Intended for healthcare professionals

Letters The weekend effect

Variations in care quality occur across the whole week, not just at weekends

BMJ 2016; 353 doi: (Published 07 June 2016) Cite this as: BMJ 2016;353:i3151
  1. Kevin Stewart, clinical director, clinical effectiveness and evaluation unit1,
  2. Ben Bray, quality improvement fellow, clinical standards1,
  3. Rhona Buckingham, operations director, clinical effectiveness and evaluation unit1,
  4. Chris Boulton, project manager, clinical standards1
  1. 1Royal College of Physicians, London NW1 4LE, UK
  1. kevin.stewart{at}

The “weekend effect” is an oversimplification.1 Attempting to address it is a distraction 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.

What we need to know is, 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 deal with 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. Patients with stroke 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.2 These are clinically important deficiencies. Patients with hip fracture are less likely to receive evidence based care the later in the day that they are admitted on weekdays, or if they are admitted on Fridays and Saturdays (National Hip Fracture Database, unpublished data).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 5 pm on weekdays or at any time on weekends.3 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 outpatient visits 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.4 Pressure eases as the week progresses, as discharges begin to exceed admissions, and when elective and outpatient activity drops 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, in most hospitals “routine” services (radiology, pharmacy, laboratories, outpatients, physiotherapy, and most clerical and ancillary staff) follow a very different pattern—Monday to Friday 9 am to 5 pm. 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.

Thus, 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 weekend 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 recognise that none of the potential solutions are likely to occur without serious investment.