The quality of care provided by hospitals needs to be assessed objectively not only to stimulate clinicians and managers to make improvements but also to ensure public accountability, to enable patients to make informed choices, and to facilitate informed commissioning. Given the importance of all these activities, the measures used to assess quality must have sufficient validity and reliability. This is not true of the main measure being used in many countries, including the United Kingdom, the hospital standardised mortality ratio (HSMR).1 Before considering practical and methodological shortcomings in England, many of which are considered by Lilford and Pronovost in the linked article (doi:10.1136/bmj.c2016),2 the concept of using hospital deaths to judge the performance of a hospital needs to be considered.

A consequence of a failure to provide alternative forms of care has been that hospitals have taken on the role of providing a place for people to die. About half of us will end our days in a hospital bed. This makes it perverse to use a hospital’s mortality statistics to judge its quality of care, given that deaths are often an expected and accepted outcome. The incongruity of using mortality to assess a hospital is exacerbated by geographical variation in the proportion of deaths that occur in hospital (40-65%), which reflect not only the availability of alternative forms of end of life care, such as hospices and …