Anyone who has been at the sharp end long enough has had the experience of explaining what went wrong to grieving relatives. You can apologise, and explain as honestly as possible what has happened, and sympathise. It is true but of no comfort that the NHS is vast and highly complex and that most care is good most of the time.
Recent research conducted for the DH across ten hospitals (selected at random) found that around 6% of deaths in hospital were avoidable; either something was done which led to the death, or something was not done which could have prevented it. Other studies suggest a slightly higher level maybe around 8%.
It is against this background that you can reflect on headlines (yet again) that hospitals are killing hundreds of people a year, based entirely on the “evidence” that their published mortality rates are significantly above average. They should all be below average.
People who attend our hospitals are seriously ill and we have to accept deaths will occur. The concern is about variation. We now have several published schemes which try and create some league table for hospitals – HSMR and SHMI being leading examples. These try to make inter hospital comparisons possible by adjusting for the case mix but the methodology and the value of the results remains controversial. But they must indicate something.
We know and have always known that some hospitals have consistently low mortality ratios whist others have been consistently higher, and some move about – but the major fluctuations between hospitals and in one hospital over time are not explained.
Helpfully, we do know a little about what makes some organisations better than others in a more general sense. The three leading predictors of a successful organisation would be long term stability of senior management team (Ferguson/Wenger), high level of staff engagement/ staff satisfaction and high proportion of women in senior management posts!
If we just concentrated on having enough well qualified staff who were engaged and satisfied with their roles – that might be a good start. And the best form of governance could be through a culture of openness and transparency with patients having access to their records and good quality information.
It is far from clear why some hospitals appear to do better than others. One factor must be the obvious one – some hospitals are simply better at attracting and keeping better quality staff! But how much variation is also accounted for by poor data recording and by the issues around adjusting for case mix variations? We simply don’t know – although journalists and commentators assume we do.
The only reliable evidence is from proper case notes studies by expert clinicians with access to people as well as paper. In a Trust I used to be responsible for we began setting up arrangements whereby every death was investigated by a (retired) Consultant who read everything in the files and if necessary talked to the clinicians involved on a peer to peer basis; and as an Associate Director sat on the Board. This was combined with a drive to greatly improve coding, and clinical record keeping and especially the direct involvement of clinicians in getting coding right. It cost, but not a lot, but was never fully implemented. But that is the way to go.
Instead of the obsession with league tables and the false reporting about meaningless things like excess deaths we should focus on better engagement with front line staff and on driving up the quality of clinical information recording and analysis and how open and transparent use of this information can improve quality.