Bruce Keogh

Weekend hospitalization and additional risk of death: An analysis of inpatient data

Objective To assess whether weekend admissions to hospital and/or already being an inpatient on weekend days were associated with any additional mortality risk. Design Retrospective observational survivorship study. We analysed all admissions to the English National Health Service (NHS) during the financial year 2009/10, following up all patients for 30 days after admission and accounting for risk of death associated with diagnosis, co-morbidities, admission history, age, sex, ethnicity, deprivation, seasonality, day of admission and hospital trust, including day of death as a time dependent covariate. The principal analysis was based on time to in-hospital death. Participants National Health Service Hospitals in England. Main Outcome Measures 30 day mortality (in or out of hospital). Results There were 14,217,640 admissions included in the principal analysis, with 187,337 in-hospital deaths reported within 30 days of admission. Admission on weekend days was associated with a considerable increase in risk of subsequent death compared with admission on weekdays, hazard ratio for Sunday versus Wednesday 1.16 (95% CI 1.14 to 1.18; P < .0001), and for Saturday versus Wednesday 1.11 (95% CI 1.09 to 1.13; P < .0001). Hospital stays on weekend days were associated with a lower risk of death than midweek days, hazard ratio for being in hospital on Sunday versus Wednesday 0.92 (95% CI 0.91 to 0.94; P < .0001), and for Saturday versus Wednesday 0.95 (95% CI 0.93 to 0.96; P < .0001). Similar findings were observed on a smaller US data set. Conclusions Admission at the weekend is associated with increased risk of subsequent death within 30 days of admission. The likelihood of death actually occurring is less on a weekend day than on a mid-week day.

Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

Nick Freemantle and colleagues discuss the findings of their updated analysis of weekend admissions and the implications for service design

How might 3D printing affect clinical practice

Customised body parts have the potential to transform care

Time to think Ebola: a message from NHS England to frontline clinical staff

Professor Sir Bruce Keogh, the national medical director, and Dr Bob Winter, the national clinical director for emergency preparedness, have released an important announcement on Ebola to frontline staff.1 2 In line with the key messages from the guidance on Ebola from Public Health England and the guidelines from the College of Emergency Medicine,3 4 it highlights the utmost importance …

Chief clinical information officers: clinical leadership for a digital age

These new roles need autonomy, authority, and a fully accredited career path

The future of health system leadership.

As the UK’s National Health Service (NHS) enters its 67th year and a new parliamentary term, eyes are drawn tow ards its future. The health service has made important strides in the past 15 years—public satisfaction in the NHS has almost doubled, cancer survival is at its highest ever, and the service was ranked the highest performing health system by the Commonwealth Fund. Simultaneously, the NHS faces the rising pressures of a growing, ageing population with more long-term conditions and increasingly expensive treatments and technologies. Achieving further improvements and sustaining high-quality care will require a cohesive eff ort by NHS staff , unprecedented leadership, and clear coordination of the 1·3 million NHS workforce. These challenges are not unique to the NHS. After the recent global economic crisis, health systems faced substantial fi nancial pressures, as well as increasing demand for health services. There are now common goals between nations of achieving the triple aim of improvements in population health, patient outcomes, and cost control, combined with triple integration of mental and physical, primary and specialist, and health and social care services. These challenges and ambitions forge unity of purpose, but if change is to be achieved a new cadre of leaders is needed. Traditionally, NHS leaders have developed along a sequential path. Front-line experience has been followed by adoption of larger scale roles. Skills are accumulated and leaders migrate from the periphery to the centre— appreciation of clinical variation, fi nancial matters, and hospital productivity is deepened, and capabilities improved. Such leaders have been clinicians, allied health professionals, or managers who progressively translate their experience from ward to board. However, better integrated and more cost-eff ective health systems require a new type of leadership. Current NHS architecture depends on alignment and consensus rather than use of crude levers. As we move forwards, leaders are needed with experience not only from ward to board, but also from across system boundaries into social care, local government, the voluntary sector, and industry. Local knowledge needs to be balanced with the ability to empower and enable from national standpoints. The NHS requires leaders with the capacity to engage and collaborate with a broader range of stakeholders across systems of care. Leaders able to maintain peripheral and central roles in parallel, delivering at both the front-line and national level, building skills in both contexts concurrently. Leaders grounded in common values with a broad outlook that is patient centred, population focused, and cost aware. Leaders with experience of innovation, improvement, and implementation at pace, empowered rather than hindered by the system. If these leaders are to be developed, new opportunities are required. In academia, tracks such as the Walport Academic–Clinical Pathway have been established that facilitate a bench-to-bedside approach with parallel clinical and research training. In the context of leadership, greater opportunities to gain experience across the system are needed in national, managerial, local health organisation, social care, or industry roles. Such opportunities could be enabled through more fl exible training possibilities. In a way similar to academic–clinical pathways, front-line and system training would need to take place in parallel rather than in sequence, through protected time for such roles, ranging from, for example, 1 to 3 days per week. Individuals See Online for a podcast interview with Mahiben Maruthappu

Can diaspora-led organisations play a prominent part in global surgery?

The high number of trained staff in countries with a disproportionately small burden of disease has exacerbated inequalities in global health and surgery. It is estimated that in low-income countries there is a shortage of about 2·5 million members of staff , including surgeons and midwives, to provide essential health interventions. Better fi nancial and education opportunities have been cited as common incentives for workers to emigrate, with risk of conflict and disease threatening their safety and security in their own countries. By training providers who later migrate overseas, lowincome countries are losing more than

Diabetes prevention in England – Authors' reply

500 million each year as they effectively subsidise their wealthier counterparts. D i a s p o r a l e d o r g a n i s a t i o n s (DLOs) can have an important role in addressing unmet surgical need in low-income and middle-income countries. These organisations have the unique advantage of being able to relate to the cultural sensitivities of local populations, which is particularly pert inent with mult ifaceted conditions such as obstetric fi stula. In many ways, obstetric fi stula represents a microcosm of the international community’s failure to emphasise the need for cost-effective surgical interventions, and the inability to encourage community-level initiatives that empower women. Although maternal mortality has almost halved over the past two decades, there exists a need to address underlying social causes such as early marriage, which substantially contribute to maternal morbidity. By facilitating clinical and reproductive sexual health programmes for women in rural Bangladesh, DLOs such as Selfl ess are well placed to achieve this. DLOs are better able to expand community links and develop longterm partnerships, contributing to a more meaningful collaboration between high-income and low-income countries. In an era of globalisation, policy makers must capitalise on this underused resource by supporting diaspora communities to improve care in their countries of origin. In so doing, this support will not only alleviate the burden of the so-called brain drain but also address widening inequalities in surgical care. If low-income countries do not address such issues by seeking solutions from within its own communities both at home and overseas, they will struggle to achieve sustainability in the post-2015 agenda.

Radically upgrading diabetes prevention in England

www.thelancet.com/diabetes-endocrinology Vol 3 July 2015 503 Authors’ reply We thank John Yudkin and Christopher Millett for their correspondence. We agree that radically upgrading prevention will require a wholesociety approach, with alteration of environmental and contextual factors, supporting people in achieving improved dietary intake and increased physical activity. Supporting this societal approach, local authorities now have a statutory responsibility for improving health, and councils and elected mayors are able to make an important impact. For example, the London Borough of Barking and Dagenham are seeking to limit new junk food outlets near schools. Ipswich Council, working with Suff olk Constabulary, is taking action on alcohol, and other councils are following suit. The mayors of Liverpool and London have established wide-ranging health commissions to mobilise action for their residents. Local authorities in greater Manchester are increasingly acting together to drive health and wellbeing. Aligned with these initiatives, the Five Year Forward View proposes leading where possible, or advocating when appropriate, a range of new approaches to improving health and wellbeing. With specifi c regard to the National Diabetes Prevention Programme (NDPP), at least fi ve major randomised controlled trials, done in China, Finland, the USA, Japan, and India have documented 30–60% reductions in type 2 diabetes incidence in adults with impaired fasting glucose or impaired glucose tolerance through implementation of intensive lifestyle change programmes. It will indeed be a challenge to match the results of the trials in real community settings but that is the whole point of attempting population-based interventions. To ensure the NDPP is underpinned by robust evidence, Public Health England commissioned an evidence review on which the specifi cation for the programme is being built. Subsequently, the feasibility, cost-eff ectiveness, and eff ect of the NDPP will need to be robustly evaluated and determined.