At the conclusion of Sir Bruce Keogh’s letter to the health
minister are these paragraphs;
“Finally,
not one of these trusts has been given a clean bill of health by my review
teams. These reviews have been highly rigorous and uncovered previously undisclosed
problems in care. The rapid responsive review reports and the risk summit
summaries make uncomfortable reading.
However,
this is not a time for hasty reactions and recriminations. Any immediate safety
issues we uncovered have been dealt with. It is a time for considered debate, a
concerted improvement effort and a focus on clear accountability. So, I expect
the carefully considered and agreed action plans to be enacted with serious
consequences for failure to do so.”
I’ll be taking him up on that and here are a few issues for
debate;
It’s clear that there were arguments raging amongst the
people involved in the review, as these passages on mortality rates show:
“It is
important to understand that mortality in all NHS hospitals has been falling over
the last decade: overall mortality has fallen by about 30% and the improvement
is even greater when the increasing complexity of patients being treated is
taken into account. Interestingly, the rate of improvement in the 14 hospitals
under review has been similar to other NHS hospitals.”
Which shows that the 14 had had some improvements, but they
had started 10 years ago lagging behind and after the decade ended, they were
still lagging behind.
The usual excuses didn’t explain what was going wrong, though;
“Factors
that might have been expected – and are frequently claimed - to impact on high
mortality, such as access to funding and the poor health of the local
population, were not found to be statistically-correlated with the results of
these trusts. The average for the 14 trusts is broadly the same as the England
average in terms of funding and the socio-economic make-up of the populations
they serve.”
This following passage says it all really – some of the
failing hospitals were more concerned about explaining away the bad figures
rather than improving patient outcomes. That makes it a management failure
although nowhere in the report is there any mention of managers or boards.
“Clinical
coding accuracy, and depth of coding, can in some cases impact on mortality
indicator values for hospitals. Coding patients to make them appear sicker or
identifying a higher amount of co-morbidities can improve mortality ratios. No
statistical measure is ever perfect, but some organisations were not engaging
in the message the data was giving as they felt it was wrong. Investigation
into the signals that the data gives needs to be both about how data quality
can be improved by clinician engagement and also clinical care and service
delivery investigation to identify if improvements can be made. We found some
trusts focusing too much time on the former and not the latter.”
This passage in the covering letter is an attack on
government leaking a few days before publication – that 13000 had died
needlessly in these trusts (a Lynton Crosby briefing, allegedly), which echoed
leaks earlier in the year that 30,000 had died in the NHS as a whole, due to
neglect. As I said back then, this was a political attack on the public ownership
basis of the NHS and on its staff, who deserve better;
“the
complexity of using and interpreting aggregate measures of mortality, including
HSMR and SHMI. The fact that the use of these two different measures of
mortality to determine which trusts to review generated two completely
different lists of outlier trusts illustrates this point. However tempting it
may be, it is clinically meaningless and academically reckless to use such
statistical measures to quantify actual numbers of avoidable deaths. Robert
Francis himself said, ‘it is in my view misleading and a potential misuse of
the figures to extrapolate from them a conclusion that any particular number,
or range of numbers of deaths were caused or contributed to by inadequate
care’”
This next passage confirms what I have been arguing about for
so long – that the Accident and Emergency is the heart of any hospital. Shut it
down and you start the process of closing the hospital. If it isn’t working
right, the problem is going to spread further:
“Over 90%
of deaths in hospital happen when patients are admitted in an emergency, rather
than for a planned procedure. It is not altogether surprising, therefore, that
all of the 14 trusts we reviewed had higher than expected mortality in
non-elective (urgent and emergency) care and only one (Tameside General Hospital)
had high mortality for elective (planned) care. The performance of majority of
the trusts was much worse than expected for their emergency patients, with
admissions at the weekend and at night particularly problematic. General
medicine, critical care and geriatric medicine were treatment areas with higher
than expected mortality rates.”
Here he is saying that you have to look at the whole system
and especially at staffing and staff morale;
“Understanding
the causes of high mortality is not usually about finding a rogue surgeon or
problems in a single surgical speciality. It is more likely to be found in the
combination of problems that to a differing extent are experienced by all
hospitals in the NHS: busy A&E departments and wards, the treatment of the
elderly in and out of hospital, and the need to recruit and retain excellent
staff. Such issues are complex and require a ‘whole system’ approach to deal
with them. This is why it has been so important that this review has involved
all the key players.”
My conclusions tomorrow.
Neil Harris
(a don’t stop till you drop production)
helpmesortoutthenhs.blogspot.com
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