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People admitted to hospitals on Saturday or Sunday are more likely to die than those admitted Monday to Friday. This is the so-called ‘weekend effect’. It has been assumed that extra deaths occur because fewer hospital consultants are present at weekends than during the week.

New research challenges this assumption. It shows that people admitted as emergencies at weekends are sicker and more likely to be near the end of life than those who come in during the week. A large 5-year study found hospital care at the weekend is, if anything, better than weekday care. However, markers of community care were worse at weekends than on weekdays. 

The study found that the numbers of consultants did not account for the weekend effect. There was no evidence that errors in hospital care were more common at weekends. Over the course of the study, consultants worked increasing hours in hospital at the weekends caring for emergency admissions. But this increase in their hours was overtaken by the increase in the numbers of people admitted at the weekends.

The weekend effect is likely to be a result of insufficient care in community settings at the weekend, the researchers say. This could mean, for example, that people nearing the end of life, who would be better cared for at home, end up in hospital because community services are not available.

Using an expert panel, and computer modelling, the study found that investing in more consultant hours at the weekend could be cost-efficient. But this was only because it might speed up discharge decisions rather than reducing death rates. However, there was also evidence that earlier discharge may be associated with transferring hospital deaths into the community.

The study concluded that the best way to bring weekend care up to weekday levels would be to invest in community services.

What’s the issue?

It is 20 years since researchers discovered that patients admitted to hospitals on Saturdays or Sundays are more likely to die than those admitted Monday to Friday. The ‘weekend effect’ was assumed to be because fewer hospital specialists work at weekends, meaning care was less good. However, there was no evidence to support this assumption.

In 2013, NHS England introduced a system which aimed to ensure patient care at weekends is as good as during the week. Measures included an increase in the number of specialists working at weekends. At the same time, this project (HiSLAC) was funded to examine whether this policy improved patient care, was cost-effective, and what other factors might be involved in the ‘weekend effect’.

What’s new?

This large study brought together information from different sources. Researchers studied national trends on how many patients died in hospital or soon after they had gone home. They surveyed specialists at 115 Trusts about their working patterns; they interviewed hospital staff and patients at 20 Trusts about their experiences. Data on emergency admissions to one large NHS Trust included a score of how severely ill patients were (based on routinely collected information such as temperature and blood pressure).

Senior doctors also reviewed case notes covering 4,000 emergency admissions to 20 hospitals. They looked for errors, adverse events and assessed the overall quality of care.

The research confirmed the ‘weekend effect’. People admitted at weekends were 16% more likely to die than those who arrived in the week. There were also half (48%) as many specialists available for each person on Sundays compared to Wednesdays.

However, there was no clear link between the availability of specialists at weekends and the death rates. Over the study period, more specialists became available at weekends, but the numbers of emergency admissions also rose.

The study in fact found that hospital care was as good or slightly better at weekends than on weekdays. It improved over the study period.

At weekends:

  • processes for emergency admissions were more reliable; there were fewer elective admissions to compete for operating theatre time or other scarce resources
  • errors, adverse events, and overall quality of care were similar to weekdays.

However, people admitted at weekends were more severely ill than those admitted during the week. They were:

  • more likely to have long-term conditions
  • more likely to need palliative care (to manage pain and other distressing symptoms in people with illnesses that cannot be cured)
  • less likely to have been referred to hospital by their GP
  • more likely to arrive by ambulance
  • more likely to be admitted to intensive care within 48 hours of admission.

These trends suggest that people were unable to access good quality care in the community, and that the quality of community healthcare was deteriorating. Over the course of the study, these trends became more pronounced and people admitted at weekends became progressively sicker.

The study found that employing more specialists at weekends would be cost-effective. This is mainly by reducing the length of time patients stay in hospital, rather than by improving the quality of care.

Why is this important?

The study disproves the common belief that hospital care of emergency admissions is poorer at weekends. It provides reassurance to people admitted to hospital on a Saturday or Sunday that they will not receive poorer care than during the week.

The ‘weekend effect’ was not caused by lack of care in hospitals, but by lack of services in the community. Researchers found that this led to patients becoming more severely ill before they were admitted to hospital. People at the end of life were also admitted to hospital when they might have been better served with palliative care at home.

Better weekend care is needed in the community to identify people likely to become sicker, and thereby prevent avoidable hospital admissions.  This includes primary care, nursing care and palliative care, so people are able to get timely treatment in the community or be referred to hospital earlier, as appropriate.

The findings suggest that policy makers do not need to prioritise weekend care in hospitals. Instead, they need to look for improvements to emergency and acute care (short-term treatment for illness or injury) across the whole system, 7 days a week. That means in community services and not just in hospitals; social care, primary care and secondary care need to work together in a joined-up way. 

What’s next?

Better integration between social, primary, and secondary care is needed to improve weekend care outside of hospitals. This should include integration of IT systems, so that GPs and hospitals can access full patient records, the lead author says.

In addition, improved conversations about end-of-life care would allow people to be appropriately treated at home and to receive palliative care at home if they wish to. At present, they are admitted to hospital when their condition gets worse. Acute care in the community must be improved, so that monitoring and treatment of acute illness can be done in people’s homes, rather than requiring emergency admission.

These changes are needed across a wide range of services. They require investment and policy support from NHS England, among others, if they are to be put into action.

You may be interested to read

This NIHR Alert is based on: Bion J, and others. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. Health Services and Delivery Research 2021;9:13

Funding: This research was funded by the NIHR Health Services and Delivery Research Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

One lesson is how important it is to test your hypotheses. I remember a sense of disappointment that my favoured theory – that the comparative lack of specialists at weekends caused the weekend effect – did not hold true. What I expected to see wasn’t there. Then I realised that the absence of such a relationship was much more interesting. If it was not lack of consultants causing the weekend effect, what was it? It was a detective process that got us to the point where we confirmed that the probable causes lie in the community.

Community care is in some difficulty now.  Community nursing has suffered severe cutbacks.  There have also been big changes to the ways GPs work and a marked increase in workload. Primary care at nights and weekends is delivered by deputising services in large cooperatives (out of hours cover, often by GPs other than the person’s own) which do not favour detailed knowledge of patients’ individual circumstances.  Hospital at home services are a valuable development which deserve further investment.

We also need to promote conversations with people coming towards the end of their lives about their preferences, including where care should be delivered.  We have outstanding palliative care services in hospital and in the community, but we need better upstream collaborative decision-making to avoid late and burdensome treatment before palliation can be activated. The current model of death in hospital is not optimal, is expensive, and has additional hidden opportunity costs.

Julian Bion, Professor of Intensive Care Medicine, University of Birmingham 

Former commissioner

This research would have been very relevant to me when I was a commissioner specialising in integrated urgent and emergency care. I am confident the findings are robust. They should inform national and local integrated care system (ICS) policy. ICSs aim to remove traditional divisions, and create partnerships between hospitals and GPs, for example, so that people receive joined up care and support.

It is difficult to say what impact this research will have in the short-term but it will be of interest to emergency care teams, A&E clinical directors and ambulance commissioners. Each ICS Urgent and Emergency Care Lead should consider or act on these findings.

Daniel Mason, Former Commissioner specialising in Integrated Urgent and Emergency Care 

Member of the public

The researchers reviews a large number of cases from 20 hospitals using sound methods. GPs will want to see these results to help them make sure that patients are adequately cared for, and less likely to be admitted as emergencies at weekends.

Any improvements are likely to be heavily dependent on resources. Commissioners need to know that rates of death are no longer going down; they have plateaued.

Trevor Benn, Public Contributor, Bolton 

 

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