Background to the Keogh Review

The review looked at 14 Acute (Hospital) Trusts, see Table 1, which had a significantly high SHMI[1] or HSMR[2] over both the last 2 years.  The use of these measures remains contested.  Given the nature of statistical investigation there will always be a group at the bottom of the distribution.  The Keogh review used clinicians to look beyond the statistics and exaggerated claims of excess deaths.

The review did not look at other trusts to establish any kind of baseline.  There are trusts not in the Keogh 14 that have high mortality rates, poor finances, weak governance and quality issues.  Table 3 at the end shows all the trusts identified on various measures over the last 4 years.

The review used mortality from the last 2 years; SHMI was not used prior to this period.  The 14 trusts with the highest HSMR’s for the two years prior to those studied (see Table 3) are a completely different group.  Looking at a five year period and a wider range of indicators shows trusts move in and out of categories.

It is striking that none of the 14 are London trusts.  The 14 are generally smaller than average size, with 2 (Tameside and George Eliot) being small.   Just over half of all acute trusts are now Foundations Trusts (FT) but in the Keogh group 9 of 14 are FTs which is significantly more than would be expected since they are assumed to be better performers.

Spells indicates the number of in inpatient procedures carried out and turnover is the income of the trust. The mortality figures are from Dr Foster Good Hospital Guide 2012.

Explanation

Research into the 14 trusts was carried out by Prof Sheena Astana and Alex Gibson at University of Plymouth and the results published in the Health Service Journal on 4 March.  The work looked at what significant differences could be found between the 14 trusts under investigation and those that were not.

The results showed that those in the Keogh group had 56.1 doctors (of all grades) and 19.7 consultants per 100 beds compared to 67.5 and 24.0 respectively for the rest.  They also had fewer cleaners! with 18.0 and 23.1 respectively.  In terms of nurses there was a clear difference 136.8 compared with 143.4 but this was not significant at the 99% confidence level used.

Further research by the same team also identified that there was a clear link between resources available the mortality rate – confirming statistically the common sense idea that hospitals with access to a higher level of resources (income) will be able to employ more staff.

This also confirms the established position that there is a clear correlation between staff satisfaction and quality of care.

Private Finance Initiative

6 of the 14 trusts have a PFI (some have two) but in only one case – Sherwood Forest – is there a likelihood that the PFI is having a detrimental effect.  Colchester (uniquely) cancelled a £185m PFI scheme just prior to contract close.  The Capital Value and Current Unitary Charge level are shown in Table 2 alongside the turnover.

There are trusts that have large PFIs but which have low SHMI and HSMR.  Examples are Leeds with a £265m scheme and SHMI/HSMR of 92/92; Newcastle £299m, 95/97; Portsmouth £256m, 98/99. Central Manchester (£512m), Derby (£313m), Oxford (3 schemes ~ £300m total), Coventry (£379m) and Peterborough (£336m) all have large PFIs but SHMI and HSMR within normal limits.

Variation & Anomalies

The various attempts to assess trusts using crude headline figures, such as mortality rates, throws up many anomalies.

• Two of the most financially challenged Trusts, both in London, South London and Barking, Havering & Redbridge have SHMI and HSMR below average.
• Barnet & Chase Farm has been trying to reconfigure for many years and has many challenges but has SHMI/HSMR of 87/91.
• Peterborough has an unaffordable PFI scheme and unsustainable financially and is under scrutiny by the PAC but has good mortality rates.
• Stafford Hospital (part of Mid Staffs) had very high mortality rates 6 years ago but has now got amongst the lowest.  It has taken on many additional staff and in doing so became financially unsustainable and is being broken up!
• Cambridge University Hospitals (Addenbrooks) is highly regarded and has SHMI/HSMR of 83/81 – amongst the lowest.  Yet it has regulatory issues with finance, governance and quality and is in breach of its terms of authorisation!
• Medway and George Eliot in the Keogh 14 both had poor HSMRs in 2008 but in 2009 both were congratulated on the steps they had taken to bring the figures down significantly and by 2012 they were back in the worst category!

Foundation Trusts

• 9 of the trusts are FTs.  Of these 5 have a RED current rating from the regulator Monitor, 3 have an AMBER/RED rating and one (Blackpool) has an AMBER/GREEN rating have recently come out of special measures.
• 5 FTs (Basildon, Burton, Medway, Sherwood Forest and Tameside) are regarded by Monitor as in breach of their terms of authorisation.  In total 19 FTs are in breach.  Burton, Sherwood Forest and Tameside have financial risk ratings indicating serious concerns.
• Blackpool was in breach until recently but is judged by Monitor to have recovered its position.

NHS Trusts

Of the 5 NHS Trusts East Lancs is currently being considered by Monitor for FT status.  North Cumbria and Medway are in discussions over mergers.  George Eliot is looking for a merger partner or other solution but accepts it cannot stand alone in its current form.  United Lincs has no resolved position in its FT journey status.