Walsall CCG Mortality Review Group

Exploring hospital standardised mortality ratios at

Walsall Healthcare NHS Trust between 2010 and 2013

Lead authors

Dr David Pitches, Locum Consultant in Public Health, NHS Walsall

Dr Paulette Myers, Consultant in Public Health, Walsall Council

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Contents

1. Executive Summary

1.1 What was already known?

1.2 What was our approach?

1.3 Were there any other driving factors?

1.4 What were the principal activities of the group?

1.5 What were the main findings of the group?

1.6 What lessons can be learnt from this group?

4

2. Introduction to hospital mortality statistics

2.1 Definitions

2.2 Causes of high mortality statistics

6

3. Historical perspective and relevance to Walsall

3.1 Early attempts to publish hospital mortality statistics

3.2 Publication by the Dr Foster unit at Imperial College London

3.3 Alternative explanations for high mortality rates

3.4 Changes to palliative care coding

3.5 Monitoring of changes to coding and effects on mortality by Walsall PCT

3.6 Extending patient choice and availability of preferred place of death

3.7 Redevelopment of Goscote Lane and the opening of the Palliative Care Centre 3.8 Additional consultants in palliative medicine recruited to Walsall Healthcare NHS

Trust

3.9 Hospital review of mortality

9

4. Walsall CCG Mortality Review Group 14

5. External Drivers 16

6. Summary of Phase 1 findings of the Mortality Review group

6.1 Performance monitoring and assurance

6.2 Hospital activities

6.3 Mortality and care homes

6.4 Data and intelligence

6.5 Addressing and strengthening the role of General Practices

6.6 End of life

17

7. Impact of mortality review group

23

8. Independent management consultants’ report

25

9. Lessons learnt and conclusions

26

10. Next steps

27

11. Acknowledgements

28

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1. Executive summary

As a local leader and commissioner of NHS services, Walsall CCG (formerly PCT) has a

responsibility to ensure services are safe and of high quality. In 2011-2 Walsall (then) PCT and

Walsall Healthcare NHS Trust (WHNT) identified concerns at the apparently high standardised

hospital mortality ratio (HSMR) observed at Walsall Manor hospital.

1.1 What was already known?

Walsall Manor Hospital has had a history of having a high HSMR which is investigated, falls, and

rises again. Importantly therefore, the mortality review group therefore was not approaching the

question in isolation, but coming aware of contributing factors and interventions (including

coding reviews) that had been undertaken previously.

1.2 What was our approach?

WHNT launched its own review and agreed an action plan to tackle the issues within its direct

control but as a system also agreed that there was a need to take a wider approach to reducing

mortality.

The PCT convened a mortality review group to examine the contributory causes of the high

HSMR during 2011/12 and exploit opportunities to improve choice and quality of care throughout

the local health system. This group included partners from across the health economy – public

health, primary care, hospital and palliative care services and social care, with a lay Chair at arms’

length from the CCG (since for most of the duration of the mortality review group the CCG was

operating as a sub-committee of the PCT cluster). The group was aligned both to PCT corporate

core business (for example clinical quality review and safety, quality and performance groups)

and to regional (SHA) work.

The collective focus of the group was to understand the current situation and make

improvements where opportunities presented themselves, not only in the hospital but in the

community too, since it was well recognised that a high HSMR may have its origins in factors

outside the control of the hospital alone. The group had two main objectives:

(i) to ensure that the actions taken by the hospital trust were having the required effect

(ii) to identify and address the wider health economy issues contributing to high

mortality rates (e.g. performance of nursing homes or availability of palliative care).

System wide leadership underpinned both the group as a whole and the separate workstreams

that reported into the group. Strong leadership, high levels of trust, transparency and openness,

and being prepared to challenge one another in each of the workstreams were vital to the overall

success of the group.

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1.3 Were there any other driving factors?

Separately to the PCT group, the council Health Scrutiny and Performance Panel commissioned

an independent review of hospital mortality. Meanwhile the Mid Staffordshire NHS Foundation

Trust public inquiry was expected to report imminently, with the potential to attract further

attention to other hospitals with high HSMRs. Discussions about hospital mortality cannot be

separated from palliative care, and the Liverpool Care Pathway is an important framework of

best practice in palliative care. However it has recently come under the spotlight itself in the

wake of criticism that it might not always be being used appropriately.

1.4 What were the principal activities of the group?

Several workstreams were set up under the mortality group to analyse specific areas, including:

(i) Assurance

(ii) Hospital care

(iii) Nursing home care

(iv) Data collection and hypothesis testing

(v) Primary care

(vi) End of life care

1.5 What were the main findings of the group?

• Historically Walsall has been under-provisioned for end-of-life care meaning a higher

proportion of terminally ill patients die in hospital than the national average and this

effect can be reflected in hospital mortality statistics

• Opportunity and choice for hospice and other end of life care has been expanded

recently

• Many cancer patients are dying in their preferred place of death

• Admissions in nursing home pilots have reduced

• Clinical pathways have been strengthened

• HSMR has been steadily declining since April 2012 and SHMI is within the expected range

• Assurance has been strengthened

1.6 What lessons can be learnt from this group?

• Secure and trusted ownership of the exploration of HSMR has to come from all partners

• The group must have independence – it was totally separate from a hospital Trust

mortality review group and had an arm’s length lay Chair

• There needs to be good evidence and the ability to interrogate data

• Findings need to support actions

• This was no small undertaking for the members of the group

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2. Introduction to hospital mortality statistics

Walsall CCG has a responsibility, as local leader and commissioner of NHS services, to provide

assurance that health services, including hospital care, are delivering high quality and safe

healthcare to the people of Walsall.

Hospital mortality statistics, of which there are a number of different measures, are a commonly

used tool that can be used to scrutinise safety and quality of hospitals. However there are many

caveats and limitations on the use of hospital mortality statistics and their interpretation requires

great care to ensure a complete understanding of the contributory factors to an unacceptably

high mortality statistic.

2.1 Definitions

Hospital mortality statistics include the Hospital Standardised Mortality Ratio (HSMR), the

Summary Hospital Level Mortality Indicator (SHMI) and the crude mortality rate. These are

published at different intervals (monthly, quarterly or annually) by a range of organisations and

each is calculated using different formulae and definitions and each has its limitations. These

currently include:

(i) HSMR (produced by the Dr Foster company) includes the deaths of patients who die

in hospital from the most common conditions causing 80% of deaths (thus some

patients who died may be excluded from the calculations). It is defined as the ratio of

the number of actual (observed) deaths in a time period e.g. a month, divided by the

number of “expected” deaths, where Dr Foster calculates a probability of death for

each patient who is admitted to hospital and estimates how many deaths a hospital

might reasonably be expected to have had during that time. There is substantial

disagreement of expert opinion however about what factors to take into account

when estimating how many patients might have been expected to die over a given

time period. In addition for statistical reasons, any one hospital’s HSMR cannot

meaningfully be compared against any other hospital, because no two hospitals will

admit exactly the same patients. Despite this, HSMRs are routinely published and

compared against one another.

(ii) SHMI (NHS health and social care information centre) includes patients who died in

hospital and patients who died up to 30 days after coming out of hospital and thus

may include patients whose death might have been caused by the hospital but which

would not be detected by the Dr Foster company. Conversely, deaths occurring in the

community as a result of poor out-of-hospital care may appear to adversely affect the

hospital’s mortality rate. The SHMI also fails to account for the effect that deprivation

can have on a patient’s likelihood of dying, and the likelihood that if they are receiving

palliative care they are probably being admitted with a terminal illness and their

death is unlikely to be preventable.

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(iii) Crude mortality rate: this is typically the number of deaths divided by the number of

admissions, but takes no account of the variation in severity of illness that patients in

different hospitals present to hospital with so cannot be used to compare hospitals.

In addition, mortality statistics are usually given in the context of a range of values within which a

hospital would be expected to be by chance. Outside of (ie outlying) this range, chance alone is

unlikely to explain why the rate is higher (or lower) than could reasonably be expected by

chance, implying other factors may be at work. This is important because one factor that

seemingly self-evidently might explain why the rate is higher is that there is poor quality of care.

2.2 Causes of high mortality statistics

The reality is however far more complicated and it is invariably premature to jump to the

conclusion that a high mortality hospital has a poor standard of care. It is essential to stress that

hospital mortality statistics are a consequence of a complex mix of factors including

• case mix (how severely ill patients are who are admitted to hospital)

• lifestyle choices such as smoking and died

• disease coding (how accurately the patient’s presenting conditions are categorised to

one or more standardised disease categories, to allow comparison between patients with

different conditions)

• quality of care in primary care and community settings e.g. care homes

• quality of care in hospital

• availability of end of life care options e.g. local hospices

• patient choice of where to die

• chance variations

Therefore a high mortality rate or ratio in itself does not necessarily imply that there is any reason

for concern about the quality of clinical care at the hospital; rather it is described as a “smoke

alarm” that should trigger examination of pertinent factors including clinical care to see whether

they can explain the outlying mortality statistic. In fact often the majority of factors that cause a

hospital to have a high mortality statistic are outside the direct control or influence of the

hospital. Furthermore, within hospitals there may be areas of exceptional care and other less

strong areas and in theory if a department had a high mortality rate as a result of poor care, this

could be masked by stronger performance in other areas.

A recent very detailed review of a thousand deaths in a range of NHS hospitals in England found

that on average around 5% had factors in their clinical care that might have contributed to the

patient’s death, which as a headline figure is actually similar to research studies of avoidable

hospital death in other industrialised countries1. Mathematical modelling suggests that at this

level of “preventable death”, avoidable mortality can only explain 8% of the variation in hospital

mortality rates and only one in every eleven hospitals identified as having a significantly elevated

1 Hogan et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Quality and Safety 2012

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mortality statistic may have problems with quality of care2. The majority of hospitals with high

HSMRs or SHMIs are unlikely to have more quality of care problems than hospitals with normal or

low mortality statistics.

Two research papers illustrate the difficulty of linking poor quality care to high mortality rates.

Firstly, a systematic review was published in 2007 of all studies that attempted to measure quality

of care and mortality rates (after adjusted for patient case-mix) across several hospitals3. It was

evident that there was a very tenuous link if any between quality of care and hospital mortality;

for every study that showed that higher mortality rate hospitals delivered poorer care, another

study found either no association or even a negative association (that is, the better quality

hospitals had higher mortality rates).

Secondly a unique experiment in Massachusetts in 2008 cast doubt on the ability of

commercially-calculated hospital mortality statistics to discriminate between “good” and “bad”

hospitals4. They provided a complete dataset of all admissions over a period of several years for

83 hospitals and invited four companies, including the British hospital mortality statistics

company Dr Foster, to try to identify the “highest” and “lowest” mortality outlying hospitals. 12

of the 28 identified by one company as “significantly worse than expected” were simultaneously,

and using the same dataset, identified as performing “significantly better than expected” by the

other companies. The researchers suggested that it was not safe to assume that hospitals could

be identified as good or bad on the basic of mortality rates alone.

There are three key mistakes that can be made when reviewing hospital mortality statistics:

(i) attempting to explain a high HSMR or SHMI solely through use of data on the

grounds that they are imperfect indicators of quality of care – for example improving

coding can bring down mortality without changing clinical quality of care

(ii) being falsely reassured by a low or “within expected limits” mortality and not

noticing clinical or organisational failings that are causing harm to patients

(iii) only focussing attention on the hospital when attempting to understand hospital

mortality statistics, and failing to consider the impact that events in the wider health

economy are contributing to the mortality rate.

Any approach undertaken in Walsall therefore had to be sufficiently robust to ensure that careful

attention was paid to understand where the data and intelligence was pointing and what clinical

and wider health economy areas should be considered, rather than simply trying to “improve”

the data. Conversely. whilst improvements in quality of care do not automatically lead to changes

in hospital mortality statistics, potential for improved care could not be ignored where it was

identified.

2 Girling et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study BMJ Quality and Safety 2012 0:1–5. 3 Pitches et al. What is the empirical evidence that hospitals with higher risk adjusted mortality rates provide poorer quality care? Biomed Central Health Services Research, 7. p.91. 4 Shahian et al. Variability in the Measurement of Hospital-wide Mortality Rates. New England Journal of Medicine 2010;363:2530-9.

Item 8.3 Appendix 1

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3. Historical perspective and previous actions in Walsall

3.1 Early attempts to publish hospital mortality statistics

The first attempt to calculate and compare mortality rates in different hospitals was undertaken

by Florence Nightingale in 1853. Her attempts were highly criticised and generally considered

unsuccessful for a number of reasons, some of which remain valid today and are worth studying:

(i) Firstly, there were shortcomings in the formula she chose to use to calculate

mortality rates: she divided the number of deaths by the number of beds in the

hospital. In some hospitals this meant they had apparent mortality rates of nearly

100%, which does not convey meaningful information.

(ii) Some hospitals with high mortality rates claimed this was something to be proud of,

since they were clearly taking care of the sickest patients.

(iii) Others tried to conceal deaths by discharging very sick patients before they died.

(iv) Finally, getting hospitals to provide her with comparative statistics proved more

difficult than she had anticipated.

3.2 Publication by the Dr Foster unit at Imperial College London

Hospital mortality statistics first began to be routinely published in England in 2001 in the Sunday

Times as the Dr Foster “Good Hospital Guide”. Three quarters of the hospitals with the lowest

HSMRs were in London and the South East (University College London Hospital’s HSMR at 68

was the lowest) whilst several hospitals in the Midlands were identified as having the highest

HSMRs in the country. These included the hospitals of Walsall (119, where 100 was the “England

average”), Sandwell (117) and Nuneaton (114) and prompted much analysis and investigation to

understand why the mortality ratios varied so much across the country.

Following the publication of the Good Hospital Guide a number of changes were introduced in

Walsall Hospitals NHS Trust. These included the formation of specialist clinic governance groups

to implement changes in a wide range of clinical disease areas such as respiratory, renal and

elderly care, and changes to many different management areas such as audit, education,

information services and bed management. Over the period 2000 to 2004 the HSMR dropped

from a high of 130 to 92.8. This suite of improvements coinciding with a falling HSMR was written

up in the British Medical Journal by Dr Foster as an exemplar of good practice5, though the Dr

Foster researchers reserved judgement about the extent the changes made to the HSMR

compared to other potential factors (better disease coding (classification), different admission or

discharge policies or simply the hospital emerging from a chance period of unusually high

mortality). Additional improvements included audits of unexpected deaths and (from 2008) the

adoption of the Global Trigger Tool.

5 Jarman et al. Monitoring changes in hospital standardised mortality ratios. BMJ 2005;330:329

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3.3 Alternative explanations for high mortality rates

At the same time a separate line of inquiry was focussing on a different possible cause for

variations in hospital mortality measures – the relatively high proportion of people in Walsall who

died in hospital compared to the national average for place of death. After taking into account

the high proportion of hospital deaths in Walsall it was concluded that if people in Walsall had the

same access to other places of death (home, hospice) as the national average, the HSMR at the

time (126) would actually be only 1106.

3.4 Changes to palliative care coding

The Department of Health issued new guidance in March 2007 about coding hospital patients

with terminal disease and palliative care. The significance of this is that the Dr Foster organisation

calculates the number of expected deaths based, amongst other things, on the clinical disease

codes that they are classified as having been admitted to hospital with in order to estimate the

probability of dying. According to these calculations, patients whose medical conditions include a

palliative care code are likely to have a terminal condition and the effect of coding more patients

than normal with a palliative classification code increases the number of patients who are

expected to die in hospital, which potentially can reduce the HSMR. By the summer of 2007 the

Walsall Hospitals NHS Trust HSMR was identified as being high again by Dr Foster. An internal

review was undertaken of how patients with terminal disease were being coded and it was

observed that Walsall hospital was a relatively low user of palliative care codes and patients for

whom they might well have been appropriate were not being coded with palliative care.

Fig 1 Changes in palliative care coding and effect on HSMR, 2007-2010 Walsall Hospitals NHS Trust

6 Seagroatt V. Hospital mortality league tables: influence of place of death. BMJ 2004; 328

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Along with a number of other hospitals at the same time, the Manor Hospital coders

misinterpreted the guidance as recommending an increase in the use of palliative care codes and

hence during 2008 and 2009 more patients who died were recorded as having a palliative care

code then previously. The increase in palliative care coding was accompanied by a commensurate

decrease in HSMR (Fig 1).

Upon the appointment of a new coding manager in September 2009 the palliative care coding

approach was reviewed again and the amount palliative coding used was changed downwards

again. The Stafford Inquiry noted the misinterpretation of Department of Health guidance in a

number of hospitals at the time, including Walsall, but did not consider this to have been

deliberate.

3.5 Monitoring of changes to coding and effects on mortality by Walsall PCT

The PCT and now CCG has been actively monitoring the change in coding practice and its effect

on HSMRs. Mortality ratios as calculated by Dr Foster are presented on a monthly basis to the

safety, quality and performance (SQP) and clinical quality review (CQR) committees. Assurance

was sought through a WHNT board paper on palliative care coding, and detailed analysis of

coding was undertaken by the public health intelligence team in early 2011.

A number of tools have been routinely used by both Walsall PCT (now CCG) and WHNT to

monitor the mortality rates, including the Healthcare Evaluation Data (HED) tool produced by

University Hospitals Birmingham and used by the former Strategic Health Authority (SHA); the

SHMI, the HSMR, crude mortality rates and actual numbers of deaths.

3.6 Extending patient choice and availability of preferred place of death

Historically the proportion of patients dying in hospital in Walsall has been very high in

comparison to other parts of the country (fig 2), and it would be appropriate to expect a

relatively high proportion of deaths in Walsall hospital to be coded as palliative care. In other

areas, where fewer patients died in hospital and more died in a hospice, all the hospice patients

by definition would be terminally ill and would receive palliative care. So logically if those patients

were instead to die in hospital it would be anticipated that they should be coded as palliative

care. However, by 2011 the proportion of patients coded as palliative care had been reduced to

pre-2008 levels. Meanwhile the HSMR increased, and the six month period to February 2012 it

was 118 making Walsall a high outlier and thus unlikely to be that high just by chance.

There has long been the option for Walsall patients to die under hospice care, but prior to the

opening of the St Giles Walsall hospice, this was limited to a small number of places at out-of-

borough units including Compton Hospice (Wolverhampton) and St Giles Hospice Lichfield.

Hence end of life profiles prior to the opening of the St Giles unit in 2011 still show a small

proportion of hospice deaths (in 2008-2010 the proportion was 1.8% of all deaths) but since the

opening of the St Giles Walsall hospice in mid-2011 the proportion has increased to over 5% of

deaths, meaning that Walsall is on a par with the national average for the proportion of people

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dying in a hospice. Note that this statistic was calculated locally; the national data calculates a

three year average and so will continue to suggest that Walsall has a lower access to hospice care

than the national average for the next two years until the pre-Walsall hospice opening year

figures are completely out of the equation.

Fig 2 Proportion of Walsall residents who die in hospital, home, care home or hospice, 2008-10

(National end of life profiles)

Since the opening of the Walsall hospice the proportion of patients dying in hospital before and

after has changed from 61.9 to 58.1% - a fall of 3.8%. The effect of opening the hospice has been

primarily to reduce the numbers of people dying in hospital and balance this with an

approximately equal number of people dying in the hospice, with the proportions of people

dying at home or in care homes remaining largely unchanged.

Nationally the majority of people say they do not want to die in hospital, though nationally

around half of us will eventually die in hospital. Choices of preferred place of death can change at

different stages of a patient’s illness, and also may depend on the condition. A recent survey of

cancer patients referred to the Walsall community palliative care team found that under 1% of

patients preferred to die in hospital, and of those asked where they wanted to die, the vast

majority ended up dying in their preferred place of death (home, care home or hospice – not

hospital).

3.7 Redevelopment of Goscote Lane and the opening of the Palliative Care Centre

Well before any concerns were raised in late 2011 about the way the HSMR had crept back up,

significant work had been undertaken by Walsall PCT to improve patient choice in end of life care.

The land occupied by the former Goscote Hospital in Goscote Lane was redeveloped into a

hospice and end of life unit, the £5 million Palliative Care Centre following up to two decades of

planning and preparation. Construction began in 2009 and the unit officially opened in April 2011,

though throughput did not get up to full capacity for the first few months.

3.8 Additional consultants in palliative medicine recruited to Walsall Healthcare NHS Trust

At the time the hospice opened there was only one consultant in palliative medicine working half-

time in the Manor hospital. With the opening of the Goscote hospice (requiring four consultant

sessions, or two full time days per week input) in early 2011 this presented an opportunity to

completely rethink the provision of palliative medicine across the health economy. Funding was

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agreed from the PCT to create two new posts, employed by the WHNT and arranged so that one

worked primarily in the Manor hospital and the other worked primarily in the community, but

with significant overlap and cross-cover, in addition to the sessions provided in the hospice (and

for completeness, there are additional sessions funded in Wolverhampton hospital for Walsall

patients who are admitted there). Two new consultants were appointed in April 2012 and

provision of consultant palliative medicine sessions has greatly expanded as a result.

3.9 Hospital review of mortality

WHNT developed an action plan to address HSMRs which was presented at the January 2012

Health Scrutiny and Performance Panel. This had four key areas:

(i) Improving the care of patients with respiratory conditions

(ii) Enhanced senior medical review at evenings and introducing six day ward reviews

(iii) Improvements in palliative and end of life care

(iv) Reviewing all deaths and seeking best practice from other organisations

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4. Walsall CCG Mortality Review Group

The recent concern about mortality rates at Walsall is therefore not new but is a continuation of

publication of mortality statistics over a period of over a decade flagging the hospital as being

higher than the “expected-by-chance alone” range, followed by internal quality and process

reviews and subsequent reductions in mortality rates.

Independently of this and following discussions during 2011 at Health Scrutiny and Performance

Panel (HSPP), the CCG in collaboration with the Black Country PCT Cluster has been undertaking a

range of actions culminating in a project plan for a mortality review group consisting of a number

of partner agencies across Walsall to effectively address the high HSMR, looking at the wider

health economy as well as the hospital. The purpose of this project plan was

• To understand the factors that contribute to HSMR and SHMI

• To devise and prioritise effective strategies that impact on these measures

• To monitor the impact of the actions put in place

In recognition of the contribution of the wider health economy to HSMRs, the project working

group was designated the CCG mortality review group, rather than HSMR review group.

The project has consisted of several workstreams and functions, including

• Performance Assurance – formal critique and performance management of the WHNT

action plan for reducing HSMR by the SQP Committee of the CCG.

• Quality of care provided by WHT in the acute and community settings

• Quality of care provided by nursing homes, including reviewing and implementing

effective options for improving care and improving referral options for care homes with

deteriorating patients

• Review of data, estimations of mortality rates, coding and reporting of figures

• Addressing and strengthening the role of General Practices

• Review of local end of life services, in particular, the performance of hospices and

community end of life services

• Quality and accessibility of community services provided by the Local Authority

Each project workstream has reported into the mortality review group which meets monthly and

is a subcommittee of the Walsall CCG Improving Outcomes Programs Board, accountable to

Walsall CCG governing body. A wide membership of health economy stakeholders includes CCG,

WHNT medical director, other clinicians and senior managers, Walsall Council and CCG Board. A

lay Chair was appointed who was at arms’ length from the CCG but had past experience of the

PCT to chair the mortality review group meetings. A formal project plan was agreed by the CCG

Board in June 2012. Progress updates were provided to the National Commissioning Board Local

Area Team. The mortality review work is aligned to regional work examining mortality rates and

is aligned to the corporate business (SQP and CQR committees) of the CCG.

A key purpose of each workstream was to understand the issues that it was responsible for

which could influence hospital mortality, and ensure that opportunities for improving quality

Item 8.3 Appendix 1

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could be identified and acted upon. Underpinning this was both agreement that robust data and

evidence would be required in order to gain the fullest understanding of the contributory factors

to hospital mortality, and recognition that the groups were not intended to try to improve the

data for its own sake, but to improve quality, regardless of the impact this might have on the

data.

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5. External Drivers

A number of external factors also directed the work of the mortality review group. These

included the decision of the HSPP to commission a review of hospital mortality rates at WHNT

that would be entirely independent of the Walsall healthcare economy and provide additional

assurance during the period in 2010 to 2012 when the HSMR was a significantly higher than

expected outlier. The management consultancy Mott Macdonald was commissioned to

undertake the review, the findings of which were presented to HSPP on 23 April 2013.

Meanwhile in late 2010 the Government had set up a formal public inquiry into standards of care

at Stafford Hospital, the second “Francis Inquiry”. This reported in early 2013 and was highly

critical of patient care at that hospital. However, during throughout the time that the Walsall

mortality review group has been meeting, it was felt inevitable that there would be wider

implications and recommendations from the Stafford inquiry for the entire health service. Any

hospital known to have high mortality rates, such as Walsall, could potentially expect to be put

under intense scrutiny.

Following the publication of the Francis Inquiry in February 2013 it was announced that fourteen

hospitals would be investigated for their quality of care by the Medical Director of NHS England

during the summer of 2013 as a result of persistently high SHMIs or HSMRs. WHNT is not included

in these reviews.

At the same time concerns were raised at the suggestion that hospitals might attempt to

“massage” their data to lower their mortality statistics, prompting the Health Secretary to

announce that this would become a criminal offence. Bolton NHS Foundation Trust was initially

highlighted as a possible example of a trust “gaming” data to improve mortality statistics

because coding rates for sepsis were much higher than expected, increasing the apparent

number of “expected” deaths. It was later completely exonerated, since it transpired the Trust

was following the UK Sepsis guidelines on early identification of sepsis patients and patients

were being coded with sepsis who elsewhere would not have been identified. Ironically the

combination of following a model of best clinical practice and an ambiguous diagnosis code

without national definitions had led to a situation that at first sight appeared to be suspicious,

and is a helpful lesson in the limitations coding puts on hospital mortality statistic calculations.

Finally, the Liverpool Care Pathway, though offering a framework of best practice in palliative

care when applied properly, has recently come under intense scrutiny and generated significant

public anxiety as a result primarily of media reporting of its potentially inappropriate use. This

therefore features prominently in contemporary discussions of improving end of life care.

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6. Summary of Phase 1 findings of the Mortality Review group

6.1 Performance monitoring and assurance

Routine and ongoing monitoring of HSMR provided by WHNT happens on a monthly basis during

the PCT/CCG’s regular SQP and CQR committees. These committees monitor the quality of care

and critique and performance manage the WHNT action plan for reducing HSMR.

For additional assurance, the GP chair of the SQP committee attends the hospital mortality

review group.

6.2 Hospital activities

Actions undertaken in the hospital to improve quality and reduce mortality have included six-day

consultant ward rounds, standardisation of ward rounds, implementation of care bundles

modelled on the Nightingale Foundation approach, in-depth reviews of every patient who dies

and improvements in clinical coding. There are particularly detailed reporting processes for

patients dying from causes that have historically had high mortality rates, especially pneumonia

and sepsis.

A review of consultant job plans enabled extension to six day specialty ward rounds. This is in

addition to existing emergency admission areas which receive seven day 24 hour consultant

cover. Additional investment enabled the appointment of six acute medical physicians and four

further Accident and Emergency consultants plus an orthogeriatrican and renal specialist.

A “consultant dashboard” has been developed based on each consultant’s activity, mortality,

length of stay, and readmission rates to identify outliers and is used in the consultant appraisal

process.

The model chosen for the internal mortality review group was developed with assistance from Dr

Martin Farrier of Wrightington, Wigan and Leigh NHS Foundation Trust, who is a national leader

in this field. Membership comprises a senior multi-professional team including medical director

(chair), GP (CCG) representative, retired consultant, Nurse Director and Chief Executive.

Published evidence and experience from other NHS organisations has shown that reviewing all

deaths in hospital is a key to identifying issues in care delivery, and two senior consultants are

specialist reviewers, along with a senior coding manager and the patient’s consultant in all cases.

Feedback and learning points are disseminated widely. This model of mortality review is

considered best practice.

A monthly mortality report has been delivered during the delivery of the action plan and

continues, supplemented with in depth analysis from data analysts within the organisation, the

Dr Foster organisation, University Hospital Birmingham’s HED team and regional experts.

Analysis of data provided both new areas for attention and tracking of progress.

There have been significant improvements in palliative care coding and improvements in coding

of comorbidities. The HSMR has been recalculated by University Hospitals Birmingham excluding

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palliative care coded patients and this has fallen, suggesting improvements irrespective of

palliative care coding practices.

Care Bundles have been launched for pneumonia and sepsis (“surviving sepsis” campaign). These

evidenced based checklists promote prompt care and have been adopted well in clinical areas.

Review of existing clinical guidelines commenced in 2012 including fluid & electrolyte guideline

which is being prepared with teaching provision.

The respiratory & heart failure service provide guidelines and assertive in-reach to acute medical

admission areas. In addition the orthogeriatric service is supported via in reach from older adult

physician to orthopaedic wards to ensure medical management is optimised.

WHNT recognises that communication skills are essential and is funding two-day communication

skills courses for consultants, following an accredited model. There is an ongoing programme of

education for nurses and allied health professionals.

6.3 Mortality and care homes

A six month pilot project sought to improve quality of clinical care and resident care in care

homes. Audit of reasons for why patients are admitted from nursing homes to hospital has

demonstrated opportunities for synergy between care homes and the Manor hospital for

reducing avoidable admissions and potential mortality for conditions that could have been

managed in the community.

A clinical wrap around team to support frail elderly patients at the end of life was introduced in

four nursing homes with support from two GP practices and secondary care domiciliary elderly

care physician. This resulted in fewer admissions to hospitals and those patients who were

admitted were more appropriately admitted. It was notable that patients with cancer tended to

receive a more collaborative approach than patients with non-cancer long term conditions. Of 15

unplanned admissions during the pilot 9 were due to respiratory conditions and audit suggested

that all these admissions were appropriate. 89% of the deaths reported during the project were in

the patient’s preferred place of death. GPs reported fewer emergency call-outs to the homes,

whilst the homes reported greater confidence in applying end of life care pathways. The majority

of patient reviews were for respiratory or urinary tract infections.

All nursing homes in Walsall have been supplied with new syringe drivers in line with NICE

guidance and a comprehensive education package was provided for the use of them in end of life

care in nursing homes.

Medicines management reviews in nursing homes have identified where long-term prescribed

medicines might be substituted by more effective or better tolerated medicines, enhancing

compliance and avoiding waste. This has made savings of over £76,000 whilst ensuring that

patients with repeat prescriptions were on the most appropriate medicines.

A locally developed and delivered five-day leadership program has been undertaken for care

home managers, and the majority of managers have now attended this program. A self-

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assessment contract monitoring framework has been developed to assess clinical care quality,

support improvement and benchmark performance.

6.4 Data and intelligence

A desktop review of current literature on hospital mortality statistics was undertaken to identify

current thinking and emerging trends. The 2010 “Dying to know” document7 is particularly

helpful in explaining what factors outside the control of hospitals – particularly palliative care

services – can influence mortality rates, and recommends how to investigate high mortality rates.

The NHS Confederation has also published guidance on investigating HSMRs8.

A meeting of the Health Statistics Users Group in London was attended in January 2013 to

observe a detailed discussion of hospital mortality statistics, including limitations regarding social

and demographic details and the problems with palliative care coding. For instance the HSMR

methodology includes palliative care coding and attempts to adjust for deprivation but the SHMI

does not. The NHS health and social care information centre (which calculates SHMI) illustrated

the difficulty of defining when an episode of care could be classed as palliative care – for

instance, should it be applied to any patient admitted to hospital who is cared for by a

community palliative team, should it only include patients who are seen by a palliative medicine

consultant (or maybe nurse) during their admission, or should it include patients who are not

seen by a palliative care specialist but whose admitting team discusses their care with a palliative

care specialist during admission. The significance of this is that these definitions can affect the

“expected” mortality of a patient and hence can influence the hospital’s HSMR.

One reasons for a high HSMR could be that a comparatively high proportion of hospital deaths

occurred soon after admission in patients referred in from care homes. Transferring patients to

hospital from care homes at the end of life is often not considered the most appropriate care. In

Walsall around 6% of patients aged over 65 who died in hospital died on the day of admission and

31% died within 3 days of admission. Discussion with national experts suggested that deaths so

early in admission were unlikely to result from poor care and most likely reflected admitting

behaviour. However national comparative data was unavailable to benchmark Walsall’s position.

On average around four Walsall GP-registered patients a month are admitted to Walsall Manor

hospital from care homes and die within three days of admission (using postcodes of care homes

as a proxy for care homes). A further six patients die in a care home within 30 days of discharge.

It is reasonable to ask whether for some of these patients the hospital admission was

appropriate or whether the patients could have been better supported to die at home. A limited

number of care homes contributed many of the admissions and could be targeted for extra end-

of-life support. Around one patient a month was referred from a care home to the Accident and

Emergency department but died before they were even admitted.

7 Dying to Know - How to interpret and investigate hospital mortality measures. Flowers et al. Association of Public Health Observatories 2010 8 Hospital standardised mortality ratios: their uses and abuses. NHS Confederation 2010

Item 8.3 Appendix 1

20

A relatively low proportion of patients (4%) admitted from care homes died from cancer within 3

days, whereas 30% of deaths within 30 days of discharge were from cancer, suggesting

considerable success in averting hospital admissions of patients with cancer at the end of life and

success in discharging patients with cancer away from hospital to their preferred place of death.

Fig 3A & B Proportion and actual numbers of patients dying per month in hospital, hospice, home

and care homes in Walsall 2008-2013, showing changes when the palliative care centre opened.

Review of local data and comparison with national benchmarks confirmed that historically

Walsall has had a very high proportion of people dying in hospital compared to other parts of the

country (almost 62% in the period 2008-10) and comparatively few deaths happened in care

homes or in hospices (due to lack of availability – prior to the opening of St Giles only 1.8% of

people died in hospices, and Walsall has comparatively low availability of care home beds too).

Since the opening of the St Giles Walsall hospice in April 2011, a steady increase in the proportion

of people dying in the hospice has been matched by an equal reduction in people dying in

hospital, so that the proportion currently dying in the hospice is similar to the national average

(over 5%) and the proportion dying in hospital has fallen to 58%, though this is still some way

above the national average (Fig 4A & B).

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21

6.5 Addressing and strengthening the role of General Practices

Heart failure pathways have been developed jointly between lead GPs and cardiologists and

presented to CCG locality groups. Care plans are issued by secondary care to patients with severe

heart failure who are approaching the end of life, and the care plans are then used by GP

practices to manage patients. The palliative care team now has a joint heart failure clinic at the

Goscote palliative care centre.

GPs highlighted concerns that some patients in care homes were experiencing repeated

admissions, sometimes of patients who had not been brought to the GPs’ attention even when

they were visiting the home earlier the same day. This led to the development of the pilot twice

weekly joint proactive “ward rounds” with a community elderly physician of all nursing home

patients in four selected nursing homes, rather than only those that the nursing homes were

requesting the GPs to visit.

A workshop was convened in early 2013 jointly with WHT to look at the contribution primary care

can make to end of life pathways. A communications skills training package for GPs has been

developed to build GPs’ confidence in initiating conversations about “do not resuscitate” orders

in primary care. West Midlands Palliative Care Guidelines have been circulated to every GP.

Other conditions have been identified that can be supported by formal end of life services,

allowing local care pathways to be developed, beginning with respiratory disease.

6.6 End of life

The primary aims of end of life care in Walsall are to ensure that patients, their families and carers

are treated with dignity and respect, being supported to die in their preferred place of death

where possible, whilst patients will be listened to and able to contribute to a personalised

advance care plan wherever possible.

This depends on recognising and acknowledging the palliative and/or end of life phase, offering

patients and carers the opportunity to discuss their priorities for care and place of death, treating

on assessment of need, reviewing and amending the plan, identifying the most appropriate

location for care to be provided avoiding admission to acute trust services unless clinically

appropriate, and to achieve a seamless and timely transition across care environments.

The palliative care and end of life service aspires to achieve the following:

• Increase in the number of patients being identified as entering the palliative or end phase

of life and benefitting from the development of an advanced care plan

• Increase in number of patients having their preferred place of care and death identified

and recorded within their records

• Increase in number of patients achieving their preferred place of care and death

• Year on year increase in number of non-cancer patients accessing palliative and end of life

care services

• Increase in number of patients receiving end of life care closer to home

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22

• Reduction in number of patients receiving end of life care in the acute trust environment

where this is safe and viable to do so

• Increase in number of patients receiving co-ordinated care

• Improved patient and carer experience

In 2011 the St Giles Hospice Walsall opened in Goscote, and during 2012 two consultants in

palliative medicine were employed by WHNT, one based primarily in the hospital, the second

working in the community. Following the publication of the NICE Quality Standards and advice

for commissioners for end of life care, and more recently from the National End of Life

Programme, “The route to success in end of life care - achieving quality in acute hospitals”, the

palliative care team are exploring new models of provision, focusing on the following “enablers”

to allow acute hospitals to deliver excellent end of life care:

1. Advance Care Planning (ongoing within NHS Walsall). As of March 2013, the new Advance

Care Plan for the Walsall borough is available for health and social care providers to

adopt;

2. Electronic Register of Palliative Care Patients. WHNT are currently using the Gold

Standard Framework and are planning some Patient and Public Engagement before

extending this further into the hospital on a rolling basis throughout all specialties;

3. AMBER Care Bundle – this is a new opportunity for the Trust and is being implemented on

a ward-by-ward basis. It will allow staff to identify patients whose recovery is uncertain,

and to make plans with the patient and family in a timely manner;

4. Use of Liverpool Care Pathway – this is already embedded in the hospital and existing

community nursing teams however the working group continue to seek assurance on the

quality and impact on the team, the patients and members of their families.

5. Rapid discharge home to die. This enables people who are in hospital with terminal illness

to go home to die, and the Trust is working with the CCG to implement this.

There has been considerable success ensuring cancer patients have been able to die in their

preferred place of death (which is rarely a hospital setting). Palliative care capacity in the Trust

has been reflected in the increase in patients coded as palliative, which is now above the national

average again (and appropriately so, since even after opening the hospice a higher proportion of

patients still die in hospital compared to the national average).

Whilst end of life services have got most experience in cancer pathways, it is recognised

nationally that end-of-life services for patients with non-cancer terminal conditions are in general

less well developed, even though more patients have non-cancer terminal conditions than

patients with cancer. A heart failure outpatient clinic has been set up at Goscote and there is a

joint heart failure and palliative care multi-disciplinary meeting, as part of the ongoing work to

improve access to palliative care services for non-cancer patients with life-limiting conditions.

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23

7. Impact of mortality review group

Nursing home pilot studies have observed fewer admissions and more appropriate admissions.

Patients are increasingly dying in their preferred place of death and there has been a shift of

around ten patients each month who are now able to choose to die in the St Giles Walsall hospice

who prior to 2011 would have had no choice but to die in the Manor Hospital. The palliative care

coding rate between April 2012 and January 2013 was 3.7%, against a national average of 2.5%

which is entirely to be expected given the additional resources of two new consultant positions

in a hospital in which historically a high proportion of the population died. Clinical pathways that

can prevent admission to hospital and improve care in the community, and improve the safety of

patients in hospital have been prioritised. Assurance of safe, high quality clinical processes and

pathways has been strengthened.

Between April 2012 and March 2013 the HSMR has been below 100 for twelve consecutive

months. The latest available month at the time of writing (June 2013) is March 2013 with a ratio

of 94.6 and the year to date HSMR is 89.3. The latest SHMI is 1.11 (October 2011 – September

2012), and this is within the expected range. The SHMI data does lag behind the HSMR data and

currently includes a time period during which the HSMR was higher, though the SHMI and HSMR

are measuring slightly different things – the SHMI includes patients who died within 30 days of

discharge whereas HSMR only counts those who die in hospital. So certain patients who are no

longer included in the HSMR may still be counted by the SHMI if they die within 30 days of

discharge.

In addition to changes in HSMR and SHMI, it is important to consider absolute numbers

(observed numbers of deaths) and crude (unadjusted) death rates. Over the past two years it is

notable that the absolute number of deaths, and the crude death rate, have fallen (Fig 4), whilst

the expected number of deaths has increased. The fall in absolute numbers is probably directly

attributable to the opening of the St Giles Walsall Hospice. Crude mortality tends to increase in

months when there are higher numbers of deaths, particularly during the winter season

(coloured green in Fig 4), but it is less clear why HSMR, which is supposed to take account of

casemix, should also increase during these months. Most likely the HSMR is failing to completely

adjust for casemix, especially if coding has improved since early 2011. A fall in crude mortality can

signal the effect of improvements in quality of care.

Any mortality statistic that is presented as a ratio of observed to expected deaths (for example

the HSMR and the SHMI) can be affected by one or both of observed and expected deaths. For

example if observed deaths falls (e.g. because improvements in choice for end of life mean some

patients can now die in the hospice who previously would have died in hospital, or because

clinical pathways have been improved) HSMR will fall. If expected deaths rises (e.g. because of

improved coding or a sicker patient population), HSMR will also fall. In the case of Walsall, the

expected mortality over the past two years has been rising whilst the observed mortality has

fallen, which helps to explain why the HSMR has fallen as sharply as it has in Walsall.

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Fig 4 Changes in HSMR, crude mortality, observed and expected deaths 2011-12, including the winter

peak (green shading).

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8. Independent management consultants’ review

The independent Mott Macdonald report was presented to Council HSPP in April 2013. It included

assessments of the wider health economy, quantitative analysis of data and qualitative appraisal

of quality of care. The remit and scope of the study precluded detailed ward-level observations

however.

A number of hospital-led initiatives were highlighted as potentially contributing to the reduction

in HSMR, including the introduction of six-day consultant ward rounds, increased staffing levels

in the Acute Medical Unit, introduction of care bundles, mortality reviews of all patients who died

in hospital with discussion across many participants and dissemination of lessons learnt, and

standardisation of ward rounds

The report drew attention to the improvements in end of life care, including the appointment of

the two new palliative care consultants, improved palliative care coding and the contribution of

the St Giles Walsall hospice to removing observed deaths from the calculations underpinning

hospital mortality and thus reducing both HSMR and SHMI. The contribution of the PCT/CCG,

both to improved quality of care and confidence managing frail elderly patients in care homes,

and to establishing the CCG-led mortality review group was acknowledged.

The report identified additional areas that further work should investigate, including a perception

that discharge planning arrangements were not working optimally, leading to longer than

necessary length of stay, and the need to ensure palliative and end of life services that have been

so successful to address the needs of cancer patients also can ensure they meet the needs of

non-cancer patients. Certain specific areas of improvement, such as relieving pressures in

Accident and Emergency, and improving access to non-invasive ventilation support were also

recommended.

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9. Lessons learnt and conclusions

A number of important lessons were learnt in the process of undertaking this review that could

be considered steps for other organisations considering setting up a review group. Firstly,

establishing a core purpose that required system-wide support and board level signup.

Commitment of senior management attendance, openness and transparency and establishing

high levels of trust are essential to a robust and wide-ranging discussion. Strong leadership of

each individual organisation and their separate workstreams complemented the collective

leadership of the CCG mortality review group, creating a synergy in the group. Willingness to

consider from the outset the whole health economy rather than a narrow focus on just the

hospital was essential since it was clear from early examination of local data that many of the

factors that contributed to the HSMR were beyond the immediate control of the hospital in

isolation.

The importance of secure ownership of the problem and trust by all parties to find solutions

cannot be overemphasised. The subject matter of hospital mortality statistics is technically

complex, easily misunderstood, professionally controversial, emotionally distressing and

politically challenging. Another key lesson was the importance of independence and

interdependence, with both CCG and hospital leading their own review groups. It is essential to

use all the available evidence and interrogate and challenge interpretations and explanations,

and use the findings to support and review actions.

Use of data was important to help focus attention on what were likely to be the key areas

contributing to hospital mortality – particularly end of life care and community factors – but data

was not studied for its own sake nor was it analysed with the intention of assuring the group that

there was no scope for further improvement. Conversely, even if some of the improvements in

quality of care identified by the project have no measurable impact on HSMR they are still

important.

Finally it is no small undertaking to commit to a review of hospital mortality statistics, especially

when it includes wider health economy and community stakeholders.

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10. Next Steps

Care homes

Phase two of the CCG project workplan will focus particularly on the contribution of community

services and of primary care to reducing HSMR. The Interim Director of Social Care & Inclusion is

developing a project plan for the community services workstream.

Primary care

The CCG Board member lead on quality is developing a project plan for the primary care

workstream, including work on end-of-life respiratory pathways, communication skills training for

GPs to initiate end of life discussions, supporting community nursing teams in end of life care and

linking the primary care workstream to the work in care homes. The nursing homes pilot is

expected to be rolled out further.

Palliative and end of life care

A working group is looking at rapid discharge home to die, with the intention of minimising visits

to Accident and Emergency Departments and supporting patients to die in their preferred place,

i.e. at home or their care home with the appropriate support package in place. Consideration

needs to take into account how out of area patients may be managed. A specification for a

Hospice at Home Service to include supporting those patients who may live alone or lack

support, is being considered.

Work is ongoing to improve access to palliative care and end-of-life services for patients with

non-cancer life-limiting conditions, especially heart failure, respiratory failure and dementia.

The End of Life Quality Assessment Tool (ELQUA), a national quality assurance and measurement

tool is being adopted by Walsall. WHNT intend to use the tool to benchmark themselves against

providers and track progress and share good practice.

Palliative care coding within WHNT is expected to be independently audited and benchmarked

for further assurance.

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11. Acknowledgements

This was a highly complex and detailed piece of work that required the support of many people.

Particular recognition and thanks must be recorded to Ms Salma Ali, Geoff Archenhold, Mr James

Avery, Mr John Bolton, Ms Reena Bhardwaj, , Prof. Michael Campbell, Dr Steve Cartwright, Ms.

Simone Chung, Ms Sue Crabtree, Mr Paul Deeley-Brewer, Dr Isabel Gillis, Mrs Wendy Godwin,

Miss Ruth Hall, Mr. Andy Hood, Mr. David Hughes, Ms Suzanne Joyner, Mr Amir Khan, Mr Richard

Kirby, Dr Radka Klezlova, Mr Roman Kuciaba, Dr Raj Kumar, Dr. Sue Laverty, Dr Raj Mohan, Dr

Paulette Myers, Dr Su Nambisan, Mr. Bharat Patel, Dr David Pitches, Dr Najam Rashid, Mrs Sally

Roberts, and Dr Esther Waterhouse for their invaluable contributions.

Item 8.3 Appendix 1