Hospital Mortality: fact, fiction or politics?

Stafford has become both justification and template for a full-scale assault on NHS hospitals - exploited by politicians and businesses who profit from cuts and privatisation.

Steve Walker
24 July 2013

How do you take something that is hugely popular and enjoying it’s highest-ever approval ratings, and turn it into a feared institution that people are happy to see broken up, reduced and sold off?

It appears, through a concerted ‘hearts and minds' programme, using friendly or suborned media to drip-feed, and then flood, negative stories about the NHS into the public consciousness. Even BBC journalist Nicky Campbell - whose employer is seen as many as culpable - marvelled at the “seemingly incessant criticism of the NHS” in the media.

Sir Bruce Keogh was commissioned to investigate 14 NHS Trusts after the mid-Staffs crisis. Several days before his report’s publication last week, and briefed by persons unknown, headlines blazed that Keogh had found 13,000 'needless deaths' in 14 NHS Trusts. Along with increasingly strident Telegraph articles, the Daily Mail's 13 July headline was typical:

“Doomed to die by the NHS: Devastating report to reveal thousands dying needlessly as 21 hospitals probed in scandal that eclipses Mid Staffs horror”

Within days, health insurance brokers were running adverts entitled “Your 3 step guide to avoiding the NHS crisis” suggesting health insurance could buy “peace of mind” in the light of the “13,000 deaths”. Clearly heeding the advice of Tory chief election strategist Lynton Crosby, whose lobbying company was last week revealed to have advised the private healthcare industry on how to exploit perceived NHS ‘failings’.

 Calls were made for the resignation of Shadow Health Secretary Andy Burnham for his supposed culpability in the 'carnage'.

Except it never happened.

The report did not reveal any such thing, nor did its author intend it to. As I revealed on my blog Sir Bruce Keogh stated in an email prior to the release of the report that the ‘avoidable death’ claims were

Not my calculations, not my views. Don’t believe everything you read, particularly in some newspapers.

In the report itself, Keogh was even more emphatic:

“However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths. Robert Francis himself said, ‘it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care.’”

His quotation from the Francis report into events at Stafford hospital is particularly significant. The misrepresentation of events at Stafford hospital was a watershed in the strategy of attacking the NHS by abusing statistics. Francis could not have been clearer that there is no evidence for the figures of “400-1200 needless deaths” at Stafford figures. The hospital was not demonstrated to have had high mortality rates once the coding of deaths at the hospital was corrected. But the claims are repeated without challenge whenever hospital safety is covered or debated in the media.

The media also ignores the obvious fact that, in any 'mean' average, about half of those measured must always be worse than average.

HSMRs (Hospital Standardised Mortality Ratios) are deeply flawed, and have in fact been set aside by the NHS in favour of an improved (but still flawed) measure, the SHMI (Summary Hospital-Level Mortality Indicator).

Key weaknesses in the HSMR system included:

 - That it only measures certain sets of deaths, not all deaths.

  • - That it ignores deaths that happen just after discharge from hospital so that, perversely, a hospital could improve its HSMR scores by sending seriously-ill patients home early to die, or will have better HSMRs if it has a lot of hospices nearby to take patients for their last days or weeks.
  • - That it is dependent on the ‘Payment by Results’ data reported by hospitals for financial purposes. This data is often seriously incomplete. Dr Foster, the company behind HSMRs, offers no training or auditing to ensure that the ‘coding’, the recording of the full range of conditions from which a deceased person suffered, is done correctly. This means that a hospital can suffer from having poor coders (a frequently-cut area for cost-savings), or simply because it reports its deaths more honestly than average.

 Yet the government selected this flawed measurement as its preferred criterion for special inspections in spite of the fact that only 5 of the selected 14 hospitals had high mortality according to SHMI.

The 'incessant criticism' and constant misuse of mortality figures are clearly designed to eat away at public affection for, and confidence in, the NHS.

The real issues remain unaddressed. The health secretary's earlier 'response' to the Francis Report completely ignored Robert Francis' overwhelming conclusion (mentioned 250 times by Francis) that the key cause of the poor care that did exist at Stafford hospital was understaffing - particularly of nurse numbers.

All bar one of the 14 Trusts Keogh investigated had a lower ratio of nurses than the national average. His report states that he found “frequent examples of inadequate numbers of nursing staff”.

Interviewed by the BBC he added:

“the nurses who were on the review panels...very senior nurses who understand these issues deeply, were concerned, and indeed, one of the hospital's beds was closed because it was deemed that it wasn't safe to run that number of beds with that number of nurses.”

One would struggle to discern the issue of nurse shortages in the media coverage or Jeremy Hunt's Commons statement. When challenged by Labour about staffing ratios, Hunt avoided any commitment to actually address the problem. No wonder, since the government has cut thousands of nursing posts and left almost 20,000 unfilled.

It would be an astonishing U-turn if Hunt now made clear announcements to correct the most crucial cause of care quality problems. Instead, he tells us that he is “unable to guarantee safety” in the hospitals for which he is at least notionally responsible.

And anounces that the 11 hospitals that failed to meet standards will have a “strictly limited period of time to rectify” their failings -after which they will be candidates for closure or break-up and sell-off. 

Stafford, the poster child for Hunt’s approach, is now facing exactly this closure or sell-off despite the overwhelming support for the hospital from the town’s population.

Behind the headlines about needless deaths lies a clear pattern and progression in the way events are used and misreported, one that misuses the suffering and loss of patients who die and families who are bereaved.

It's absolutely essential that the parts of the media that are not allied to the government have the courage to start to question the prevailing claims of mortality at Stafford hospital and elsewhere in the NHS, the failure to address the real causes of poor care, and the misuse of data to influence public opinion on the NHS.

Asked by the BBC what he thought were the thoughts and motives of 'national politicians on the front bench', Keogh's response was characteristically diplomatic, but no less telling for that:

“National politics has its own aims.”

For those ideologically committed to ending state-provided healthcare, record NHS approval ratings were a major obstacle. Former Tory minister Michael Portillo famously said that the Conservatives would be unelectable if they told the truth about their plans for the NHS. It was clear that achieving their long-held aims needed both a stealthy approach and a major shift in the public's perception of the NHS.

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