Category Archives: Mortality figures

How bad could the coding really be?

Listening to the evidence of Roger Taylor from Dr Foster Intelligence on day 99 of the Mid Staffs Public Inquiry the last piece of the jigsaw that I needed to see how we got into a hopeless mess about Mortality information at Stafford fell into place.  I had had it all the time, but just had not seen that this is the piece that counted!
There was a happy time back in early 2009 when I had never heard of HSMR or the Hospital standardised Mortality Rates.  But since 17th March 2009 the matter has never been far from my thoughts.
The reason I know this date, when I have difficulty remembering family birthdays is that this is the day when the press and TV brought a media hurricane to Stafford.
We had known for 18 months before that there was a band of relatives who had suffered real tragedies at Stafford. There were demonstrations in the town square and outside the hospital, they were working closely with the press to tell their stories and had already forced the resignation of the Chief Executive officer and Chair of the trust. What no one had reason to suspect that we would see press headlines that 400-1200 people had died as a result of poor care in Stafford.
The problem with the mortality rate figures in Stafford were known to a relatively small number of people – I knew of them, but did not even know the name “Dr Foster Intelligence”at that time. What I did know is that a considerable amount of research had been carried out which showed that there were serious problems with the coding of the data which was producing the apparently high mortality figure.
I was not directly involved in the chaos that followed the arrival of the world’s media in Stafford so what I did was I sat down and read the Healthcare commission report from cover to cover 4 times. It took that many times to convince myself that the “excess death figures” which appeared in every press item and every TV interview were not there, and that there was no other material contained within the body of the report that could imply these figures. This was clearly a hospital with problems, a hospital where lots of people would have had an uncomfortable time, I could imagine that there will have been some people who will have died, I found an interview with Sir Ian Kennedy who said it is likely that “some people may have died”. This seemed to me to be a completely fair balanced and reasonable statement. The rest looked like media induced hysteria.  
There are clear caveats in the HCC report about the limitations of what the data can tell us.
For the data to accurately reflect hospital
activity, there must be clear, accurate and timely
information recorded in the patient’s notes;
accurate and consistent clinical coding; and
clear procedures for collecting and processing
the data. There also needs to be appropriate
training and accreditation of staff.
This is the passage which came to dominate my reading of the report.
The highlighting is mine. This seems to me to be the very simple human story at the heart of this chaotic chain of events.
Background
We were told by clinical staff and managers
that the trust had a long history of poor quality
information about its services. ..
A report by CHKS was commissioned by the
trust in early 2007, due to concerns about the
coding of clinical data. The report identified
deficiencies in the clinical coding entered in
the Patient Information Management System
(PIMS). This was manifested by inaccuracies
in coding and under-reporting of co-morbidities
(that is, patients’ other health
problems).
The coding manager at the time
had been on long-term sick leave and the rest
of the team were working part-time. Contact
with clinicians was also poor, with coders
being reluctant to approach them about
unclear notes. Clinicians had little
understanding of the need to make notes
clear for the coders.
The trust recruited a new coding manager in
July 2007, when the previous post holder
retired. More investment was put into the
department and new members recruited to
the team. Staff told us that the new coding
manager had had a positive impact on the
quality of coding. The new manager built
better relationships with clinicians and
motivated her staff to attend training courses
and gain accreditation. Examples of positive
developments included having consultants on
the clinical coding and data quality group, and
systems that the coders could use to crosscheck
information, such as radiology and
pharmacy reports.
The coding manager told us that she still had
concerns about some of the clinical input to
coding. It was reported that junior doctors
could present a problem because of their
frequent job rotations. They were often
imprecise about diagnoses, whereas the main
problem encountered with senior consultants
was the tendency to under-report comorbidities.
The trust had a history of poor performance on
mortality. The data from Dr Foster showed that
the three-year HSMR for 2003-2006 was 125.
This was the fourth highest ratio in England.
The trust had only begun to monitor clinical
outcomes after the publication of Dr Foster’s
Hospital Guide in 2007, and had relied on the
use of the Dr Foster ‘real-time monitoring
tool’ to identify areas of concern (‘red bells’).
This tool was used by the trust’s lead clinician
for clinical governance.
In response to its apparently high mortality
rate identified by Dr Foster, the trust initially
focused on the poor quality of the clinical
coding of the cases involved. It also
established a group to consider mortality
outcomes. The group’s follow-up of high
mortality rates had focused on reviews of
individual case notes of patients who had died.
This was conducted by clinicians at the trust
over a period of time. The general conclusions
of the follow-up were that the deaths were
predictable and that no problems with care
were identified.
There is further on in the report the description of the work of the mortality report – which carried out a limited case review of deaths, and found that around 80% of these had been miscoded. ***** I have still to find this reference.
As the story has moved on and the press headlines have kept on coming I have watched for every bit of information which might help to explain what happened here. How is it that the world in general has accepted this mysterious assertion that 400-1200 people died unnecessarily in Stafford when this information does not appear in any official document and there is clear evidence that the coding on which the information was based was of exceptionally poor quality.
Here are some of the pieces of the jigsaw.
My Attitude to HSMR
I am not a statistician though I have had some experience of using statistical systems. I have only learnt about any of this because of the truly dreadful experience that the people of Stafford have suffered. I am a fan of statistical information and believe that where people understand how to use them and use them well that they can often give a really good way of seeing what is happening. I accept that HSMR and some of the newer systems that Dr Foster are developing in partnership with other organisations are of considerable value, but they are, as Roger Taylor himself has clearly stated very vulnerable to misuse. Rubbish in will result in rubbish out.
No one left to fight the story.
When the story broke the only people with enough knowledge to contest the story had already gone. Everyone else was in a state of severe shock.
25 out of 75
It would be easy to assume from all that we have heard about HSMR that this is a universally used and accepted system, tried and tested, the single measure for comparing Quality of care and performance on Mortality in the country.  This is not the case. We now have a definitive statement signed by many prominent names within the NHS including DFI which clarifies the limits of what HSMR can do.  It is a system used by some hospitals. It would like to be the dominant system accepted by all hospitals. Maybe one day it will be, but it is not there yet. It has not won universal acceptance, and the huge amount of controversy surrounding the Stafford Hospital story has not helped it to win this.  I would suggest there is a real opportunity now for DFI to mend some fences and put the matter right!
All hospitals have to try and set systems in place to monitor quality. Stafford was using a whole raft of systems. For whatever reason – and this is lost in the mists of time, they did not regard HSMR as a high priority. They had bought into it but were not enthusiastic supporters.  On their prioritised list of indicators I believe (this information was given at one of the hospital board meetings) that the HSMR was ranked 25 out of the 75 indicators that they used.
I suspect that this means that staff were going through the motions of making returns rather than giving it any kind of priority.  A hospital which was seriously understaffed, and where admin staff had been cut, and the coding manager was off on long term sick leave will not have had the time, training or motivation to do this tricky job well.  
Lack of understanding.
Professor Jarman was shown a report by Helen Moss which showed her understanding of the function on Primary coding. She was struggling with the reality that they often did not know what a patient was admitted for, they were there for investigation, the diagnosis would come later, and she would then wish to code it with the dominant condition.  He was clearly very puzzled by this. Robert Francis asked him to clarify – if you get a case with admission for a broken hip and the person later develops CDiff, then what is the right code. Professor Jarman would not give an answer to this. It was clear that Helen Mosses understanding did not match with his, so there was confusion right at the centre.
Counter intuitive coding.
What a hospital would want this system to do is to give a clear indication of the overall health of the patient, so that it is possible to spot if a death occurs unexpectedly.
Roger Taylors very clearly stated example, of a diabetic being admitted for an in-growing toe nail and being coded by the in-growing toe nail is very helpful, but I can see that it would really be of serious concern to a clinician. 
Reflecting the state of health.
DFI in their analysis of the coding for Stafford say that the Primary coding seemed ok and that therefore the results are valid.  I would suggest that for a hospital with the kind of case load Stafford actually has, with many elderly patients suffering from 5-10 chronic conditions, that if the system does not clearly reflect this and weight it adequately then HSMR based largely on primary coding will give highly misleading results.
Poor recording of Co-morbities.
The evidence in the HCC report shows us that recording of co-morbidities was completely inadequate, it had been for years, and it continued to be so for some time after 2007.
(follow up – I would say that Dr Foster has work to do to satisfy hospitals that it can pick up on cases of people dying when they come in with a broken toe nail – but also accurately represent people whose general health makes death a likely outcome. The “information revolution” probably gives the way forward on this. I am certain that Roger Taylor left the Inquiry with the clear understanding that there is work to be done to ensure people understand the system better, and that it is responsive to their needs.)
The PCT investigation
The PCT carried out its own check – comparing the coded cases to the GPs notes. They thought it was the coding.
CHKS
Carried out an investigation and thought it was the coding.
The SHA investigation
through Birmingham university thought it was the coding.
Who thought what?
In the run up to the HCC report all the health experts close to Stafford were confident that  though there were clearly some problems at the hospital that so far as the mortality problems were concerned they were looking at a coding problem. Doctor Foster, Some elements of the HCC, Bill Cash, The pressure group, elements of the local press and possibly the Conservative central Communications team though that there had been huge numbers of deaths.
The piece of paper with the figures.
We learn from the evidence of Bill Moyes what happened at the meeting held in Alan Johnsons office immediately before the release of the HCC report.  The HCC appeared at the last minute with a piece of paper with the Excess deaths. None of this had been discussed fully with other parts of the health service before.  There was a huge row and a consensus view was formed that the material could not be released because the foundation of the figures was insufficiently sound and because it would cause widespread misunderstanding and concern.
The leak to the Daily Mail
We still do not know who leaked this figure to the Daily Mail. Bill Cash was asked directly about this by the BBC and said that he would not talk about it. The figures appeared with quotes from Bill Cash and from Julie Bailey.
Promotion of the figures
Whoever chose to put these figures into the public arena, they have been heavily used by the press, the Conservative party (including David Cameron, and Andrew Lansley)  and the Pressure group.
Why the numbers changed
One of the mysterious facts about these figures only became clear to me through the evidence of Professor Jarman and Roger Taylor.  The Hospital had been expecting their HSMR figure to come out as 114, when in fact the 2007 figures it came out as 127. This was a huge shock to them. There are two explanations for this, as Brian Jarman made clear.
The base line for HSMR shifts. The general trend is downwards, and so hospitals are “re-benchmarked” each year. To do this they have to get returns in and Stafford failed to do this. The other big element was that a new code for Palliative Care had been brought in, and that this had entirely escaped the notice of the people struggling with the coding in Stafford.  They had not used the palliative care core, but lots of other hospitals had, so there was a major shift occurring at this point. The 2007 League table quickly highlighted this problem and brought about action to recode cases.
The Palliative care recoding first pass
What really exited the press from the Professor Jarman evidence is that he clearly took the view that a group of hospitals in West Mids, under the guidance of the SHA had set out to game his system by recoding loads of people as palliative care. So we have again had lurid headlines involving many thousands of deaths!  
Roger Taylors evidence under careful questioning has I think helped us to get to the bottom of this. I am sure that there was a concerted action to get the coding sorted out. I think that the hospitals will have taken the immediate action of switching primary codes. This was sometimes the wrong thing to do. It certainly made an impressive graph!
Getting the coding right
Once the understanding of the system improved then I think what happened is that the hospitals recoded again, doing it the hard but right way in entering all the co-morbidities to give a balanced view of the health of the patients.
David Stone
David Stone was acting Chair after March 2009. He gave evidence to the Health scrutiny committee indicating that the coding at that time was robust – with an HSMR of 88 at that time. with the implication that it may not have been previously.
The 80% miscoding and Roger Taylors surprise.
What made a real impression on me was that Roger Taylor gave the bulk of his evidence with the conviction that though there were some real areas where the HSMR figure could be a little misleading, that there was no way that it could be very far out. He is used to thinking that everyone always says “it’s the coding”.
He was visibly shaken by the idea that the coding could be 80% wrong and clearly thought that if this was the case then the admin must be pretty chaotic. I could see him thinking  (of course this is just my impression) if the coding is really out by that much then the implications would be major!
Today I spotted a tweet about the Titanic being designed by professionals.  I think that the HSMR system is designed by very clever professionals and is an elegant system capable of being really helpful to the NHS. I think it is also vulnerable to being holed under the water line as comprehensively as it was by the unique series of events in Stafford.
I hope that if anyone from DFI gets to read this that they will think about this.
After looking very closely at this issue for three years, I think it is the coding!   
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The Healthcare Commission Story Part 1

For anyone who has been close to the Stafford Hospital Story over the last three years one of the most significant and contentious events was the decision by the Healthcare Commission to launch an investigation into the hospital in early 2008.
The Midstaffs Public Inquiry has been taking evidence from a number of people who were involved in the HCC at the period that this decision was being made.
This is a brief summary of some of the things that have seemed most important to me. I am aware that I will need to come back and flesh this out much more fully, but I am also aware that the messages I am picking up through the Inquiry raise really serious questions about the assumptions of “a failing NHS” which lie behind the Governments proposed Health reforms. I want to alert more people to this possibility now, at a crucial time for decisions about the health reforms.
The assumption that has been made in the press, and by many of the politicians who rely on the press for their information is that the sequence of events which led to the HCC Stafford Hospital investigation is as follows:
·         The Dr Foster Intelligence produced in mid 2007 a league table of hospital mortality rates which it published in the Daily Telegraph, raising widespread public concern (and also widespread outrage within the NHS about the appropriateness of using the data in his way)
·         Julie Bailey’s mother died in November 2007, sparking a low key local campaign which led to the formation of “Cure the NHS” in Early 2008.
·         Cure the NHS began systematically contacting anyone concerned with the Health service, and build up their contacts with the local press to raise the profile of the concerns about basic nursing care that they felt about Stafford Hospital.
·         Cure the NHS contacted the Healthcare Commission in early 2008 and it was the combination of the Dr Foster mortality rates and the Cure the NHS concerns that triggered the Healthcare Commission investigation of the hospital.
This assumption – according to the testimony given by different members of the HCC is wrong. What actually happened is this:
·         The HCC were aware of the Dr Foster league table, but shared the opinion of other statisticians and regulators within the NHS that the HSMR rates were useful as a management tool, but that the mortality rates produced by this method are insufficiently robust to be used as a league table, and cannot be used as an indicator of quality of care.
·         The HCC did not monitor the local press and so had not picked up on the campaign by Cure the NHS.
·         The HCC received a flood of complaints brought together by the newly formed Cure the NHS in early 2008. They had received no complaints from Stafford before this. They noted the complaints, but would have been unlikely to have triggered an investigation as a response to this.
·         What did trigger the investigation was a new statistical system that the HCC was working on in conjunction with the Dr Foster Unit. (It is important to note that the Dr Foster Unit, which is an academic body attached to imperial college, is entirely separate from Dr Foster Intelligence, which is a commercial company which sells mortality information and consultancy to the health service).
·         This new statistical system was to look at outliers. It was being developed by the Dr Foster Unit as a means of measuring outcomes in the NHS. It is broader that mortality, taking in matters like the development of bedsores, or delays in discharge, or readmissions. Whereas the HSMR system gives a composite figure for a hospital which may for a number of reasons give a very misleading impression, the Outliers system is intended to allow people to focus on the fine detail of performance on a particular ward, or kind of surgery.
·         The reason why this system was being developed is that the Dr Foster Unit and HCC both recognised the limitations of HSMR and needed something that would give managers a much more detailed window into their own performance. This system is, as the evidence of Martin Bardsley makes clear, primarily designed as a tool to assist managers and clinicians drive up quality. It was not conceived as a means of measuring quality of performance.
·         The work on these new outliers was being carried on in a rather clandestine way. The HCC make it clear that they were nervous of word of this new system getting out as they believed that they would be criticised by many people within the health service for this groundbreaking new approach. The Dr Foster unit may also have been aware of the commercial possibilities of the system, and wanted to “keep it under wraps”. The wider Health service was not told about this work which the HCC witnesses have all been at pains to say was a “pilot scheme”. They have said this in reply to questions of why they were not sharing the information they were getting through the alerts generated by the system with the SHA, PCT and Monitor.
·         The very first alert produced by this brand new pilot system came in July 2007 and related to operations on the jejunum carried out at Stafford Hospital. The very cautious approach taken by the HCC statisticians to this new information was that this was not necessarily telling them anything, but it raised questions which they wished to follow up with the Hospital. They expected that the outlier was probably caused by coding problems. The process that they followed was to write a letter to the Hospital asking for further information.
·         Robert Francis speculates on how this would have been received by the hospital. They were being asked to respond to a system that they knew nothing at all about, and they may not have understood what was expected from them. (It is clear that this would have been happening at the time when the hospital was undergoing significant problems as a result of cut backs caused by the financial problems. There were real problems occurring within the hospital and dealing with this extra paperwork exercise may not have seemed like a high priority task.)
·         Between July and November more outlier alerts into a number of different clinical areas all associated with A&E were generated from the hospital. The Mortality Outlier group at the HCC continued to follow these up with more letters seeking further information.
·         By the end of 2007 the HCC mortality outlier group were becoming concerned by the number of the outliers, and by the lack of a full response from the hospital. They had still not drawn any conclusion about what this might actually mean, they were perfectly aware that the results could easily be explained by either the case load, or by idiosyncrasies in the way that the Hospital was coding cases. (In practice I think that Martin Yeates and his team would have considered that this matter would be covered by the work being carried out by Professor Mohammed of Birmingham University, at the instigation of the SHA to look at the High HSMR figures in 6 of the hospitals in the West midlands region.) The HCC mortality outliers group were however sufficiently concerned to refer their findings to the HCC Investigation team who then prepared to carry out a preliminary visit to the hospital.
·         The Preliminary unannounced visit took place in early 2008. Heather Wood describes that they were concerned about the EAU where they found an elderly lady out of the sight of a nursing station, in a dark corner of the ward, and at risk of falling out of bed. The lay out and Staffing levels that they found on this visit to the EAU was sufficient to persuade them that a full inspection was necessary.
·         Once an inspection was announced then the HCC rapidly became aware of the Cure the NHS campaign and their complaints fed into the investigation process.
·         The high level of attention given by the press to the investigation and to the Cure the NHS campaign ensured that more people came forward to tell the HCC team about their stories. Many of these people have never been directly connected to the Cure the NHS campaign, but felt that they had information which might be relevant.
How did the wider Health service see the investigation?
·         People at all levels within the health service have shown how concerned they have been about the role played by the press. Whilst no one has directly criticised individual papers yet, there is a very high level of awareness of that stories need to be managed in order to try and prevent the damage that can be done by misleading and sensationalised stories in the press.
·         There has been considerable disquiet about the length and the conduct of the investigation, and the damage that has been done to the hospital and public confidence in both the individual hospital and the health service as a whole both by the investigation and the consequences that flowed from it.
·         The investigation has clearly been extremely divisive within the health service with many direct criticisms having been made both of the process and some individuals within the team. Heather Wood made it clear that her relationship with the rest of the health service has been deeply damaged by this. The animosity that she feels towards a number of individuals was clearly displayed within her evidence. The key members of the Investigations team interviewed by the Inquiry are no longer working for the CQC.
What did the Investigation tell us?
·         When Ben Bradshhaw as Secretary of State for health had discussions about the investigation in May 2008 he asked the question “is this another Maidstone and Tunbridge Wells.” He was given the assurance – some four months after the investigation had begun that this was not the case. So this means that even after four months actively looking for problems that the HCC investigations team were not seeing anything that led them to expect that large numbers of deaths had occurred.  
·         With my personal reading of the Healthcare Commission report I saw that a very thorough trawl of information about the hospital had been done and that there were a number of real problems that had been identified. I also read with interest the sections on the statistical material which did make it clear that there were significant problems with coding which would have made the Dr Foster material unreliable.
·         A reading of the report showed plenty of areas where improvement needed to be made. The body of the report does this with a certain detachment. The Summary is much more dramatic than the report, and many people within the health service were concerned about the “sensational” way in which the report was presented.
·         Though it is completely clear that there were many things going on that will have made peoples stay in hospital undignified, unpleasant, and perhaps at times unsafe I personally found it difficult to see anything in the report that might have explained death on a widespread scale.
·         The “excess death figures” that appeared everywhere in the press and have continued to be used ever since were particularly puzzling because they simply do not appear in the report at all.
Why don’t the Excess death figures appear?
·         The figures which have formed the central assumption in every piece of press coverage from March 17th 2009 onwards is that there were 400-1200 excess deaths as a result of poor care. These figures apparently appeared as part of an appendix in a draft version of the report
·         Sir Ian Kennedy explains that the decision not to use the excess death figures was taken by him.
·         A very limited number of people have seen this material. I am not one of them, so I cannot give any reliable account of what the document said or implied.
·         The assumption made by the press is that the figures were removed as a result of pressure from the DOH. Sir Ian makes it very plain that he does not bow to that kind of pressure and that the DOH did not ask him to do this. Bill Moyes from Monitor did say to him that the figures were insufficiently robust and should not be used.
·         Ian Kennedy says that his decision to leave the figures out is based on his experience of Bristol, where there were a number of “unnecessary deaths” identified, but there was no way of connecting these to individual deaths. His concern was that if a figure of numbers of deaths were to be used by the press that this would cause a great deal of pain for many people who had lost relatives in this period. They would wonder if there was more that they could or should have done.
·         This fear is entirely borne out by the evidence given by many of the bereaved who have given evidence to the Inquiry. They believe that their loss was “the tip of the iceberg” and they feel driven to pursue to the matter so that “no one else has to suffer”. As Ian Kennedy gave his evidence I was sat directly behind a lady who has said to me in so many words “My (relative) was one of the 400”.
·         It is clear from the evidence of Heather Wood and Nigel Ellis that they felt that the figures should have been included in the report. At least in the case of Nigel Ellis he felt that the figures should be there for completeness but with strong provisos that these were theoretical figures which related to probabilities, and did not tell us that any number of people were known to have died as a result of poor care.
Degrees of certainty about the Excess death figures.
At the moment there is still huge uncertainty about these figures. This is something that the inquiry still needs to actively explore.
I do not know the following:
·         Who wrote the deleted material?
·         What is the statistical source of the excess death figures?
·         How the deleted material is phrased – is the word “If” included?
·         If the figures are based on the Dr Foster figures then has it been made clear that the NHS as a whole does not accept these as a robust indicator of quality of care?
·         If it is based on the mortality outliers then has this material been subject to peer review?
·         What do other statisticians think of it?
What I do know is that the degree of certainty with which people talk about the Excess death figures is in inverse proportion to the understanding of their statistical basis.
We can trace this through the evidence given to the Inquiry.
·         Martin Bardsley who was the person within the HCC who understood the statistical material best is very cautious about the conclusions that can be drawn from the material. He sees the Mortality outliers as management tools, there to assist in improving quality. They are not to be seen as an indicator of quality.
·         Nigel Ellis, is almost as cautious about the use of the figures. He is an investigator who will use statistics, rather than a statistician. He does see the excess death figures as telling us something about what happened at Stafford. He wanted the figures to be used with qualifying statements about what they meant.
·         Heather Wood who was the head of the investigation team says clearly of herself that she is not a statistician. She has clearly accepted from her more expert colleagues that the figures are telling her something, and she is then falling back on her own preference for dealing with what other people pejoratively call “anecdotal evidence”. It is Heather Wood who was directly questioned by the press at the press release of the HCC report, following the leak to the press of the excess death figures on the previous day, and her response to their questioning gave the press the go ahead to attribute these figures to the HCC.
·         Sir Ian Kennedy is at a further remove from this, he accepts the information that is given to him by others working within the HCC and his comment is that he thinks their methodology is sound, but that it would be unhelpful to use the figures because the press would misinterpret them and they would be into a major dispute about statistics rather than being able to focus on the real problems associated with poor care and the impact that had on individual families.
The Impact of the figures:
·         Sir Ian was completely right about the way the press would misread the information.
·         The fact that the material was not in the report and we could not see where it came from means that we have taken from March 2009 to May 2011 to see what actually happened, and that even now we do not know the detail of what was said in the appendix.
·         What perhaps could not have been anticipated is the degree of enthusiasm with which politicians then used these figures.
·         We have already seen from the evidence of Bill Cash that he had no idea where these figures came from, he simply accepted them at face value, as something he had picked up from the newspapers. He certainly continued to use these figures in his election leaflets for 2010 Even after the publication of the Robert Francis Independent Inquiry.
·         Other local politicians followed suit, and the figures were widely used in the Local election campaign of 2009.
·         We do not know what David Cameron and Andrew Lansley understood about these figures. It is possible that if they had their information from Bill Cash, or even from Ian Kennedy or Heather Wood that they may have read more into them than the statisticians themselves would have wished. What we do know is that Andrew Lansley and David Cameron have used these figures on a number of occasions, and have made Stafford a central “image” in their general election campaign.
·         I am not certain that they have used the figures since the statement on the publication of the Robert Francis Inquiry, with its clear indication that the figures are unsafe, Though David Cameron did use the figures in PMQs immediately before the statement. What I can say is that they have never attempted to correct the impression that they have repeatedly given that Stafford is proof of the failure of the health service, and is a justification for major reforms of the health service.
Is anyone to blame for the confusion?
I came to the evidence of the HCC sharing the anger felt by many people within the Health service about the way in which the Stafford hospital story has been sensationalised and the way in which misleading material has been used. I was prepared to blame individuals within the HCC for what had happened.
Having listen to and read the evidence so far I am able to see understand the motivation of the individuals concerned much more clearly.
Everyone who I have seen from the Health service at the inquiry has been genuinely concerned to try and deal with the real challenges that the health service is experiencing. They want to find ways to help the health service deliver the best possible standard of care. They each bring different skills and different approaches to this task.
The task that the PCT, The SHA, the HCC, and now the Care Commission are all seeking to perform is finding ways of seeing how good the quality of care is and how it can be improved. This is an ongoing task. We are not talking about some perfect time in the past when we could clearly see this information, the tools for doing this job have been under active development for the last decade or so.
Targets were a step on the way, The Dr Foster HSMR figures were a step on the way, The Clinical Dashboard developed by the SHA is a step on the way, The Mortality outliers system being developed by the Dr Foster Unit and HCC are a step on the way.
All of these things are tools designed to assist managers to manage. They are not and should not be used as hard and fast indicators of quality of care, in a way that the Press and public can use as a single headline indicator of how good a hospital is.
These are good systems, being driven by good people for a good reason. They are also highly confusing.
The problem only arises when they are used for a purpose that they are not intended by the press and politicians.

Helen’s Story: Stafford Hospital

The first time that I became aware of Helen Moss was at the Midstaffs foundation trust AGM in 2009.
To call this a lively meeting would be an understatement. The pressure group were out in force and well organised. It was the first time that many ordinary members of the trust were exposed to the level of anger the pressure group is capable of producing. In the AGM Helen Moss was called to answer a question on “hand overs”. The group all stood up with placards, and shouted “we want you to go”.  The ordinary members in the room were visibly shocked.
Over the following weeks there were frequent photographs in the local press of the protest group holding placards demanding the resignation of Helen Moss. The reasons for their demand were never explored.
Eventually the protest group got their way. She gave up the job and moved away.
Earlier this year there was an interview in the local press with the head of the protest group which set this in context. I have no way of knowing how accurate this account may be. The report indicates that It came back to a phone call from her to Helen. It was clear that there was no meeting of minds. The head of the protest group describes “a switch” going off in her head, and she made up her mind to get Helen out of her job.
There have been demands from the protest group for the sacking of all the staff, and for closing the hospital ward by ward and clearing out any staff that were not up to their jobs, but in the case of Helen it was personal.
28th March 2011 was the first day in which I had an opportunity to hear Helen’s story. Full transcript here She is a quietly spoken, intelligent woman, trying hard to answer difficult, and at time hostile questions with precision.
It is clear that she took up her job as director of nursing at a very difficult time. The staff numbers had been allowed to run down as part of the cost saving exercise to get the hospital back into line financially. The pressure of working constantly with not enough staff was beginning to tell and staff morale was low.
Helen gave the best description I have yet heard of the peculiar culture that is said to have existed at the hospital. There was nothing at Stafford to attract ambitious young nurses, Stafford did not look like a hospital that offered a career path. Many of the nurses that came did so directly from the university, and therefore did not gather experience in the wider world of the NHS. It was, as we had heard from other witnesses an enclosed world, with not enough challenges from outside. There were things that were being done to ensure greater quality in many hospitals which did not seem to have taken off in Stafford.  (All of these issues have been actively addressed now).
Helen was faced with a big problem. She needed to do what she could to change the culture of the hospital, and she also had the task of trying to recruit more nursing staff to get things up to “establishment”. She did not have as much money as she felt she would need for this task. This is a task that was as time went by becoming increasingly difficult. Nurses were reluctant to come into a hospital which was understaffed The effects of the under staffing led to the complaints from the pressure group. As the pressure group’s campaign gathered force there were the growing pressures of media attention.
It became impossible to recruit the full time staff the hospital needed at the speed that it needed to do it. This was like running a bath with the plug out. Recruitment was going on constantly, but staff turnover was accelerating. 
This article which takes us back to October 2008 before the issues of the health care commission report gives us a snap shot of the growing pressures.
The Health Care Commission investigation was experienced by the staff who were trying to make the hospital work as an additional burden. Helen, like many of the staff who have spoken before, talks about how difficult and hostile this investigation process was. It was clear that the HCC was not there to help the hospital.
The inquiry focused in on Helen’s understanding of the mortality figures. This is now a standard part of the questioning to virtually all witnesses. Helen’s evidence here is important because she was there and in charge of clinical governance at the time that the figures were an issue. Her testimony is in line with that we have heard from all those people who were part of the hospital and had reason to understand the mortality figures.
The Dr Foster figures first became an issue in 2007. This was the time at which the Dr Foster system was shifting from being a management tool that some hospitals had brought into, to being a tool that foundation trusts, or hospitals seeking to become foundation trusts, were required to use in order to show their “performance”. It was clearly know in the hospital from before the issue of the figures, that their coding of cases was not being done properly.
They had expected to come in with a coding figure of 114 which was moderately high, but a last minute change in the methodology by which the Dr Foster company generated the figures led to a significantly higher figure of 127. This put the hospital in the “worst” 5 in the country.
The hospital were alarmed by this and immediately sought advice. The Dr Foster company provided re-assurance. It was clear to them too that the coding was “shallow” and that this would have led to an elevated HSMR figure. They thought that the high figures could be adequately explained by this.
The Hospital did not leave it at that they took a series of steps. They recruited a new coding manager. This was necessary, because funding was now partially dependant on HSMR level. The coding manager worked with a newly formed mortality group, which reviewed deaths over the previous year. This we have heard from Eric Morton was cross referenced by the PCT with GPs case notes, and it verified that the coding had been done wrongly in many cases, and that a misleading figure was therefore produced.

The Mortality group began the task of focusing in on the fine detail of mortality figures to see if there were any patterns. Or any indication of underlying problems.

As the coding manager began to take on new cases, the mortality rates being produced by this new “robust” data dropped steadily from high, to average, to well below the national average.
The hospital sought advice from the SHA and Birmingham university. Research was carried out into the Dr Foster Methodology.  (This has led in 2010 to changes in the way in which mortality is measured on a national basis.)  The Birmingham research did also spell out that the Hosptial should not rely exclusively on the coding, and should explore ant other areas of weakness which might account for the high figures. This feeds back to the work that the mortality group was undertaking.

The hospital took on board the advice from the university that the HSMR figures in themselves could not provide a reliable picture of the quality of service and advised on looking at other ways of measuring the quality of work including performance dashboards, which look at a wide range of indicators.
Through all this careful painstaking work there were problem areas being identified, and the hospital sought expert advice from the college of surgeons to produce a report on one specific area where concerns had been raised.
The Healthcare commission for reasons which have yet to be explored chose not to accept the line which was accepted by the Hospital, the PCT, the SHA, Birmingham university, and even we hear from the Dr Foster company, that “it was the coding” and they came in to carry out their investigation.
The HCC did not share information with the hospital during this process, and because of that the hospital called in Price Waterhouse Cooper to give them advice on what they needed to do to improve matters.
Helen was asked about her reaction to the horror stories that are now so familiar to everyone through the press about poor care in the hospital. She like virtually all the people who have been asked this question expressed the shock she had felt. She also showed that there was nothing in her own experience of the hospital that prepared her for these stories.
She did carry out regular visits to wards all over the hospital as a key part of her job. She had staff expressing to her their frustration about staffing levels and staffing mix. She was actively working to satisfy this through the recruitment process, and through a staff mix review, that was put in place to help push for the extra funding that was needed to bring staffing up to the right levels. She did not in her frequent visits to the wards see anything in line with the stories told in the press, and she did not have nursing staff coming to her and saying that the staffing levels had reached the point where it was impossible for them to do their job.
The impression that I was left with at the end of this evidence was of a genuine caring and hardworking person, who had tried to do a difficult job under difficult circumstances, and was in the end defeated by a unique set of circumstances. This article shows the kind of pressure that she was under.
I would have liked the inquiry to invite her to say what she had felt about being on the receiving end of such pressure. I am sorry that they did not ask her this.
Helen gave the apology to the bereaved which is now a standard part of most people’s evidence.
Here is the coverage of the day from BBC and Express and Star.