Mortality variations as a measure of general practitioner performance: implications of the Shipman case
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7233.489 (Published 19 February 2000) Cite this as: BMJ 2000;320:489
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Another GP, the daughter of the local funeral director and some
patient's relatives all expressed concerns. They saw the irregularities.
They were ignored because most were duped by this plausible man, and
because of that more people died.
A generous way of describing one of the the real problems seems to
relate to closed systems which do not allow for unusual events and so do
not hear unusual concerns.
Alternatively, one of the real problems could relate to arrogance,
mainly, I'm sorry to say, on the part of the men in positions of power in
this Greek tragedy, and their dismissive attitude to mainly women, with
concerns.
If statistics do not match possibly intuitive and insightful
perceptions of those expressing concerns, yet ultimately those concerns
are proven correct - isn't it about time we started to weave intuition and
complexity thinking into our procedures?
I can think of at least one more shocking scandal in which intuitive
complaints, increasingly being proven to be true, have been ignored for
many years, putting many at risk of the destructive actions of plausible
men who dupe the system - and the scandal is that this is still happening.
Competing interests: No competing interests
Dear Editor,
Shipman and monitoring GP mortality, post Dame Janet Smith.
Stepeh Frankel, Jonatan Sterne and George Davey Smith provide a sound
argument for not expending a great deal of time in monitoring the
mortality rates in general practice, after Shipman's conviction. But, of
course, their analysis was based on 15 deaths attributable to Shipman's
excesses over three years. Just for the sake of statistical completeness
it ought now to be formally noted that for several years the number of
murders was actually around 30 per year, in a practice of some 3500.
Even the most basic and mundane montitoring system would have spotted
that - without any serious doubts. Futher investigation would have quickly
identified special features with respect to time of day and place of
death. Let nobody be under any illusion that this was a straightforward,
and inexcusable, deficiency of the exsiting public health systems. They
could not even pick this carnage up. That is truly serious.
Klim McPherson FFPHM FMedSci
Competing interests: No competing interests
Frankel et al 1 make a valuable point in stressing the inherent
variability of the number of deaths in a single year in a general practice
and hence of the difficulty in identifying a case of excessive mortality.
I think it is unfortunate that the discussion of factors which might
affect this variability is dealt with rather briefly in the discussion
since their effects may be large. In particular the effect of the age
distribution can be very substantial. Using published national mortality
rates and the age structure of individual practices in the Bro Taf Health
Authority, the expected crude mortality rate per thousand was found to
vary from 2.7 to 16.0. The lowest rate occurred in a practice of about
5000; using the calculation method of Frankel, the number of deaths
needed to trigger an alarm would be 77; in fact the probability of at
least 25 deaths is less than 1 in 300. Similarly, the highest rate
occurred in a practice of 4000. Frankel's method suggests that 63 deaths
would trigger an alarm; for this age distribution the probability of at
least 63 deaths exceeds 0.5 and 87 would be needed for the trigger. If
factors such as deprivation are included too, the inter-practice variation
will be even greater. The danger of quoting an over-simplified analysis
is that the figures may acquire a status beyond what was intended by the
authors.
On a technical note, it seems strange to present figures based on
calculating a confidence interval for a national rate using data from a
single practice. Surely it is more sensible to apply the national rate
to a practice and to quote the probability of observing at least a
specified number of deaths? It leads to the same threshold, if we ignore
one side of the confidence interval, but quantifies how unlikely it would
be to observe such a result if national rates applied. A two-sided
interval seems perverse here; would we want really to investigate, in
this context, those whose mortality rates are in the lowest 0.5% of the
distribution?
Reference
1. Frankel S, Sterne J, Davey Smith G, Mortality variations as a
measure of general practitioner performance: implications of the Shipman
case, BMJ 2000; 320: 489
Dr F.D.J. Dunstan
Senior Lecturer in Medical Statistics
Department of Medical Computing and Statistics,
University of Wales College of Medicine,
Heath Park,
Cardiff
CF14 4XN
Competing interests: No competing interests
Frankel et alii(1) are right to warn us of the dangers of
inappropriate policy responses to the outcome of the Shipman trial. As
they have so excellently demonstrated, the production of mortality league
tables in general practice would be an wholly misconceived, expensive and
utterly
useless way of monitoring in this field.
The irony is that we already have a system in place which, with relatively
minor changes, would allow us to conduct individual audit on three
quarters of the deaths in this country and which could easily be extended
to cover
the remainder. The reasons why this system failed so many of Dr.
Shipman's patients are complex but the medical profession must not be made
the scapegoat for the failures of others. If the Home Office continues to
refuse to discuss the essential changes necessary to regulations under the
Cremation Acts proposed by the Association, it should not surprise us that
doctors conclude that no-one is interested in the outcome and reduce the
process to a bureaucratic chore to be completed as quickly as possible and
with the minimum inconvenience to all those involved. We must plead
guilty that we have not maintained the necessary suspicion that some of
our colleagues will be guilty of serious errors, and worse, from time to
time.
A Nelsonian blind eye to such possibilities has no place in modern
medical practice. The lack of clear guidance concerning the doctor's
responsibilities in completing the confirmatory certificate and its
ambiguous wording do not help matters. Crematorium referees told the
Association that they want more training and more uniform standards(2)
rather than more money whatever their detractors claim(3). One wonders
whether their needs will be considered by the General Medical Council in
its present rush to measure individual performance at regular intervals?
Will the existing powers of crematorium referees be made effective in
fact as well as in theory?.
The matter is now the subject of the inevitable public inquiry. This will
delay the much needed reforms as the various parties dispute their
respective responsibilities and the subject fades from public memory. A
previous attempt at reform(4) took seven years to consider the issues and
none of its key recommendations was ever implemented. We owe it, both to
Dr. Shipman's patients and to our own, to make sure that does not happen
again.
Stuart Horner
Professor in Medical Ethics
Centre for Professional Ethics, University of Central
Lancashire, Preston PR1 2HE
stuart.horner @tesco.net
1. Frankel,S; Sterne, J & Davey Smith, G; Mortality variations as
a measure of general practice performance: implications of the Shipman
case BMJ 2000; 320: 489
2. Horner,S Crisis in cremation BMJ 1998; 317: 485-6
3. Arber,R.N. Crisis in cremation: May have been created to increase
fees BMJ 1999; 318: 812
4. Home Office. Report of the committee on death certification and
coroners. London: HMSO, 1971 (Cmnd 4810)
Competing interests: No competing interests
Frankel et al say "Strengthened avenues for informal intelligence of
aberrant practice from patients, relatives, other
doctors, practice staff, pharmacists, coroners, undertakers,
and others are the key protection against lethal doctors."
Since there was a police enquiry opened against Shipman the
focus of our attention now should be why the police found no
"avenue" to "other doctors" willing to comment on Shipman's
notorious drug-taking. Furthermore, their statistical
"analysis" fails to consider that all his victims were
(incredibly) the same sex and age.
I have no competing interests.
Competing interests: No competing interests
Frankel et al state, "Even if such monitoring were restricted to
deaths that occurred outside hospital, random variation would mask
considerable illegitimate mortality."
What about deaths that occur inside the precinct of the practice, or
within 24 hrs of attending the practice? That would be a much more
sensitive measure. After all, aren't deaths that occur within 24 hours of
admission to a hospital referred to the coroner in many places?
Suspicion surrounding the high mortality associated with Harold
Shipman's practice was raised, however, the Health Authority's inquiry did
not follow up its request for a further five sets of case notes. Was this
because of the perception that doctors are immune from the failings of
humanity?
It doesn't matter what systems are put in place, until it is widely
accepted that the health system is responsible for a great deal of
mortality and morbidity through even preventable medical misadventure,
then nothing will change.
The health system must be required, by law as is the case with all
other places of employment, to do everything practicable to reduce the
risk to 'others' in the workplace.
The failings of the present system need to be acknowledged and new options
explored. The airline industry provides a useful model. Captains used to
reign supreme. Questioning the judgement of the captain severely
handicapped career
advancement. An accident where the co-pilot knew what was about to happen,
but did not question the captain, resulted in Captain Management Systems
(CMS) becoming Cockpit Management Systems. Then there was an accident
where a flight attendant knew that a wing was iced over but said nothing
because "who am I to question the judgement of the cockpit?" The ‘C’ then
became Crew. Then came an accident caused by factors outside of the
aircraft so the ‘C’ now stands for Corporate. All air accidents and even
incidents (near misses) must be reported and investigated to see how the
risks associated with flying (1 death per 8 million
passenger-flights) can be reduced further.
Requiring employers to take ‘all practicable steps’ to improve safety
by reducing risk has resulted in a measurable reduction in workplace
deaths of about 30% over the past decade in New Zealand. Why hasn’t this
happened in medicine? The airline pilots union does not investigate air
accidents, yet those few medical accidents that are reported are
investigated, in camera, by the medical union.
The ‘business’ model has been imposed on the health system in many
countries over the past 15 years with neither the injection of capital,
nor the leadership required to manage change effectively. In management
terms, this has resulted in a focus on economic efficiencies while
forgetting about organisational objectives (effectiveness) such as safety
of those under its care. Justice Noble's New Zealand Commission of Inquiry
concluded that a tourist viewing platform collapse was due to "the failure
of a system" to balance competing fiscal and social responsibilities, as
much as through the efforts of individuals.
A non-punitive systems-safety approach is proposed for our healthcare
system. The magnitude of the problem makes it imperative that a
legislative environment is developed to ensure a safe healthcare
environment. All accidents and near misses in our healthcare system
should, by law, be reported and investigated so that the system can learn
what went wrong and change policies and procedures to minimise
repeat occurrences of the same error. Just as pre-flight plans and pre-
flight checks are undertaken by the airline ‘team’ so should the
healthcare team undertake pre-surgical plans and checks. Amputating the
wrong limb, or giving the wrong drug are unacceptable and easily avoidable
errors and should no longer go unchallenged.
Urgent legislative changes are needed to require hospital and
practice management to do every thing practicable to provide a safer
environment for patients under their care.
Accident compensation law needs to acknowledge that medical misadventure
is real, that it is common, and that it costs society dearly. The third
thread to legislative change is the urgent need to ensure that whistle-
blowers are protected when they act in the interests of patient safety,
usually at the expense of their career and reputation.
It is time for an integrated team-approach within the healthcare
system, not only to protect the safety of their customer base, but also to
protect their professional
credibility, and tax payers’ dollars. It won’t be easy and will require a
radical departure from traditional demarcation – we’ve done it in nearly
every other sector
of society over the past 15 years, why not the State subsidised health
system?
Competing interests: No competing interests
Will we ever learn?
The Shipman murders has evoked a whole series of knee-jerk reactions.
There will be a net of suspicion cast over the single handed
practitioners. The public will challenge professionals when there is an
unexpected death. The government will promise the public of robust systems
in place that will prevent such incidents from occuring.
Shipman was a freak human being who unfortunately became a Doctor.
Had he been an electrician he would have a number of people by
electrocution.
He was found guilty of serious charges several years ago and still
allowed to practise. It was perhaps unfortunate that he did not belong to
a minority ethnic group. I am certain that he would not have been allowed
to practise had he been a non-white Doctor.
The system still has no real mechanism in place to safeguard the
patient. Can an employee such as a receptionist challenge a Doctor who
pays her wages. I am sure some of Shipman's receptionist must have had
suspicions, but still could not act.
It is a good cosmetic exercise to spend millions on clinical
governance and other activities, but the system is still flawed.
We must be more sincere in our approach in protecting patients-they
deserve the best. The system is still far from acheiving this.
Competing interests: No competing interests