Political spin and public opinion: #Imatworkjeremy

“#Imatworkjeremy. Not just this weekend, in fact as a full time trauma consultant, I work one weekend a month with scheduled operating and clinical sessions from 8am to 10pm on Friday, Saturday and Sunday.”

There has been something of a political storm in the UK health service recently, sparked by the allegation from the Secretary of State for Health, Jeremy Hunt, that senior and junior doctors are not working a full seven-day week, and the consequent lack of services is ‘placing lives at risk’. The ensuing public relations war between the British Medical Association and the Department of Health has been one of the biggest public spats of recent British political history, overtaking many of the social media channels and culminating in over 200 000 signatures to a petition calling for the resignation of Jeremy Hunt.¹

The Government response is interesting. Citing a paper² (although not directly) suggesting increased mortality at the weekend (OR 1.16), these ‘excess’ deaths actually occurred on other days of the week in patients admitted at the weekend, and the Government analysis illustrates a lack of understanding at the highest level of not only statistics, but the basic principles of healthcare research; a very worrying truth. Either the top Government advisors are ill-informed (unlikely) or the Prime Minister and Secretary of State have decided that, in fact, ‘they know better’. The public are divided in their opinion, and the popular press has ventured mostly support for consultants’ concerns.^3,4 As a consultant surgeon, it’s easy to be wound up by the whole topic – I know in my own institution, patients already receive consultant-led care seven days a week. The deliberate misdirection concerning contract negotiations, weekend elective working and safety has created a quagmire which is inescapably difficult to resolve, with salary reductions, changes in working practice and changes to the role of the consultant being snuck in under the banner of patient safety. This set me thinking, however; are health services actually safer during the week? If so, is this an effect of a preponderance of planned admissions, or higher staffing levels?

Estimates of national mortality are hard to come by. Perhaps the best paper on the topic, in the surgical field at least, is that published by Pearse et al.⁵ In their pan-European study of 46 539 patients, mortality was estimated in 28 European countries, with the UK having a mortality of 3% following surgery: among the lowest in Europe for all diagnoses. One of the key messages from this paper was that the authors saw a dramatic variation in survival between both nations (OR = 6.92 in Poland vs UK and surgical type with, as would be expected, dramatic differences in mortality following elective (OR = 1.0), urgent (OR = 1.71) and emergency (OR = 3.2) surgery. There is then some evidence that case mix must come into the equation. In fact, on the basis of these figures alone, you could explain the increased weekend mortality. The rudimentary and generalised statistics of ‘Dr Foster’ are badged as adjusted appropriately for case mix, but there is plenty of evidence that adjustments through systems such as POSSUM do not adequately adapt for a range of diagnoses.⁶

So, is the ‘weekend effect’ real or false? There is some reliable evidence to suggest that in standardised diagnoses, treated at the same institutions, there is likely to be increased mortality at the weekend.^7,8,9 However, this cannot be due to a lack of consultant care as these results are carried out with purely consultant-led care, so this leaves us with an understanding gap.

Before attempting to correct the problem, the scientist in me wants to understand why this is. Amazingly, the Department of Health seems hell-bent on a different direction that will inevitably damage healthcare provision for many in the UK without first knowing if the problem is real, or identifying its cause. As there is no additional funding for moving to seven-day working, and as this approach is resource-hungry, the end result will be reduced staffing levels throughout the week. Without understanding the causation (and apparently without understanding even the basics of statistics), the politicians are using policy to change working practice in the name of patient safety. For what it’s worth, I’m proud of the professional and reasoned response the UK body of consultants and trainees has made, but I’m growing more and more concerned for the future safety of our hospitals.