NHS watchdog names trusts with outlier death rates

The NHS’s watchdog body has published online the names of hospital trusts in England that were investigated in the past two years because of apparently high death rates. A total of 53 trusts were subjected to 87 investigations over the period.

The data from the Care Quality Commission cover completed investigations it carried out between June 2007 and June 2009. The details include the name of the trust, the medical condition or procedure where deaths rates seemed to be high, what action the commission took, and the reasons why each alert was closed. Alerts could be closed because it was discovered that the data were faulty, because the trust was treating a high number of complex cases, or because the trust had taken appropriate action to address the issue. However, the published data do not give details of exactly what clinical action was taken.

Some of the 87 alerts were at the same hospital, notably Mid Staffordshire NHS Foundation Trust, which accounted for 11 of the investigated incidents. The incidents there led to a separate investigation by the Healthcare Commission (now part of the Care Quality Commission) earlier this year (BMJ 2009;338:b1141, doi:10.1136/bmj.b1141).

Most of the alerts concerning so called outlier trusts—those that seemed to have higher than normal death rates among patients undergoing particular interventions or with particular illnesses—came from the Dr Foster Intelligence Unit, which is based at Imperial College London.

Richard Hamblin, director of intelligence at the Care Quality Commission, said that the vast majority of the alerts were nothing to do with quality of care. He added that the published results highlighted potential difficulties but did not reveal any clinical lessons that doctors in other trusts could learn from.

He said, “It [the investigation] looks at the range of Hospital Episode Statistics (HES) data for individual diagnoses but it does nothing more than raise an alert. The numbers are in effect ‘tin openers.’”

The high death rates that warranted further investigation included that for septicaemia at Barking, Havering and Redbridge NHS Trust, fracture of the neck of femur at Basingstoke and North Hampshire NHS Foundation Trust, pulmonary heart disease and non-transient stroke at Mid Staffordshire NHS Foundation Trust, and acute myocardial infarction at Salisbury NHS Foundation Trust.

After the commission looked into the data it found that only 29 alerts merited further investigation. In seven cases the trust’s response included a plan of action for improvement in the quality of care that the commission found acceptable.

If there were any lessons for clinicians it was that accurate data recording was “very important,” said Mr Hamblin. “How can you know how well you are doing if you are not recording it accurately?” he asked, and he suggested that clinicians have more input into this from the outset, when the data codings were set up.

Mr Hamblin welcomed the shift towards a more positive attitude among managers and doctors when the data showed up an anomaly.

“We have gone from quite a defensive response [in the past] to people being quite open now,” he said.

Nigel Edwards, chief executive of the NHS Confederation, which represents most NHS organisations, said, “The CQC [Care Quality Commission] mortality outlier statistics are a potentially useful tool as they provide another set of data that can act as early warning flags if things are going wrong.

“They also seem to have a careful method for screening out chance events and misleading results to avoid premature conclusions.”

The commission plans to publish each quarter the names of trusts where it has completed an inquiry.