Keogh and Mortality

Mortality Quality of care

The general response to the Keogh review was positive; it showed how inspection and analysis could be used.   As many have already pointed out, it used a methodology similar to that used by the Commission for Health Improvement a decade ago (and found to be too expensive!).  The absurd pre publication hype about 13,000 avoidable deaths from the usual media sources was as predictable as it was disappointing.  It is about time some of those who passively condone this type of ridiculous reporting actually spoke out.

Bruce Keogh (Photo credit: Cabinet Office)
Bruce Keogh (Photo credit: Cabinet Office)

The review of 14 acute trusts with a recent history of high comparative mortality rankings (using either HSMR or SHMI) showed that in all of them there were serious issues; issues which had NOT been picked up by either regulators or performance managers.  It was accepted that many of the issues had been identified within the trusts but the rate at which remedial action was being taken was too slow.

Since there are no suitable benchmarks it is possible that such a thorough review would find issues at most trusts; and indeed may find trusts with, for example, weak governance but good mortality rankings.

The issues found in the 14 were a mixed bag – poor managerial and clinical leadership, weak governance processes and some technical failures (eg failure to maintain equipment) but the most obvious linking factor was lack of suitable staff at the right time in the right place.  The data appeared to show sufficient staff but the reality was they were not always in place: the most useful conclusion and the one most likely to be ignored.

But – the review did not say anything about excess or avoidable or unnecessary deaths.  The stories spun by the Tories and reported without critical analysis by some parts of the media were shown to be nonsense.

To further emphasise the point many of us have been making for years the report recommends that a proper study is done to see if there is any link between league table style mortality ratings and unnecessary deaths.  A proper evidence based study.

Then we need an evidence based study which shows why some trust have high ratings – we still do not know.  As a simple example one trusts of the 14 has had a higher than average crude mortality rate (deaths divided by activity – not affected by coding) for as long as records are available.  During this time it has had a complete change in management, completely different governance structures, completely different regulation and performance management – and it is still higher than average – so WHY?

The review also served as a test of methodology and it largely passed.  If sufficient resources can be mobilised then similar reviews could and should be made at every provider – not just acute trusts and not just NHS; with the results properly published.

So we get a more thorough approach using managerial and clinical expertise from within the NHS and also properly involving the public and patients.  It will not come cheap and you wonder how long such a regime will survive before someone says would it not be cheaper just to get a better quality of management and enough staff?