Is the “seven-day NHS” a fuss over nothing?

The Department of Health has published a number of studies which it says support the “weekend effect” and the need for a “seven-day NHS”. A number of doctors and academics have questioned the quality of this research. We’re going to look into it, but here’s what you need to know for now.

The government says that weekend hospital patients are more likely to die and that people admitted at the weekend get a poorer service than in the rest of the week.

It lists eight studies on its website which it says show evidence of this “weekend effect”.

A group of doctors and academics say this research is no good. They have pointed to a pile of other academic papers to prove it. 

In total, the government and the doctors have pointed us towards 34 studies on this topic. That includes one study which is somehow being used by both sides to back up their arguments.

Here’s where the argument has got to so far. We’re now seeking funding to look at all 34 of these studies to bring you our independent take on the debate.  

The backstory

In 2015 the government claimed that thousands of people lose their lives every year because we don’t have a “proper seven-day service in hospitals”.

We concluded that the evidence did not support this claim. There was no way to be sure that poor care at weekends was to blame for thousands of “excess deaths”.

Full Fact has twice requested that the Health Secretary correct the record on a specific version of this claim. To date he has not done so.

“Shaky” evidence, say doctors and academics

A group of doctors and academics have questioned whether there is a “weekend effect” at all in a letter in the Guardian.

They wrote that only four of those eight studies used by the Department of Health are peer reviewed and just two are “from the last decade”. They also told us they questioned the independence of some of these studies as some were commissioned by NHS England.

The letter dismisses the other four studies cited by the Department as they haven’t been peer reviewed.

It’s correct that only four of the studies were peer-reviewed and appeared in medical journals.

Three of the remaining publications are reports published by East Midlands NHS Clinical Senate, NHS England, and the Academy of Medical Royal Colleges. The last report listed by the Department of Health was commissioned by former Health Secretary Andy Burnham and written by Professor Sir John Temple on behalf of what’s now Health Education England.

One of the letter’s authors, Dr Hugo Farne, told us that the reference to two of these being from earlier than “the last decade” means that the patient data they use was collected before 2010. He considered that any of the articles written before this time would contain out-of-date findings as healthcare systems change quickly.

The peer-reviewed articles considered by the group to be within date, as it were, appeared in the British Medical Journal (BMJ) and the BMJ Quality and Safety in 2015.

The others, considered “out of date” were published in the BMJ Quality and Safety and the Journal of the Royal Society of Medicine.

Department of Health lists more evidence

The Department of Health provided us with a list of evidence previously supplied to the Health Committee in support of the “weekend effect”. Eight of these fifteen reports are those already published on the Department of Health’s website. The other seven are from peer reviewed journals.

The doctors who wrote to the Prime Minister have also provided us with studies which they say question whether the weekend effect exists.

One study, on weekend deaths has actually been used as evidence by both the Department of Health and the doctors. It suggests that although a weekend effect does exist, it is mostly because patients admitted at the weekend have different types and severity of illnesses.

The Department of Health’s evidence

• 2015 “Mortality of emergency general surgical patients and associations with hospital structures and processes”, Odzemir et al., British Journal of Anaesthesia
• 2015 “Association between day of delivery and obstetric outcomes: observational study”, Palmer et al., BMJ
• 2015 “Exploring the impact of consultants’ experience on hospital mortality by day of the week: a retrospective analysis of hospital episode statistics”, Ruiz et al., BMJ Quality and Safety
• 2015 “Increased mortality associated with weekend hospital admission: a case for expended seven day services?”, Freemantle et al., BMJ
• 2015 “The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week”, Ruiz et al., BMJ Quality and Safety
• 2014 “Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study”, Aiken et al., The Lancet
• 2014 “7 Day Services project: Acute Collaborative Report”, East Midlands Clinical Senate, NHS
• 2013 “Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics”, Aylin et al., BMJ
• 2013 “NHS Services, Seven Days a Week Forum”, NHS
• 2012 “Dying for the weekend: a retrospective cohort study and the association between day of hospital presentation and the quality and safety of stroke care,” Palmer et al., Archives of Neurology
• 2012 “Weekend hospitalisation and additional risk of death: an analysis of inpatient data”, Freemantle et al., Journal of the Royal Society of Medicine
• 2012 “Seven day consultant present care”, Academy of Medical Royal Colleges
• 2011 “The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix”, Mikulich et al., Journal of Acute Medicine
• 2010 “Weekend mortality for emergency admissions. A large, multicentre study”, Aylin et al., BMJ Quality and Safety
• 2010 “Time for training: a review of the impact of the European Working Time Directive on the quality of training”, Temple, Health Education England

The evidence from the group of doctors

• 2010 “Mortality in out-of-hours emergency medical admissions – more than just a weekend effect”, Maggs et al., Journal of the Royal College of Physicians Edinburgh
• 2011 “The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix”, Mikulich et al., Journal of Acute Medicine
• 2011 “Mortality from acute upper gastrointestinal bleeding in the United Kingdom: does it display a “weekend effect”?”, Jairath et al., The American Journal of Gastroenterology
• 2012 “Mortality outcome of out-of-hours primary percutaneous coronary intervention in the current era”, Noman et al., European Heart Journal
• 2013 “Obstetric consultant weekend on-call shift patterns have no effect on the management of spontaneous labour in a large maternity hospital”, Woods et al., Journal of Obstetrics and Gynaecology
• 2013 “Mortality from meningococcal disease by day of the week: English national linked database study”, Goldacre et al., Journal of Public Health
• 2013 “Effects of out-of-hours and winter admissions and number of patients per unit on mortality in pediatric intensive care”, McShane et al., The Journal of Pediatrics
• 2013 “Out-of-hours primary percutaneous coronary intervention for ST-elevation myocardial infarction is not associated with excess mortality: a study of 3347 patients treated in an integrated cardiac network”, Rathod et al., BMJ Open
• 2013 “Similarity of patient characteristics and outcomes in consecutive data collection on strok admissions over one month compared to longer periods”, Kwok et al., BMC Research Notes
• 2014 “The weekend effect: does time of admission impact management and outcomes of small bowel obstruction?”, McVay et al., Gastroenterology Report
• 2014 “Variations in acute hospital stroke care and factors influencing adherence to quality indicators in 6 European audits”, Wiedman et al., Stroke
• 2014 “A multicentre cohort study assessing day of week effect and outcome from emergency appendicectomy”, Ferguson et al., BMJ Quality and Safety
• 2012 “Emergency medical admissions, deaths at weekends and the public holiday effect. Cohort study”, Smith et al., Emergency Medicine Journal
• 2016 “Biases in detection of apparent “weekend effect” on outcome with administrative coding data: population based study of stroke”, Li et al., BMJ
• 2016 “Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission”, Meacock et al., Journal of Health Services and Research Policy
• 2016 “Effect of weekend admission on in-hospital mortality and functional outcomes for patients with acute subarachnoid haemorrhage (SAH)”, Deshmukh et al., Acta Neurochirurgica
• 2016 “Mental health services, suicide and 7-day working”, Kapur et al., British Journal of Psychiatry
• 2016 “Using routine blood test results to predict the risk of death for emergency medical admissions to hospital: an external model of validation study”, Mohammed et al., QJM
• 2016 “Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care”, Bray et al., The Lancet
• 2016 “Retrospective analysis of 30-day mortality for emergency general surgery admissions evaluating the weekend effect”, McCallum et al., British Journal of Surgery

More to come

This is a complex issue which we can't make final conclusions on just yet. We want to look at all of the studies presented by the Department of Health and the group of doctors. We will bring you our independent take on the seven day NHS if we get the funding.

 If you would like to help fund this work, please get in touch with our Director, Will Moy, on 020 3397 5140 or william.moy@fullfact.org. You can also donate online at fullfact.org/donate.