DATA BRIEFING

A 7/7 NHS: what price equity?What are we willing to forgo to rectify unequal outcomes between weekend and weekday admissions?And, harder still, can the NHS justify spending the money to iron out these differences, asks JohnAppleby

John Appleby chief economist, The King’s Fund, London, UK

A founding principle of the NHS is equal opportunity oftreatment for those in equal need. It is this principle thatunderlies the way the NHS global budget is allocated across thecountry and the setting of nationwide standards and targets, forexample. And it is this principle—expressed as “equality oftreatment or clinical outcome regardless of the day of theweek”—that underpins government policy to move towards aseven day NHS.1But what does it mean in practical terms?Whatservices need to be provided and at what cost?There are two further fundamental questions. What is theevidence that there is inequality of treatment and outcomes?And, if inequality does exist, there is the standard economist’squestion: given scarce resources that could be spent onsomething else to benefit patients, what are we prepared to forgo(for example, the reduction of other inequalities such as thosearising from geographical variations in admission rates) torectify the inequality?All of these questions would be answered by a formal healthimpact assessment (usually required for major policy initiatives).Unfortunately there isn’t one. However, the NHS has produceda slew of policy documents and evidence reviews, and there issome (limited) research on mortality differences betweenpatients admitted at weekends compared with those admittedduring the week and currently just one published study of thecost effectiveness of seven day working in secondary care.2-12

Just as demand and need for hospital services vary by hour ofthe day (meaning that it would be inefficient to maintain a 24/7service, with no variation in staffing or services between dayand night time), so there is also variation between weekendsand week days. There are fewer admissions at weekends thanon week days (fig 1⇓), and the nature of the patients and theirillness varies too; non-emergency cases are generally admittedon a week day, for example. But is there evidence of avoidabledifferences in health outcomes across the week?Research suggests that even after standardising for variousfactors (age, sex, comorbidities, diagnosis, etc) there is asignificant difference, both in England2-4 and in other countries,5-8in death rates of patients admitted on weekends compared with

those admitted on week days (figs 2⇓ and 3⇓). There is alsoevidence of differences between weekend and weekdayadmissions and the risk of an emergency readmission withinseven days (fig 4⇓). 13

The most recent study using data for NHS patients treated inEngland suggests a 15% higher risk of death for patientsadmitted on a Sunday compared with those admitted on aWednesday (the least “risky” day).4However, this finding relieson accurately ironing out factors unrelated to the provision ofcare. The statistical and interpretive difficulties of identifyinga weekend admission effect is illustrated by Palmer et al’sresearch, which estimated a 7% higher relative risk of a stillbirth for mothers admitted at weekends compared with thoseadmitted on a Tuesday.9 This finding was heavily criticised,10and indeed, the paper itself noted extensive limitations in itsanalysis.It is also important when dealing with relative risks to bear inmind the absolute risk. In this case absolute risk is 1.8% for alldeaths within 30 days of discharge4 so a 15% increase in therelative risk adds 0.27% to the absolute risk.While many of the studies speculate on the causes of differences(consultant availability, access to diagnostic services, etc) noneare able to categorically identify the reasons for the highermortality among weekend admissions. Nevertheless, based ona small sample of eight hospitals in England, the costs ofproviding various forms of seven day services have beenestimated at from 1.5% to 2% of a hospital’s income.11 Scaledup, this amounts to around £1.07bn (€1.4bn; $1.5bn) to £1.43bnacross the NHS.Taking these costs together with an estimate of 29 727 qualityadjusted life years (QALYs) lost because of the weekend effectand a separate estimate of 36 539 QALYs based on Freemantleel al’s analysis,3 Meacock and colleagues calculate a cost perQALY saved ranging from £30 000 to £48 000.12 This assumesany new seven day service arrangement actually eradicates allexcess deaths and that there are no knock-on costs to otherservices and patients. If seven day working was a new drug theNational Institute for Health and Care Excellence (NICE) would

jappleby@kingsfund.org.uk

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have to think twice before recommending it to the NHS, giventhat it exceeds NICE’s value for money threshold (of £20000-£30 000 per QALY).This is a hard message, and maybe further analysis with morecertain data and accounting for benefits other than averted deathswill show something different. But the difficult fact is that theexistence of an inequality is not enough justification forspending money to reduce it.

Competing interests: I have read and understood BMJ policy ondeclaration of interests and have no relevant interests to declare.Provenance and peer review: Commissioned; externally peer reviewed.

1 NHS Improving quality. Equality for all: delivering safe care-seven days a week. 2012.www.nhsiq.nhs.uk/media/2336450/equality_for_all_-_delivering_care_seven_days_a_week_july2013.pdf.

2 Aylin P, Yunus A, Bottle A, Majeed A, Bell D.Weekendmortality for emergency admissions.A large multicentre study. Qual Saf Health Care 2010;19:213-7.

3 Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and the additionalrisk of death: An analysis of inpatient data. J R Soc Med 2012;105:74-84.

4 Freemantle N, Ray D, McNulty D, et al. Increased mortality associated with weekendhospital admission: a case for expanded 7 day services. BMJ 2015;351:h4596.

5 Bell MD, Redelmeier DA. Mortality among patients admitted to hospitals on weekendscompared with weekdays. N Engl J Med 2001;345:663-8.

6 Barba R, Losa JE, Velasco M, et al. Mortality among adult patients admitted to the hospitalon weekends. Eur J Intern Med 2006;17:322-4.

7 Ricciardi R, Roberts PL, Read TE, Baxter NN, Marcello PW, Schoetz DJ. Mortality rateafter non-elective hospital admission. Arch Surg 2011;146:545-51.

8 Ruiz M, Bottle A, Aylin P. The global comparators project: international comparison of 30day in-hospital mortality by day of the week. BMJ Qual Saf 2015;24:492-504.

9 PalmerWL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes:observational study. BMJ 2015;351:h577.

10 Electronic responses. Association between day of delivery and obstetric outcomes:observational study. BMJ 2015. www.bmj.com/content/351/bmj.h5774/rapid-responses.

11 Healthcare Financial Management Association. NHS services, seven days a week forum:costing seven day services. www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf.

12 Meacock R, Doran T, Sutton M. What are the costs and benefits of providingcomprehensive seven-day services for emergency hospital admissions? Health Econ2015;24:907-12.

13 Health and Social Care Information Centre. Seven-day services-England, provisional,January 2014-December 2014. Experimental statistics. 2015. www.hscic.gov.uk/catalogue/PUB18573.

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Figures

Fig 1 Emergency NHS admissions by day of the week, England, January-December 201413

Fig 2 Crude (unadjusted) mortality risk within 30 days of discharge by day of the week, emergency admissions in England,April 2010 to March 201312

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Fig 3 “Excess” deaths within 30 days of discharge derived from applying average week day crude mortality risk to totalemergency admissions by day of the week, England April 2010 to March 201312

Fig 4 Risk of emergency readmissions within seven days by day of discharge, England, January to December 201413

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