Surviving the weekend

Research suggests weekend surgical patients are more likely to die, so is it time hospitals switched to 24/7 care? [Analysis from 'FYi' Issue 11]

Research suggests weekend surgical patients are more likely to die, so is it time hospitals switched to 24/7 care?

The latest study, published in the BMJ, suggests patients who undergo surgery towards the end of the week are more likely to die than those earlier in the week.

Researchers from Imperial College London looked at all non-emergency surgery undertaken by the NHS in England in 2008 to 2011. Among the four million operations, they noted more than 27,500 deaths in the 30 days following surgery, making the average risk of death 0.67 per cent.

Concerns were raised about the significant variation over the week, with the lowest risk attached to surgery performed on a Monday. In contrast, patients whose operations were carried out on a Friday were 44 per cent more likely to die than on a Monday. Those undergoing surgery on a weekend were 82 per cent more likely to die than on a Monday, although the relative number of weekend operations was low. These figures include deaths both during the patient’s hospital stay and after discharge.

The researchers said the findings could be linked to various factors, including a poorer quality of care at the weekend, or that patients admitted or operated on at the weekend are more severely ill than those admitted during the week.

This is not the first time research has highlighted trends among death rates.

For years, the August change-over – when trainee doctors start their new jobs – has been referred to by a variety of alarming names, among them the “killing season” and “black Wednesday”. These tags emerged as various research studies suggested that hospital death rates rise at the start of August, with one study saying rates go up by as much as eight per cent.

Last summer NHS medical director Sir Bruce Keogh admitted publicly for the first time that the “killing season” does in fact exist and that measures were being put in place to address the problem.

The European Working Time Directive (EWTD) has also caused controversy since its introduction in 2009. Designed to end the practice of excessive working hours, it limited doctors’ average working week to 48 hours. However this had the knock-on effect of restricting training time and impacting on continuity of care due to increased staff handovers.

A survey by the Royal College of Surgeons in 2010 found that 80 per cent of consultant surgeons and 66 per cent of surgical trainees said patients were less safe because of the directive.

Add to this the statement in March 2013 by the head of the Care Quality Commission (CQC) David Prior who warned of a crisis in urgent care. He said: “If we don’t start closing acute beds, the system is going to fall over. Emergency admissions through accident and emergency are out of control in large parts of the country … That is totally unsustainable.”

This prompted renewed calls for the NHS to consider 24/7 healthcare provision, where hospitals would be expected to o­ er the same level of service around the clock, rather than reducing cover at weekends.

This has been a recurring topic in healthcare debate in recent years. A poll of more than 1,000 GPs and secondary care doctors conducted by doctors.net.uk in March 2012 found 59 per cent agreed hospitals should operate on a 24/7 rolling weekly schedule. Respondents suggested that if the current workload was spread equally over seven days and the premium salary for weekend working were scrapped, a seven day service could be implemented even in today’s tough economic climate.

Of those who opposed a 24/7 service, most were worried about the cost while some were concerned that spreading the workload might mean fewer staff would be available at any one time.

Primary care has also taken centre stage in the debate as the government has proposed returning the responsibility for out of hours care to GPs. The Urgent and Emergency Care Review by Sir Bruce Keogh, published in June, calls for a better co-ordinated urgent care system. His vision includes “decision support from a patient’s own GP practice and hospital specialist nurse/team seven days a week”.

Sir Bruce has said a forum has now been established to “develop viable financial and clinical options to help our NHS provide more comprehensive services seven days a week.”

Some hospital units are already ahead of the argument and are delivering 24/7 care. The issue has been a hot topic within the Royal College of Paediatrics and Child Health for the past three or four years.

The Royal Free London Foundation NHS Trust has been providing consultant delivered care since 2007, where consultants, rather than junior doctors, provide the bulk of clinical frontline care.

Writing for the BMJ in June 2013, consultant paediatrician Dr Susie Gabbie describes how this is achieved through a variety of different shifts. She says 12 hour day and night shifts cover the emergency department from 9am to 9pm, while separate consultants cover inpatient wards and clinics. Duty consultants are closely involved with all patients through direct supervision of junior doctors and hands-on care.

She highlights several advantages: “Patients receive direct consultant input at all times. Care is not reduced at weekends or out of hours. No child is more than four hours from consultant review, and in reality most patients are seen much more promptly, complying fully with royal college standards…Trainees are also under close consultant supervision at all times.”

She also believes the unit is “more or less cost neutral” thanks to various factors including performing fewer investigations and admitting fewer children.

While it seems 24/7 care is possible, it remains to be seen exactly how plans will progress in our rapidly changing NHS.

Joanne Curran is an associate editor of FYi