leap, from a statistical excess of deaths in patients admitted at weekends to a solution focused on more senior medical staff working at weekends, is just one way in which these data are being abused and the public misled.

The weekend effect is real, concludes Helen Crump in her review of the evidence (doi:10.1136/bmj.h4473). Paul Aylin confirms this in his Editorial but explains that we are left with a range of possible explanations (doi:10.1136/bmj.h4652). These need to be scrutinised before assumptions and suggestions harden into policy. The evidence is conflicting but seems to point more to the importance of a fully functioning service than to simply needing more senior medical cover. One study found no weekend effect on intensive care units, which have more consistent staffing levels. Another found that the weekend effect was not reduced if stroke specialists did ward rounds seven days a week but was affected by the level of nurse staffing. This link between nurse staffing and overall hospital mortality has been reproduced, says Aylin, in a recent very large European study.

Whether the right answer is more senior medical cover or an overall improvement in staffing levels at weekends, the cost is likely to be substantial, as Martin McKee points out, possibly exceeding the cost per quality adjusted life year threshold set by NICE (doi:10.1136/bmj.h4723).

Clearly something needs to be done to reduce the risk of death in patients admitted to hospital at weekends. But using these data to beat up on senior doctors, most of whom already work at weekends, is neither constructive nor evidence based. We need a dispassionate look at the existing evidence, a focused effort to improve the evidence base, and a collaborative debate about the best response.


Cite this as: BMJ 2015;351:h4840


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