Technologies and Social Practice
Joanne Grandad with her children
Last week was one of those weeks where work and personal life have collided in the most poignant of ways. Sir Bruce Keogh published his reportinto the failings of the 14 NHS Hospital Trusts identified as having unusually high standardised mortality rates (SMRs) or death rates. At the same time, my granddad (aged 92) was admitted to one of the ‘blacklisted hospitals’ in East Lancashire NHS Trust. This got me thinking. What sort of care is my granddad going to receive at th asics running is hospital? What exactly is a high standardised mortality rate an indicator of? And what, as a patient or relative, can I do with this information?
My first question was in part answered by reading the 63 page report on East Lancashire NHS Trust . While areas of good practice were identified, the report highlighted that the Trust board does not use information effectively to improve the quality of care, the complaints process lacks compassion and there are inadequate levels of nursing and medical staff. This bleak overall picture played out at the individual level when my granddad was discharged home at seven o’clock in the evening with an untreated wound, a full catheter bag with no replacement and no information for the district nurse about his medical situation or the sorts of medication he should be receiving. As he lay in his new hospital bed at home, he explained to my uncle that he hadn’t had anything to eat since his breakfast.
However, as a patient or relative, could I have anticipated these problems just from knowing that East Lancashire Trust has a higher than average standardised mortality asics running ratio? As Bruce Keogh argues, high SMRs can act like ‘a smoke alarm’ to indicate that there could be issues with the quality of care. However, they are not diagnostic and certainly don’t reveal the cause of any problems. I’ve lost count of the number of false fire alarms at work because, it turns out, someone has burnt the toast. Average SMRs are no reason to be complacent either. As Professor Nick Black, a member of the review’s national advisory board, explained in an interview last week, it’s likely that there are other NHS Trusts out there that should be in special review that don’t have high SMRs
So, in isolation, a high SMR doesn’t tell you a great deal about the quality of care you might receive in a hospital as a patient. SMRs are but one of a plethora of performance indicators on the quality of care that are available to the public. The review panel’s report into East Lancashire Trust revealed that these indicators also suggested that the warning bells should have been ringing. To paraphrase the report:
The Trust is ‘red rated’ in two safety indicators: MRSA infection rates and clinical negligence scheme payments
Of the nine measures reviewed within Patient Experience and Complaints, the Trust was rated ‘red’ on four separate measures;
Around 70% of all complaints relate to clinical aspects of care, which is unusually high
And the list goes on. However, this information is often dispersed amongst different websites and as a patient or relative, it’s not always clear where to go to find it. Furthermore, no one is pulling all this information together and presenting it in a way that patients can understand. As Ian Greener eloquently argued in his blog last year, not everyone has the capacity to understand performance indicators.
What can patients do with this information?
And this brings me to my final question what as a patient or relative can I do with this information? Current government policy contains a lot of rhetoric about the ‘information revolution’ and empowering patients to make choices about where they receive their care. The idea is that patients choosing high quality hospitals over poor performing ones will drive up the quality of patient care. In reality, we didn’t have a choice about where my granddad was admitted to. It wasn’t as though we could have said to the ambulance driver ‘take him to Leeds please!’ Apart from the contractual and financial barriers to this, it would have meant that my granddad would have been a long way from his daughter and two sons, making it difficult for them to visit him.
Frankly, I want the care at my local hospital to be excellent and I want the care at my granddad’s local hospital to be excellent. If this was the case, the issue of choice wouldn’t be such a big deal. Much of research evidence indicates that patients rarely look at publicly available performance data when choosing a hospital (see this article by Fung and colleagues for example),so the idea that patients are going to abandon poorly performing hospitals in droves hardly seems likely.
Better Information, Better Care
Thankfully, my granddad is now doing ok at home and has support from community nurses to care for him. As far as he’s concerned, publicly available SMRs and performance data don’t relate much to his own experience. So am I saying SMRs and performance data are meaningless and we should abandon the public disclosure of such information? No. I am saying that single indicators in isolation are often imprecise and it’s only when we bring them together that we can begin to see the bigger picture. In my granddad’s case asics running , Bruce Keogh’s detailed investigation, the performance indicators themselves AND our own experience all pointed to the provision of poor care in the Trust.
However, no single body appears to be responsible for bringing this information together, or more importantly, interpreting it. Even if this was done, there’s no guarantee that patients would use the information to choose a hospital. In many situations, patients have very little real choice about the hospital they go to and the public disclosure of performance data is unlikely to influence this.
The key role for performance data is in holding public bodies accountable and as a trigger for more detailed investigations into the quality of care. It’s only when we have all this information that a solution to the problems can be found. Publishing this data should act as a trigger for managers and clinicians to work together to identify and resolve the problems. It allows us, as the general public, relatives and patients, to ask questions to local NHS managers and asics running clinicians about the care they are providing. However, in order for this to work successfully, we need a much clearer and quicker vehicle for these questions and concerns to be raised. We shouldn’t have to wait for another Mid Staffs or Bruce Keogh style review for these problems to be identified and, more importantly, resolved.