Discussing avoidable deaths

Abstract

408 British Journal of Healthcare Management 2013 Vol 19 No 8 © 2 01 3 M A H ea lth ca re L td the headlines with Mid-Staffs and the Healthcare Commission’s purely statistical calculation that the hospital may have had between 400 and 1200 excess deaths. The fact that 1200 was the extreme upper end of a fan of uncertainty, and quite simply not credible if you think about it, was entirely lost on most of Her Majesty’s Media. These apparently ‘excess’ deaths rapidly became ‘avoidable ones’—there is hardly a media outlet that has not published the ‘fact’ that ‘up to 1200 patients may have died unnecessarily’ at Mid-Staffs. A ‘fact’ that has gone all around the world and been established, long before the much muddier and more complex truth (or in this case, balance of probabilities) has got its boots on. The 14 Keogh trusts were chosen because they had high HSMRs or a high Summary Hospital Level Mortality Indicator, a slightly more modern and slightly more sophisticated measure than the HSMR—although as an illustration of the difficulty of using these numbers it is notable, as Sir Bruce pointed out, that the two measures provided different lists of potential trusts to be investigated. High mortality indicators are clearly a ‘smoke alarm’ as the Keogh review puts it. But they are subject to coding difficulties and potential explanation, and the mere fact that a hospital has a lower than average HSMR does not guarantee that all is well. As Sir Bruce put it in his report, ‘however tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths.’ The silver lining is that post-Sir Bruce’s review, Nick Black of the London School of Hygiene and Tropical Medicine and Lord Darzi, the former health minister, have been commissioned to conduct a review on the relationship between excess mortality rates and actual avoidable deaths. Their study will use ‘systematic and externally audited’ case note reviews in a mix trusts with lower, higher and expected to death rates in an attempt to come up with a saner measure of ‘avoidable deaths’. It will take time. Even if it succeeds, it will take much longer to wean the media from the belief that any excess death is by definition an avoidable one. But it does offer a chance that—while there can be no acceptance of appalling standards of care—we finally may get to a more rational discussion about how far uncaring care is actually producing avoidable deaths. BJHCM Nick Timmins, senior fellow at the Institute for Government and the King’s Fund, on how the NHS’s failings have been more prominent than its successes this summer Discussing avoidable deaths