Intended for healthcare professionals


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

BMJ 2016; 352 doi: (Published 29 March 2016) Cite this as: BMJ 2016;352:i1762

The full political context was not adequately declared

In my view, the recent correction (1) still fails adequately to comply with the editorial standards set out in the ICMJE’s competing interests declaration form, as used by the BMJ, which asks (2):

“Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work?”

The correction merely reiterates that Bruce Keogh, medical director of NHS England, is a proponent of 7 day services. It ignores the wider political context to the commissioning of this paper and, in particular, the following admissions in an NHS England press release to the BBC on 23rd February 2016 which stated:

“In December 2013, a paper based on the 2012 findings and work of the Seven Days a Week Forum (SDaWF) was presented to the NHS England board. The recommendations set out in paper were accepted and agreed. At the same time, NHS England commissioned Deloitte to analyse how the system might be affected.

……In November 2014, Deloitte were invited to a meeting of the NHS England Medical Directorate Senior Management Team (SMT) to update on progress. The same update was then presented to the senior leadership of NHS England in February 2015, where further information and analysis was requested.

Consequently, on 5 February 2015, University Hospital Birmingham was asked by NHS England to re-run the analysis used in the 2012 paper on 2013/14 data to assess if there was still a weekend effect.”

In my opinion it is clear that as things stand that the full political context of the study has not been adequately declared to both readers and the general public. It may indeed be technically true that BK did end up asking for the analysis; however the background to this request was not fully and transparently declared. Given that the request from Keogh came off the back of Deloitte’s background work and a meeting involving the senior leadership of NHS England, at the very least the involvement of the senior leadership of NHS England should have been declared as a competing interest.

NHS England has invested significant effort on seven day services since setting up the ‘Seven Days a Week Forum’ in February 2013. It published a December 2013 paper recommending consultant contract changes to ensure they worked seven days a week (3). This effort is still ongoing, with well-publicised proposed changes to consultant contracts that have yet to be finalised, and consultant review within 14 hours is now a ‘priority clinical standard’. This background information is important; it may or may not have contributed to the claim in the first draft of the article that some of the prolonged weekend effect may be the ‘access to senior specialist care are reduced from late Friday through the weekend’ (4). Peer reviewers were denied the opportunity to consider this possible conflict of interest and potential source of bias. The claim was removed regardless, as one of the reviewers suggested other causes may contribute to the weekend effect.

This evidence, which has emerged only since the publication of the Freemantle study, has shown that the study was effectively commissioned by NHS England as part of their extensive body of work on 7 day reforms, following on from this previous unpublished and possibly never-to-be-published work by Deloitte. At a minimum the BMJ have a duty to their readers and the public to ensure that the article is corrected to reflect the full and true political context of the study.

1. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ (Clinical research ed) 2016; 352(i1762).
2. Dean BJF. Undeclared competing interests do not ‘worry’ the BMJ’s editor. BMJ (Clinical research ed) 2016;
3. NHSEngland. NHS England Board Paper.
4. N F. First draft of Freemantle et al paper.

Competing interests: No competing interests

30 March 2016
Benjamin JF Dean
Orthopaedic Registrar