An “open” letter to the editor of the BMJ

Fiona Godlee

Editor

British Medical Journal

12/09/2015

Dear Fiona

Imagine that you are about to board a long haul flight on a Sunday morning and you read in your copy of The Telegraph that the airline runs on a skeleton staff at the weekend and as a result your aeroplane is much more likely to crash.

Most people would cancel the trip, or rebook with a different carrier. The consequence for people with no option but to fly would be a very uncomfortable journey. The increase in stress and anxiety for nervous passengers could be very significant.

And the newspapers publishing this sort of allegation had better be confident that it is true. You can be sure the airline will use the full weight of the law to sue for reputational damage and loss of income if there is doubt about the veracity of the story.

Sadly emergency NHS patients do not have the option of delaying their treatment or changing provider in the face of similar news stories and indeed they could come to real harm if they try to do so. There is clear evidence that patient outcomes can be influenced by expectations. Increasing fear and anxiety in emergency patients could cause real distress and possibly lead to actual harm.

Which brings me on to the BMJ paper on hospital mortality rates published this weekend and the press brouhaha surrounding it.

What does this paper add to our current knowledge to justify the publicity surrounding its publication?

The paper shows an increased death rate for weekend admissions, which has been well known for many years. It is completely in line with previous findings – so no news there.

Similar results have been obtained in other health economies including the USA, Canada, France, Germany and Australia so this is not a story about the NHS per se.

It is very likely patients admitted at the weekend are sicker. The number of admissions on a Saturday and a Sunday is lower than the rest of the week and it seems probable that the missing emergencies are from the less severe end of the spectrum.

I disagree with the author’s assertion that the results have been fully corrected for disease severity – an assertion made in the paper and also in the BMJ press release. The results have been corrected for predictors of death such as comorbidity and social deprivation but these are just factors inherent in the patients. They are not indicative of the severity of the illness itself. We do not usually code for disease severity and the surrogate “admission urgency” does not really make up for that.

This is important because if disease severity had been corrected for then the differences would be entirely due to process issues.

The bottom line is that this paper provides relatively little new information about weekend death rates and or their underlying causes.

So what is the problem with the paper and the way it was released?

This study essentially just confirms and updates earlier findings. It does not tell us why there differences between weekend and weekday death rates or indeed if any of them are avoidable. A big launch with a press release and a media flourish is surely not justified by the scientific merit of the findings.

I believe the authors have overstated the importance of their findings and presented them in a sensationalised way. The BMJ has missed an opportunity to provide moderation here.

The authors seem to assume that death in hospital is always a bad thing. The vast majority of hospital deaths are unavoidable and many are expected. Patients with terminal illness may be more likely to be admitted to hospital for a crisis at the weekend when community services are thinly stretched for example. They may be quickly discharged to die in the community within 30 days but are still included in this analysis.

So the headline grabbing figure of 11,000 excess deaths is disingenuous. It compares the weekend with the best day and assumes that everything else is excess. At least the discredited “unnecessary deaths” claims in Mid Staffs were calculated using the national average – not by comparing Mid Staffs with the best performing trust in the country.

The 11,000 figure is then further inflated by extending the weekend to include Friday and Monday on the flimsy rationale that people are winding down on a Friday and overwhelmed on a Monday. This is in effect adjusting the analysis based on prejudice about the true cause of the difference. If you want to really examine the effect of staffing levels then Saturday and Sunday are definitely different to weekdays – but staffing on all weekdays is the same.

It is notable that there are big differences between death rates on Saturday and Sunday when in most trusts consultant staffing levels are identical – further undermining the argument that consultant presence is important.

It is reasonable for authors to speculate on the possible causes for their findings in the discussion and clearly medical staffing levels are a possible cause and should be mentioned. It is pushing things a little to add “a case for expanded 7 day services” to the article title though as the data does not support this unequivocally.

And now the awkward part

This is good, solid, helpful data which updates earlier findings but which really does not take our understanding of causes of weekend excess mortality very much further forward.

The major issue is the way that this paper was launched by the BMJ, with a press release and a fanfare of publicity, into the midst of a very high profile consultant contract negotiation and the debate of 7 day working. The press release talks nearly as much about this than it does about the merits of the paper.

It is clear that although these results were embargoed until Sunday morning the government had advance notice of the findings. Jeremy Hunt has already caused considerable anger amongst hospital consultants buy implying that excess hospital weekend deaths are caused by their work practices and the completely nonsensical assertion that removing the largely unused opt out from ELECTIVE work will somehow improve the situation.

I have argued that Mr Hunt’s approach – using weekend death statistics in order to strengthen his negotiating position – is unjustified and damaging to NHS patients and staff. It prompted me to call for his resignation and start the #weneedtotalkaboutjeremy campaign on social media which has resulted in the debate in parliament on Monday.

Playing political football with the NHS causes real harm and my worry is that launching this research into the current political maelstrom in the way it was done has been harmful. Politics and science do not mix well – and this is a great example of things going very badly.

What next?

There is no doubt that everyone – including consultants – want this country to have an NHS that provides effective and safe emergency care every day of the week. I think we have yet to agree as a country whether we want elective services at the weekend and if we do how we are going to pay for them.

It would be helpful if the government could make clear its top priorities to address the weekend mortality issue and indicate how they might be funded. They should do this in a transparent and dispassionate way rather than using the medical press and the media to spread half-truths and misinformation in an attempt to get political leverage.

The BMJ is in a unique position to influence the future of the NHS. I hope you will take these comments in the spirit they were intended – to stimulate sensible debate and defuse a difficult situation.

I am sending this as an “open” letter to raise awareness of the issues. I have chosen to publish it as a blog and not submitted to the BMJ for publication, as it will get a much broader readership this way.

If you would like to reply I will be very happy to publish your response on the same site.

Yours sincerely

Steve Smith