"Nineteen hospital trusts are today exposed as having alarmingly high death rates in a major report that also reveals how hundreds of people are dying needlessly because of substandard NHS care", reported The Observer.
The newspaper story is based on an annual hospital guide, published today by Dr Foster Intelligence, an independently run health information firm that is part owned by the Department of Health.
The guide is an annual publication that seeks to measure hospital performance in England with a growing series of comparative indicators. These indicators are constructed in partnership with the Imperial College London. They are based on NHS hospital data and are free of political bias.
The Health Secretary, Dr Andrew Lansley, welcomed the report, writing a commentary in The Observer detailing the steps that are being taken to increase transparency and improve hospital safety and performance:
“We need a cultural shift in the NHS; from a culture responsive mainly to orders from the top down to one responsive to patients, in which patient safety is put first.”
The guide is broken down into three main parts:
There are also new analyses of efficiency, measured by hospital readmission rates and patient experience, measured by patient survey.
The guide contains both positive and negative findings. Under the heading ‘Good news’ it reports that:
Four hospital trusts – Airedale, Royal Free Hampstead, Ipswich Hospital and East Kent Hospitals – are given accolades for exceptional performance.
Under ‘Areas of concern’, the guide reports that:
Variations in mortality ratios persist, with 19 hospital trusts having high HSMRs.
The hospital guide also makes a call for more data to be made available, noting that there is information ‘we cannot tell you but would like to know’. It highlights a need for better recording of patients developing life-threatening blood clots following treatment, more information about community and primary care services, and better measurement of outcomes in private hospitals providing NHS care, among other things.
It says that Hospital Standard Mortality Rates (HSMRs) are decreasing (i.e. improving) across the NHS in England. Only 19 of the 147 hospital trusts now have ‘significantly high’ HMSRs, compared to 27 in last year’s guide, and 26 trusts have HSMRs that are ‘significantly low’, down from 32 a year ago.
‘The overall improvement suggests greater consistency across trusts, both in terms of data recording and perhaps in the quality of care,’ it says.
The use of HSMRs to measure hospital performance has proved controversial in recent years, with experts pointing out that the measure is ‘imperfect’ and warning that it should not be used to construct simplistic league tables of best and worst hospitals.
Nevertheless, they should not be ignored. Earlier this year, the Department of Health stated: ‘A high HSMR is a trigger to ask hard questions. Good hospitals monitor their HSMRs actively and seek to understand where performance may be falling short, and action should not stop until the clinical leaders and the board at the hospital are satisfied that the issues have been effectively dealt with.’
In a bid to construct a better picture of hospital mortality, the hospital guide published a second mortality indicator measuring deaths after surgery for the first time this year. This looked at surgical patients who had a secondary diagnosis such as internal bleeding, pneumonia or a blood clot, and subsequently died.
The guide reports that there is wide variation between hospitals on this new measure. It says four hospital trusts - Hull and East Yorkshire Hospitals NHS Trust; The Newcastle upon Tyne Hospitals NHS Foundation Trust; University Hospitals Birmingham NHS Foundation Trust; and University Hospital of North Staffordshire NHS Trust - have ‘significantly high’ ratios. Two trusts – Chelsea and Westminster Hospital NHS Foundation Trust and Winchester and Eastleigh Healthcare NHS Trust – have ‘significantly low’ death after surgery results.
‘This measure uses a very different approach from the HSMR, so trusts that have high ratios on both measures – University Hospitals Birmingham NHS Foundation Trust and Hull and East Yorkshire Hospitals Trust - will want to understand the possible causes,’ says Dr Foster.
The Observer reported that sources from the Care Quality Commission have said that they have no concerns about University Hospitals Birmingham on either account or North Staffs on deaths after surgery.
The chief executive of Hull and East Yorkshire, Phil Morley, said, "We are confident that we are providing safe care of a high quality to our patients".
The hospital guide also notes that the focus on mortality ratios in recent years has caused some trusts to revisit how they ‘code’ or report patient deaths. This has resulted in some trusts increasing the number of deaths they identify as occurring in ‘palliative care’. This in turn improves the trusts’ mortality ratio because death is the expected outcome.
In the interests of transparency, Dr Foster now publishes the percentage of deaths coded as palliative care for each hospital trust. These range from less than 1% in some trusts to over 40% in others. Basingstoke and North Hampshire NHS Foundation Trust reports 45.5% of deaths as palliative care and Medway NHS Foundation Trust reports 44.5% of deaths in this way.
Two other trusts – Pennine Acute Hospitals Trust and Royal Bolton Hospital NHS Foundation Trust – are noted in the guide as having been in the ‘higher than expected’ HSMR category for the past six years.
Overall, safety standards have improved. Dr Foster says a key way of improving safety is to accurately measure and monitor the way in which it is being addressed. Hospitals were rated on a range of aspects of patient safety in 2009. A comparison with this year’s results shows:
Dr Foster says there is room for improvement in how data is recorded. It lists the available figures for several types of avoidable harm, such as pulmonary embolisms and post-operative sepsis, which it cannot put into context due to the lack of complete data.
It identifies the same problem regarding data on the rate of medical mistakes (or adverse events) that happen in hospitals. The guide says again, that trusts with higher rates of incidents also tend to have more complete records about their patients.
The prevention of blood clots also features highly. The report says that all patients admitted to hospital now must be risk assessed for the risk of venous thromboembolism (VTE, of which DVT [deep vein thrombosis] is a common type).
However, trusts gave varying responses when asked ‘What percentage of patients are risk-assessed for VTE on admission?’ Most trusts were able to report how many patients were risk-assessed, but 15 responded that they were either not assessing patients for VTE or were unable to provide the information.
A spokesperson for the Department of Health (DH) said, “We accept that VTE is underreported, and are taking steps to change that position.
“At a national level, the DH is enabling the NHS to improve accuracy of reporting incidence of hospital acquired VTE.”
Stroke is the third most common cause of death in the UK, costing the economy an estimated £8 billion a year. Dr Foster says there have been measurable improvements in the way the NHS deals with strokes but still notes ‘a worrying level of variation in care’.
The report identifies six best performing and eight worst performing trusts based on an analysis of six key indicators:
Hip and knee replacements, as well as hip fractures, are a major expense for the NHS. The guide analyses some key indicators of the quality of care in these cases:
Dr Foster identified six trusts as the best performers across its orthopaedic indicators and singled out Leeds Teaching Hospitals NHS Trust as the worst performer.
Surgery for urological cancers should ideally be performed in large hospitals where these procedures are carried out more frequently. NICE guidelines state that pelvic urological cancer surgery should only take place in units where more than 50 procedures are carried out each year.
The guide identifies 19 trusts that carried out high numbers of prostate and bladder cancer operation between 2007 and 2010. It also identifies eight trusts performing high numbers of keyhole prostate operations, which enable quicker surgery and recovery.
Overall, the guide notes that more operations are being performed for prostate cancer, more of these operations are taking place in large hospitals and more keyhole procedures are being carried out.
There is a similar trend towards performing cystectomy (removal of the bladder) in large units. In 2006/07 large trusts performed only 21% of cystectomies but by 2009/10 this had risen to 63%.
The guide notes that operations to treat benign urological conditions are performed in a wider range of units than for cancer with varying quality. Dr Foster looked at the need for repeat surgery following one such procedure, transurethral resection of the prostate (TURP), as an indicator of care quality. The report lists 13 trusts that perform best on this indicator and three that perform worst.
No, the guide shows that overall things are improving. Although there are some trusts that are poor performing relative to the average, the vast majority are in the ‘as expected’ range and there are many batting well above average.
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The hospital guide is published in full on the Dr Foster website.