Editorial: No such thing as 'out-of-hours' care

Care drops off to such an extent at weekends that the chances of dying within 30 days of surgery rise steadily, day by day, from Monday onwards

What with the higher proportion of emergencies and the relative dearth of on-duty consultants, the extra risk associated with weekend hospital admissions has long been recognised. Now, however, it appears that sparsely-staffed Saturday and Sunday shifts have implications for patients over the rest of the week, too.

The issue is the so-called “after care” provided in the crucial two-plus days following surgery. Researchers at Imperial College London, who surveyed the outcomes of more than four million elective operations, concluded that care drops off to such an extent at weekends that the chances of dying within 30 days of surgery rise steadily, day by day, from Monday onwards.

While the average risk of death may still be an encouragingly small fraction of one per cent, patients are some 44 per cent more likely to die following surgery on a Friday than on a Monday. And for an operation at the weekend proper, that rises to a woeful 82 per cent. Is it any wonder that patient safety groups are squealing in alarm or that the Royal College of Surgeons is up in arms?

It is high time to remedy the situation. Even more so given that the poor quality of many GPs’ evening and weekend services is also a growing problem. Taken together, it is hard to avoid the conclusion that the NHS’s working culture – nine-to-six, five days per week – sits awkwardly with the needs of patients. Indeed, the very notion of “out-of-hours” is surely nonsensical in the context of health. It may be unrealistic to demand an NHS that runs at full throttle, 24/7. But evidence of unnecessary deaths renders the status quo untenable.

As ever, the most obvious difficulty is financial. Some relatively minor changes – rostering more consultants on at weekends, for example – might smooth out the more egregious discrepancies. But the gaps can only really be filled by hiring more people, which is hardly practical with £20bn worth of savings to be found by 2015.

Simply throwing money – and staff – at the problem is not the only solution, though. Better to make more efficient use of the considerable resources that the health service already has; and that means a rethink of the all-purpose general hospital.

Stroke care in London is a fine example. Where once a stroke victim was taken to A&E, now they go to one of eight specialist units. The travelling time may be marginally longer, but, thanks to the concentration of expertise and facilities, the standard of care is higher – with the result that the capital’s stroke services are among the best in the country.

Calls for a shift from unwieldy, inefficient district hospitals to smaller, specialist centres are hardly new. Nor is the issue simply one of controlling ballooning spending. The steadily ageing population – with its abundance of chronic problems – also requires a different type of NHS. Yet it is proving almost impossibly difficult to deliver. Why? Because the big picture counts for little in the face of emotive grassroots campaigning. Witness the furore over children’s heart surgery – despite years of debate, the question of which centres should close to ensure safer surgery in the rest remains unresolved.

Sad to say, MPs, wary of upsetting voters, all too often lend their support to such hostilities. In fact, they would better serve both constituents and country by helping explain that fewer maternity units, say, should mean better maternity services. It can only be hoped that the latest evidence of the risks of weekend surgery will help focus minds. If we want to improve standards of care, we need to think differently about how, where – and when – it is delivered.