Funded by the NIHR HSDR Programme www.hislac.org Twitter: @HiSLACProject Funded by the NIHR HSDR Programme The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR, NIHR, NHS or the Department of Health

HiSLAC Research Questions Does increasing consultant availability at weekends improve outcomes for patients admitted as medical emergencies to English NHS hospitals? using the roll-out of 7-day services as a ‘natural experiment’ Does quality of care vary weekend-weekday? What factors make it easier or more difficult to increase consultant availability 7 days a week? Is increased consultant staffing at weekends cost- effective? What causes the ‘weekend effect’?

Weekend specialist intensity and admission mortality in acute hospital Trusts in England: a cross-sectional study The Lancet Published: 11 May 2016 Half the number of specialist hours per 10 emergency admissions on Sunday compared with Wednesday No association between Sunday-Wednesday specialist intensity difference & weekday-weekend mortality difference Key Findings The Lancet paper represents a cross-sectional analysis of the difference in weekend/weekday admission mortality rates with the difference in weekend/weekday senior doctor staffing. It is the first report from the initial phase of HiSLAC, an independent five-year study, and, we believe, the first report of weekend-weekday specialist staffing differences in a healthcare system. We found that:  Patients admitted as emergencies to English hospitals on a Sunday collectively receive, on average, less than half the input from specialists of patients admitted on a Wednesday. In terms of numbers of specialists present and attending to these emergency patients, substantially fewer specialists (27·3%) were present providing care on Sunday compared to Wednesday.  Weekend admission mortality risk was higher than weekday (10% relative risk increase).  However, we did not detect an association between hospital specialist weekend staffing and weekend emergency admission mortality risk: The absence of an association in this preliminary study is not conclusive. A longer term study (such as the full, five year life span of HiSLAC) may yet confirm that the weekend effect can be linked to an insufficient presence of specialists. However, these findings suggest the need for caution in attributing the weekend effect primarily to lack of consultants at weekends.

Possible reasons for absence of relationship between weekend effect and specialist intensity Insufficient range of specialist intensities ‘Snapshot’ versus ‘cinefilm’ Consultants alone insufficient – or ineffective Other factors more important (nurses, junior docs, community services…) Flawed metrics Specialist Intensity: response rates; self-reported Is there a ‘weekend effect’ ? Flawed metrics – is there a weekend effect? Research suggests that the ‘weekend effect’ could be down to numbers admitted rather than quality of care. “Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission’ Meacock et al, The Journal of Health Services Research & Policy (May 2016) ?

What’s next? Opportunity to study change - over time - in weekend-weekday specialist intensity and admission mortality Detailed ‘diagnostic’ evaluation of 10 high and 10 low-intensity hospitals Data drill-down: local PAS/HES data; including nurse staffing, patient satisfaction, absenteeism Quality: Case Record Reviews (deaths) Experience: Ethnography, direct observation Definitive health economics model Literature review HiSLAC Phase 1 (Feb 2014 – 2015) included: establish collaboration with acute Trusts across England (127 of 141 acute trusts agreed to participate); developing measures of specialist intensity - Point Prevalence Survey Phase 2 - Feb 2015-2019 Flexible project design to accommodate political and policy changes

Challenges “A health system buckling under the strain…The government must review… the commitment to 7-day services…”

Likely outcomes from HiSLAC Cause(s) of the weekend effect The role of specialists and numbers required Better understanding of the package of resources/support required for 7-day services Cost-efficacy of consultant expansion Patient and staff opinions of 7-day services A national professionally-led collaboration with the capacity to evolve into a quality improvement and policy evaluation programme