Intended for healthcare professionals

Letters Hospital mortality ratios

A plea for reason

BMJ 2010; 340 doi: (Published 25 May 2010) Cite this as: BMJ 2010;340:c2744
  1. Brian Jarman, emeritus professor1,
  2. Paul Aylin, clinical reader in epidemiology and public health1,
  3. Alex Bottle, lecturer in medical statistics1
  1. 1Dr Foster Unit at Imperial, Department of Primary Care and Public Health, School of Public Health, Imperial College, Jarvis House, London EC1A 9LA
  1. b.jarman{at}

    Many of the arguments in the article by Lilford and Pronovost and the editorial by Black add nothing new to the debate on monitoring the quality of care.1 2 3 We recommend section G and appendix 9 from the Francis inquiry report on Mid Staffordshire for an independent review of these issues.4

    The Healthcare Commission’s investigation into Mid Staffordshire5 preceded the Department of Health’s inquiry,4 as did reports by George Alberti and David Colin-Thomé. These were not public inquiries that “take on a life of [their] own”1 but serious investigations of what were found to be very poor standards of hospital care. Sometimes inspections by the Care Quality Commission, the Healthcare Commission’s successor, find problems and at other times they do not: finding problems is not a “self fulfilling prophecy.”1

    Without the Healthcare Commission’s investigation,5 prompted by mortality alerts, it is likely that the unacceptable situation in Mid Staffordshire would have continued unchecked and unrecognised by the commission’s self assessment system based mainly on process measures.6 Under this system, two thirds of the standards of compliance were subsequently discovered to be wrong for hospitals considered to be at risk by the Healthcare Commission.7 We believe that an intelligent approach to monitoring quality of care is called for, making use of both outcome (including mortality indicators) and process information to ensure such tragedies do not occur again.


    Cite this as: BMJ 2010;340:c2744


    • Competing interests: The authors are employed in the Dr Foster Unit at Imperial. The Dr Foster Unit at Imperial College London is funded by a grant from Dr Foster Intelligence (an independent health service research organisation).