Rachel Meacock reports on the economics of elevated hospital mortality at weekends.
On 11th June Professor Matt Sutton of The University of Manchester presented an OHE lunchtime seminar on the economics of elevated hospital mortality at weekends. Professor Sutton’s presentation drew upon recent work published by Meacock, Doran and Sutton (2015).
Rachel Meacock, also of The University of Manchester, summarises the seminar in this guest post:
The NHS recently set out plans to move towards providing comprehensive hospital services seven days a week, as a response to findings that patients are significantly more likely to die if admitted to hospital at the weekend compared to during the week (NHS Commissioning board, 2013; NHS England, 2014). Prof Sutton discussed the evidence being used to support this policy, and presented estimates of its potential costs and benefits.
Prof Sutton explained that the highly quoted figure of a 16% increase in the risk of dying if admitted at the weekend is a relative risk, with the absolute increase being just 0.3 percentage points. The absolute risk increase is the numerical difference between the probability of dying if admitted at the weekend compared to if admitted during the week; the relative risk is the ratio of the probability of dying if admitted at the weekend to the probability of dying if admitted during the week. The relative risk does not give any information on the overall risk. In this case, the relative risk increase of 16% sounds much greater than the absolute risk increase of 0.3 percentage points.
Prof Sutton also highlighted the lack of causal evidence between staffing and service levels and mortality rates.
Sutton and colleagues have estimated the likely costs and benefits of implementing comprehensive seven day services. Their focus was on emergency admissions, as this is the area in which the majority of excess weekend deaths occur and has been the focus of much of the policy debate.
It was noted that such service extensions will have an opportunity cost; requiring either an increase in training and recruitment of doctors or, more likely, a redistribution of the current workforce away from weekday cover. The introduction of a 7-day NHS could therefore narrow the gap between weekday and weekend death rates by raising mortality during the week.
Applying the weekday death rate to the volume of emergency admissions at the weekend, Sutton and colleagues estimate that between 4,355 and 5,353 lives could be saved annually if the mortality rate observed for patients admitted at the weekend was reduced to that experienced during the week. They estimate this to translate into a potential health gain of 29,727 – 36,539 QALYs per year if all of these deaths could be averted. Using the NICE £20,000 per QALY threshold, the NHS should spend no more than £595m – £731m to achieve a health gain of this size.
Whilst the potential benefits of extending services appear large, they must be compared with the additional costs of doing so. Using estimates produced by the NHS Seven Days a Week Forum, the annual cost of implementing seven-day hospital services is estimated to be between £1.07bn and £1.43bn. This exceeds the maximum amount that the NHS should spend to eradicate the weekend effect by a factor of 1.5 to 2.4, or between £339m and £831m.
Prof Sutton concluded that the statistics on increased mortality for those admitted at the weekend are insufficient by themselves to justify an organisational change. There is as yet no clear evidence: that 7-day working will, in isolation, reduce the weekend death rate; that lower weekend mortality rates can be achieved without increasing weekday death rates; or that such reorganisation is cost-effective.
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References
Funding acknowledgement: This research was funded by The National Institute for Health Research Health Services and Delivery Research (NIHR HS&DR) programme (project number 12/128/48). The views and opinions expressed are those of the authors and do not necessarily reflect those of the HS&RD programme, NIHR, NHS or the Department of Health.
OHE would like to thank Rachel Meacock for contributing this guest post.
