Lack of doctors not to blame for higher weekend hospital deaths, landmark study shows

A lack of GP services and poor community healthcare could be behind higher death rates among hospital patients admitted at the weekend, according to a landmark study.

Until now, blame for higher mortality among weekend patients has been placed on a lack of senior doctors on duty in hospitals, following studies which showed patients admitted on a Saturday or Sunday were 16 per cent more likely to die over the next month than those admitted on a Wednesday.

But the new research finds no evidence of a link between mortality rates and the number of consultants on duty.

Labour said that the government owes doctors an apology for having erroneously made the connection in the past, and that the study shows community care – which includes GP services and local nursing as well as specialist services such as physiotherapy and mental health care – needs more funding.

The findings come amid concerns over the increasing pressure on community health services in the wake of the coronavirus pandemic, with hundreds of thousands of survivors needing help after suffering from the infection. Studies have shown one in four Covid patients have difficulties coping at home, and one in 10 die within months of leaving hospital.

In 2016, the then health secretary Jeremy Hunt sparked controversy with claims patients were dying because the NHS did not offer a truly seven-day service.

It fuelled a major row between the government and the medical profession, and contributed to the dispute that led to thousands of junior doctors taking strike action for the first time since the 1970s.

Now a five-year research study examining data from 115 hospital trusts, as well as one of the largest case-note reviews ever carried out in the UK, involving 4,000 individual patients’ notes, has turned the argument about weekend care in the NHS on its head.

The study has concluded that the weekend mortality effect has no link with the presence of senior doctors in hospitals at weekends, and that care has actually improved over time.

The lead investigator behind the project told The Independent that the research has turned up unexpected results that point the finger not at hospitals, but at the state of community services and weekend GP cover, which he says could be behind the higher risk of death for patients admitted at the weekend.

Julian Bion, professor of intensive care medicine at the University of Birmingham, said an urgent examination of community services was needed to prevent the possibility of patients suffering avoidable deaths.

He said: “People need the same care on a Sunday to prevent them becoming ill as they do on a Monday, whether in the community or in hospital. We have to devise systems where the care that people need does not vary by location, by time, or by day of the week.

“We keep looking at the point of admission to hospital, but that’s not where illness begins. It starts in the community, but the level of care in the community at weekends is a bit of a black box.”

The High-intensity Specialist-Led Acute Care (HiSLAC) study looked at the number of hours of care consultants were delivering on Sundays and Wednesdays, and compared those figures with the mortality rates of patients admitted at the weekend and during the week.

While the number of hours worked by senior doctors in hospitals had increased since 2012-13 – when NHS England introduced seven-day standards for NHS trusts – the weekend figures were still around half of those for weekdays.

Prof Bion said: “We couldn’t find any evidence that trusts that had fewer consultants providing care at weekends compared with weekdays had a higher mortality. There was no relationship. When I first saw the data from our analyst, I remember feeling surprised that there was no relationship, but about 10 seconds later I realised this was a fascinating and important finding: if it’s not caused by lack of consultants in the hospital, then what is the cause?”

His team of 81 doctors then examined the quality of care at weekends and weekdays across 20 NHS trusts, examining 4,000 patient records split over weekends and weekdays. They found the care available to emergency patients was actually better at weekends than on weekdays.

The explanation lay in the type of patients coming to hospitals. He said: “Patients coming into hospital at weekends were sicker, they had more chronic disease, and they were more likely to be classed as patients who should be offered palliative care.

“We also found that the proportion of patients referred to hospital by general practitioners was a third less at weekends than on weekdays.”

He said this “signal” about the type of patients admitted from the community at weekends “got worse over time”, whereas the quality of care in hospitals improved during the study.

He added that better community care could mean patients needing interventions would be detected faster and given help before they deteriorated; alternatively some would benefit from enhanced care in the community.

The weekend mortality issue in hospitals has been known of since at least 2001, and was repeatedly linked to the lack of consultants and senior doctors being in hospitals, but without evidence to support this contention.

The full report of the HiSLAC study said the issue became political and a “source of tension” between the government and doctors.

During talks to renegotiate doctors’ contracts, the then health secretary Jeremy Hunt linked deaths to doctor numbers, saying: “Someone is 15 per cent more likely to die if admitted on a Sunday than on a Wednesday, because we do not have as many doctors in our hospitals at the weekends as we have mid-week.”

Prof Bion said: “The political rhetoric surrounding the weekend effect and seven-day services was distinctly unhelpful, because people didn’t know what the cause was and were just blaming hospital consultants. That was the target of the ire of David Cameron and Mr Hunt at the time; they made quite pungent remarks about lack of senior staffing in hospitals. I think that was unhelpful.”

But he added: “What was distinctly helpful was the principle of seven-day services, which I think was entirely right: you want to have the same quality of services every day of the week; there’s no excuse for winding it down.

“Our research does not show that weekend care is wonderful. What it shows is that it’s not worse than weekdays. There are distinct opportunities to improve the quality of care in hospital and in the community. To do that is going to take more staff, more funding, more support services, and on the part of professions, continuing commitment.”

Jonathan Ashworth, Labour’s shadow health secretary, said that the study “confirms what we all knew at the time – the campaign to blame junior doctors was utterly unjustified. They deserve an apology and indeed a fair pay rise from ministers.

“This report also reinforces the case for investment in community services and staffing. We’ve long argued for a sustained health inequalities strategy, and well-funded community health care is integral to that.”

While NHS England has pledged to shift more care to the community, some services have seen substantial deterioration in funding and workforce.

The number of district nurses working in the community has dropped from more than 7,000 to just over 4,000 over the past 10 years, with the Queen’s Nursing Institute (QNI) warning that community nurses were being forced to delay patient care on a daily basis before the Covid pandemic.

Crystal Oldman, chief executive of the QNI, an independent charity promoting community nursing care, said: “The QNI has been highlighting and providing the evidence for a number of years over the lack of investment in community services.”

She said investment was not just about capacity but also the capability of staff to provide the care required. She added that seven-day services in the community would actually help reduce pressure on hospitals.

During the Covid pandemic, some community services have seen referrals increase by more than 50 per cent as more patients have needed help at home.

Tracy Allen, chief executive of the Community Health Services Foundation Trust, said: “This report appears to show that you can’t look at hospitals and ignore the rest, because people start off in the community and go in and out of hospital, and we need the same forensic focus on our services that we’ve had on acute hospitals.”

An NHS England spokesperson said: “As well as continuous hospital access, we offer 24/7 health support to patients in the community through GP surgeries across the country, which already provide out of hours and weekend provision to patients, pharmacies and 111 online and phone services.

“NHS England has made a number of recent investments to support this network of care during the unprecedented pressure we have seen during the pandemic – including £270million to expand general practice capacity - and community crisis teams are being rolled out across the country to provide urgent care to people in their homes seven days a week.”

A Department of Health and Social Care spokesperson said the government’s planned reforms to the NHS would deliver more integrated care for patients.