A 7/7 NHS: what price equity?
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i404 (Published 26 January 2016) Cite this as: BMJ 2016;352:i404
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The most intuitive and available explanation for the different mortality rates that have been observed recently between weekday and weekend admissions to NHS hospitals in England is certainly differences in provisions of care. whose improvement or rectification would require "Money, money, money". But I wonder if in his correctly forward-looking Data Briefing, Appleby is entirely comfortable with the way the "big data" presented in the Fremantle papers handled admissions for Day Case surgery.
I have not been able to find any specific reference to these admissions in the Fremantle papers. Nor, for that matter, any definition as to what for them constituted an admission.
A lot of care is taken in NHS hospitals to make admissions for Day Case surgery as safe and good an experience for patients as possible. It is here where Atul Gawande's famous Checklist Manifesto is most readily used to "Get Things Right". And most Day Case surgery is done on weekdays.
If the expected extremely low mortality figures for admissions for Day Case surgery were somehow to have been included with the general weekday admissions in their comparison with weekend admissions, a powerful bias in favour of the safety of weekday admissions will have been incorporated. How powerful? I've no idea; but possibly, if taken into account, enough to make the reported weekend mortality figures look significantly brilliant.
I feel I should have voiced my concerns about the possible inappropriate inclusion of admissions for Day Case surgery with other weekday admissions last September when the BMJ published the second Fremantle paper, but John Appleby is easier to read and vastly experienced with "big data" and its application to care in the NHS. Should Day Case surgery be done at the weekend to achieve daily mortality equity?
References.
Freemantle: As in Appleby paper
Atul Gawande. The Checklist Manifesto: How to Get Things Right.
Competing interests: No competing interests
John Appleby's review of the data relating to the cost of a 'seven-day-service' in the NHS is a welcome addition to a discussion that has so far focussed on whether or not increased mortality at the weekend can be addressed by expanding services (see Freemantle et al. BMJ 2015;351:h4596 and responses). Appleby points out that even if one assumes that providing a seven day service could prevent all excess mortality, the cost of doing so may exceed the current NICE threshold of value for money for new drugs of £20,000-£30,000 per QALY. He concludes that 'the existence of an inequality is not enough justification for spending money to reduce it'.
This article should lead us to further question the government's pursuit of a seven-day-service and the attack on doctors' working conditions that it supposedly requires. Why then has the BMJ published a comment piece by Des Spence in the same issue which contends that 'the pressure to provide a seven day health service is an unstoppable cultural juggernaut of expectation', and that the current industrial action by the BMA is therefore a 'bad idea'? Dr. Spence also repeats the government's assertion that the public do not support strike action whilst providing no evidence to support that claim.
I find it strange that the BMJ have decided to publish Dr Spence's comments, even including the headline 'Why striking is a bad idea' on the front of the issue's print edition, as it provides a false sense of disunity within the profession on the issue of industrial action. Dr. Spence has criticised the biased nature of publishing in the past in relation to evidence based medicine (BMJ 2014;348:g22), yet his views representing the 2% off doctors who voted against industrial action are given prominent place in an international journal.
Whilst debate about the merits of industrial action is clearly necessary, giving such a large amount of space to such a minority opinion is misleading at best.
Competing interests: No competing interests
Re: A 7/7 NHS: what price equity?
Sir,
Appleby certainly raises some interesting points about the likely cost of producing what the Government calls a "7/7 service", but, although he asserts that age, sex comorbidities and diagnosis were taken into account in the production of the data taken from the HSCIC report (ref 13) to which he refers, he does not question why emergency admission rates over the weekend are approximately 23% higher than those on weekdays. Since one would expect emergency cases to be equally spread over the week the difference is daily admission rates is very suggestive that the populations are different. I can see no evidence within the HSCIC summary that any attempt was made to apply ASA or APACHE scoring to the admissions. Unless this was done we are comparing apples and pears!
Competing interests: No competing interests