Is it time to re-appraise the weekend effect?

The UK NHS is the envy of the world by virtue of healthcare offered to all patients, free at the point of delivery. The NHS provides 24/7 emergency care. However, in the majority of hospitals, non-emergency care is limited to a weekday, standard working hours pattern.^1–3 Outside standard working hours, and particularly at weekends, the levels of medical, nursing and auxiliary staffing in addition to community and social care support are substantially lower.^3,4 Over the past few years, multiple analyses suggest variations in the care received by patients in NHS hospitals according to the day of admission to hospital. In particular, admission to hospital at weekends confers significantly worse mortality compared with admission on weekdays.^1,2 The implications of these findings point towards an insufficient number of doctors providing care at weekends.^3–5

The weekend effect is clear cut, at least from a statistical point of view. Analyses by Freemantle et al.^1,2 utilising almost 15 million admissions show that admission at weekends may increase the risk of death at 30 days by 15%. Statistically, the conclusions are robust accounting for case-mix variability and adjusting for factors such as demographics and co-morbidity. Certainly, this is a hot research topic with more than 30 studies published in the last 12 months alone. A large study of 3 million patients from 28 hospitals in England, USA and the Netherlands shows that 30-day mortality is worse for weekend admissions. ⁶ Interestingly, the same study suggests that this disparity is lower in England than the USA and the Netherlands. A large study from Denmark of 175,000 acute medical patients suggests a similar pattern. ⁷ Smaller studies of patients in specific disease groups such as myocardial infarction, stroke, pulmonary embolism, critical care, hip surgery, gastrointestinal bleeding and paediatrics, again in several countries including Kenya, Taiwan, Iraq, Australia and Japan, tell a similar story. The phenomenon of weekend hospital admissions leading to greater mortality is a truly global one.

Does this mean it is time to revamp social norms? Weekends are a time for relaxation and nights are for sleep. A number of diseases, including myocardial infarction, are more likely in the middle of the night when healthcare systems are threadbare.^3–5,8 Is it time to abandon socially acceptable working patterns in favour of a 24/7 shift pattern? The answer seems to be obvious when considering the statistical evidence for the weekend effect. Beneath the surface, the decision is less clear cut and key questions remain. The most obvious is the resources required for a change at national level. While the number of UK doctors in training is steadily increasing, the number leaving the country is also doing so.^9–11 The growing demands of patient numbers, complex and multiple morbidities, and under-recruitment of doctors and nurses in key specialties pose an unenviable management challenge against a backdrop of healthcare budget cuts and a dissatisfied workforce.

Would a change in service delivery work? None of the studies of weekend mortality have a direct correlation with lack of healthcare services to explain the disparity in mortality. Therefore, it is unclear whether a change in healthcare delivery would lead to an improvement in mortality rates. A few models may guide us, such as the development of 24/7 primary percutaneous coronary intervention in the management of ST elevation myocardial infarction patients. A large study from Newcastle evaluating ST elevation myocardial infarction patients managed by a 24/7 primary percutaneous coronary intervention service showed no difference in mortality between care within and outside normal working hours. ¹² Despite this, the difference in scale between this example and a true 24/7 NHS is huge and requires vast resources.

The weekend effect is real. All healthcare stakeholders should acknowledge and embrace these statistical findings with an open mind and seek improvement in clinical outcomes. However, the interpretation of the weekend effect is difficult and any solution is complex. Spinning the facts to suggest that doctors can fix the weekend phenomenon themselves is a dangerous precedent, with the potential to disrupt the foundations of the NHS in an era of austerity and rising healthcare demand.