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The Keogh Report: reacting to reactions

Stephen Thornton
Stephen Thornton
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Yesterday's high octane ding-dong in the House of Commons over the Keogh report was an example of the unacceptable face of political interference in the delivery of healthcare. It was nothing, however, compared with what apparently went on behind the scenes in the days leading up to publication of the report.

This is an issue which, frankly, transcends politics. It’s about recognising that poor care does exist in some places and focusing our collective energies on improving standards. It’s a shame that yesterday’s focus was elsewhere.

Ministers, it was rumoured, wanted heads on plates. There was febrile talk of sacking all 14 of the affected hospitals' boards and of turnaround teams to be sent in aplenty. Bash them, fire them, investigate them, castigate them. Even send them to jail. This was the political language of the day. I hope this will be just the kind of behaviour that will be roundly condemned by the forthcoming Berwick review.

Indeed, this kind of deliberate ministerial overreaction and the equally aggressive response from the Opposition has a direct negative impact on patients and carers that politicians would do well to recognise.

In response to the Channel 4 News coverage of this unholy spat, my elderly mother rang me in a panic. With my father having only last week gone into residential care, she asked ‘What are we going to do to make sure your father gets the drinks he needs? Is he safe in there?’ There was real fear in her voice. As far as she was concerned, dreadful standards of care were now the order of the day across all of health and social care.

Could I explain HSMRs and SHMIs to her? Could I help her to see that it was scurrilous use of the data to say that 13,000 patients had died as a result of poor care? No, I couldn't. She, like very many people up and down the land, believes what she hears from the ‘responsible’ media. It was too late. This was now received wisdom.

But in his report, Bruce Keogh made a valiant attempt to put HSMRs and SHMIs back in their place. They’re two of many indicators which may trigger questions about quality and safety, but other information should also be used.

In the most telling paragraph of an eloquent covering letter in the report to the Secretary of State, Bruce bravely identifies the complexity of using and interpreting aggregate measures of mortality, including HSMRs and SHMIs: ‘The fact that the use of these two different measures of mortality to determine which trusts to review generated two completely different lists of outlier trusts illustrates this point.’ He goes on: ‘however tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths.’

It is in this context that here at the Foundation we welcome many of the ‘Ambitions and Actions’ identified in the report, in particular the efforts to develop a more robust assessment of avoidable deaths in hospitals. We think attention should be paid to ensuring that staff have the skills to improve quality and understand how to measure and monitor safety.

Meanwhile, my message to politicians of all sides is ‘Cool it, the summer is hot enough already!’

Stephen is Chief Executive of the Health Foundation and was a member of the national advisory group for the Keogh Review, www.twitter.com/thfstephen





 
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Comments
Thank you Stephen, an important message. Sensationalism based on misuse of statistics is more likely to inhibit improvement than stimulate it. Inevitably some hospitals (and some departments) will be better than others, but we all need to improve. Few will notice that the report also says, mortality has fallen 30% in a decade. I have not seen that in the media.
Bruce Keogh says Boards need to understand how to use data for improvement: maybe we also need a masterclass for politicians and the media. Is that something that the Health Foundation might sponsor to further Quality Improvement?
Poor care is often the result of the providers focussing on the system rather than the patient. We all need to have this at the forefront of our minds.
It is time for us to take a deep breath.

The interference of Politics in health has become a disaster.
There are now so many reviews and Commissions that I believe it is having an extremely negative impact on the morale of Health Care Workers. Already stressed, and with poor staffing levels, what is the option of the average Charge Nurse?

She can try to work more efficiently with the staff she has, but the attitude is now going to be frosty, as people prickle in response to these reports. Her job is being made more and more difficult as they now must prove to the public that the staff are caring and diligent. No matter how good a Nurse you are, you are damned along with the uncaring.
Or she can walk away.....as I did eventually. Unwilling to be associated with "them".

Perhaps this is the problem with these reviews. They find fault
generally.They highlight where the service is failing, without balancing it with the tremendous amount of good work and effort that goes in. While it is essential to analyse problems, it is also essential to know who the real assets are: who will walk the extra mile, who will take pride in their work and their level of care.
Can a report not be written about that? Can the excellent Nurse not be encouraged to show people how to do it?
More than anything, the Health Service needs role models. With each piece of reporting, each new target, I see these potential leaders being snuffed out.Their hands are tied. They cannot innovate and create within the rigid framework imposed on them.
With each snuffing out, the possibility of avoidable deaths increase. Professor Enrico Coiera describes System Inertia very well - and Clinical Inertia. He speaks a truth that few want to hear, and nobody has the courage to tackle.
The way forward will only become clear when we fully understand and acknowledge that the failings are that of the system being imposed on the people.
The NHS needs Shining Lights - guidance and strong leadership.
Bring them on!

One couldn't agree more with Stephen Thornton's observations.

This said, one has to understand the background of all this, which led to the politicians reacting this way. It is not naivete to say that politicians are simply being responsive to the needs of their customers (the public). The External CUSTOMER (service user) must be meaningfully considered as always right, if the care (service) design and delivery will be responsive to the customer.

This to me was the re-enforced message I came back with from my involvement over the last three months with the Keogh RRR.

This said, I hasten to caution against box-ticking co-design exercises by management.

For, while in one health economy, we noticed a management system scratching its head as to how to deal with an understandably (possibly selectively) vocal customer base, in another, however, we noticed a totally cosy (read, complacent) insular customer-manager relationship, to the extent that I couldn't help reminding the Trust and customers that we were there because a nationwide benchmarking had called us into their "island" !

Asa'ah Nkohkwo
PPE Advocate, Keogh RRR Mortality Outliers
April-July, 2013
I agree with most of this. However, to my knowledge NO one has said 13,000 did not die unnecessarily only that HSMR/SHMI does NOT mean that 13,000 patients DID die unnecessarily.

Can anyone correct me on this?

The Keogh report does not put any numbers on avoidable deaths. It is silent on this subject and perhaps too silent.

In the absence of actual numbers are we to assume the worst or the best given the reports findings on these organisations?

Are we to say to the press and public "We don't really know how many died unnecessarily and yes the trusts were really failing and yes some of the stats point to 13,000 deaths but lets not jump to conclusions".

The answer isn't to simply trash the statistics but to conduct forensic reviews on every patient mortality within specified categories. Surely that is the only way to not only ascertain the real number of avoidable deaths but also ensure that every trust learns from every avoidable death.
You are right, Keogh does not mention that number. As I understand it, the source of the 13,000 avoidable deaths that we have read about in the media is Professor Brian Jarman.

One of the reasons why Keogh has commissioned Nick Black and Ara Darzi to do a case-note review is to study the realtionship between mortality rate measures and avoidable deaths.
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