https://juniordoctorblog.wordpress.com/2015/07/18/weekend-mortality-and-the-7-day-nhs/Weekend Mortality and the 7-day NHS
“If you are admitted to hospital on a Sunday, you are 15% more likely to die than on a Wednesday”.
This is Jeremy C*nt- quoting a paper without atribution from the Journal of the Royal Society of Medicine, conducted in 2010 by Freemantle et al [1] amongst nearly 15 million admissions.
Here is the actual paper:
Here are the ACTUAL conclusions
Patients admitted on a Sunday were more likely to die over the next thirty days than a similar cohort of admissions on Wednesday- the ratio was 1.16 and the result significant, suggesting a true result of increased deaths by 16%
94% of these ‘admissions’ were emergencies
34% of deaths occurred within three days of admission
You are actually less likely to die if you are IN hospital on the weekend – the Sunday to Wednesday ratio here is 0.92, or 8% LESS likely. As the authors also conclude, this likely reflects the fact that high-risk, non-urgent procedures are performed during the week.
For elective (non-emergency) admissions, the ratio was 1.62 for Sunday to Wednesday, suggesting a 62% increased chance of death. This, as the authors conclude, is likely biased by the fact that high-risk elective patients are brought in early in general for exactly this reason, therefore this is unlikely to be significant.
Of 10 conditions specifically looked at, only 7 were found to show the same increased risk: sepsis, acute renal failure, cancer of the bronchus or lung, myocardial infarction, acute stroke, and congestive heart failure.
The authors also conclude: “7-day access to ALL ASPECTS of care” could improve such figures, but further ‘economic evaluation’ is required to ensure efficiency with ‘scant resources’ [para]
A further third of patients in this study died after discharge
So to summarise, you are 16% more likely to die, over the next thirty days, if you come into hospital on a Sunday- 30% will die within three days (Mon-Tues), and a further 30% will die after discharge. This only applies to emergency admissions, and a list of medical emergency conditions.
One major criticism, published by the authors themselves, is the fact that any conclusion completely ignores the reason for admission and the route of admission- there are no routine GP services on the weekend, and the impetus to admit on a weekend has to be higher than the week when most people would hold out for the GP unless they were very unwell. This immediately selects out a group of sicker patients than might routinely come in on a Wednesday.
Now we will play a game called ‘Jeremy C*nt spectacles’.
I look at this paper with ‘Jeremy C*nt Spectacles’ and read the abstract ‘admissions on a Sunday…16% more likely to die vs a wednesday’ and then completely stop reading and decide that a) 15% is a rounder, more soundbite-friendly number b) this must be the consultants fault c) I should go and tell them, loudly and with contract renegotiations for the entire consultant body. Or more realistically d) this would be excellent to further my agenda of privatising the NHS (despite that later in the paper the private US system shows the exact same pattern).
Now I take off the spectacles and look again.
The paper shows that patients admitted on Sunday, overwhelmingly emergencies, do worse during the entire course of their illness episode than those on Wednesday, but they deteriorate during the next three days (30%) over the weekdays, or even after discharge (34%) ie all on weekdays or even weeks of admission. Of the commonest conditions they are all medical emergencies.
Therefore, the suggestion is there is a decreased level of care on a Sunday admission, assuming that the patients are not genuinely sicker on average as suggested above, and that exarcebates or worsens an illness episode greater than a Wednesday admission. This extra initial insult, in 16% of patients, is not survivable. The ward patients however, appear generally unaffected weekend or weekday.
So what do the Wednesday patients get, that the Sunday patients don’t get? Consultants? In every hospital I have worked in that is simply not the case. Think about the admission process; in A&E there is always a consultant, on a 7-day 24-hour basis. Most have 3 or 4 at a time. For this set of patients they go to acute medicine where the standard is a daily consultant ward round, some twice or even thrice daily. So that is not going to help Mrs Sunday.*
What is not there? Only limited access to their GP, which in turn increases the workload in A&E, limited radiographer and lab techs, echocardiogram technicians, reduced pharmacy cover, and the hordes of office hours staff – secretaries for vital notes from other hospitals, semi-urgent referrals to other teams, the list goes on. In other words the missing £20 billion from the £100 billion budget that has already been cut away.
So, looking at the same problem, where emergency admissions are the chief cause of the 15% bump in mortality, what is the rational response? To increase funding and GP resources, to staff and fund A&E and acute medicine and other acute specialties and to support community services.
Has this been done? No.
Instead- GPs have been pushed on to duties they didn’t want in the form of the wholly rejected Health and Social Care Act, at a conservative estimated cost of £1.5 billion [2], and instead of funding and supporting emergency admissions A&Es have been closed and the specialty chronically under recruited, despite warnings. In other words, the areas designed to prevent this exact problem, identified in 2010, have been systematically underfunded and cut by the current Government for the last 5 years.
So, is an attack on consultant contracts, who are already working weekends and nights in vital areas, going to save 6100 lives? Clearly not. The system needs to extend through the multidisciplinary teams and out of the hospital and into GP land and social care- this needs to focus on emergency admissions. So while there is a neat political capital in claiming 7-day NHS services is good for patients- it’s an appeal to convenience, not safety, and no regard to resource. If you want all the staff and equipment and resources available 24 hours a day, you will need another two 8 hour shift equivalents- another 300,000 doctors, 800,000 nurses, 310,000 multi-discplinary team members. If you have a spare annual £200 billion, this would be a good time to speak up.
And in the meantime Lord Prior, the parliamentary under-secretary of state for NHS productivity, quietly announces an inquiry into private charges and insurance to fund the NHS. I.e to move the system from tax-funded to full charge-based private healthcare. [3]
So, Jeremy C*nt, is not stupid. He isn’t ignorant- he is inflammatory. He is not incompetent he is corrupt. There is an agenda here far wider than doctor-bashing.
While myself and my colleagues post #ImInWorkJeremy tweets in solidarity against changes to our contract, the political conversation is focused on us, while behind the scenes one of the greatest healthcare systems in the world is quietly dismantled by politicians and Lords with no democratic mandate to do so.
All doctors would like a 7-day NHS- we would like all the resources we have at the weekdays to do the best for our patients. Just come and witness the frustrated arguments with midnight radiographers and rushing to on call pharmacy at 11.55 am on a Saturday. But you learn to prioritise as well- that’s why you want to be the patient kept waiting, because the patient we are running to is usually the one in a hurry to die.
Perhaps Jeremy C*nt needs a lesson on prioritisation. Or perhaps he, Lord Prior and the rest of the Conservative government are not prioritising patients at all.
Juniordoctorblog.wordpress.com
*In fact this is exactly the changes made at Northumbria hospital, mentioned in the same breath in the same speech by Mr Hunt as an example 7-day service, to increase acute medicine and A&E Services, NOT the entire hospital.
**. And for what’s it’s worth: this is day 6 of my 12 day shift. Lazy old me.
[1] J R Soc Med. 2012 Feb;105(2):74-84 doi: 10.1258/jrsm.2012.120009. Epub 2012 Feb 2. Weekend Hospitalization and additional risk of death: an analysis of inpatient data. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, Roche WR, Stephens I, Keogh B, Pagano D.
[2]
http://www.kingsfund.org.uk/blog/2015/02/cost-reform[3]http://www.independent.co.uk/news/uk/politics/the-principle-of-a-free-taxpayerfunded-nhs-must-be-questioned-says-tory-health-minister-10395991.html
