'Worryingly high' hospital death rates reported

NHS hospitals in England are “full to bursting”, says The Daily Telegraph, while The Guardian highlights concerns over “worryingly high” death rates in some hospitals.

The alarming headlines are based on an annual Dr Foster report on hospital statistics. The independent report looks at areas such as mortality rates, bed occupancy rates, staffing and efficiency, and access to treatment in each hospital.

The report says that most hospitals are under pressure from rising numbers of emergency admissions, particularly among frail and elderly patients. It also found wide variations in hospital mortality rates, with 12 trusts showing rates higher than would be expected on two out of four measures used to gauge death rates.

The report also raised concerns about NHS inefficiency, citing the fact that around one in three hospital bed-days are caused by patients whose ‘admission might have been avoided if their care was better managed’.

Who produced the report?

The report has been published by Dr Foster, an independent research organisation that produces guides to the quality of the health services in both the public and private sectors. The guides are based on individual hospital trusts’ performance data. For the past 11 years, Dr Foster has published analyses of hospital performance through its annual hospital guide. The 2012 Dr Foster guide ‘Fit for the Future?’ is available for free online (PDF, 664KB).

Dr Foster works with many NHS organisations to help them analyse the quality of patient care to make improvements.

What were the main findings of the report?

Pressure on hospital beds

The report points out that the number of acute hospital beds has decreased by a third in the past 25 years as hospital stays have become shorter. However, it says admissions are rising, especially for groups such as the frail elderly. This is one of the main causes for growing pressures on hospital beds, which it highlights as including:

• For 48 weeks a year, most trusts are more than 90% occupied. The report says such high levels of occupancy make it harder to provide a safe, effective service. For example, infections become harder to control and mistakes are more likely to happen.
• Patients whose admission might have been avoided if their care had been better managed, account for 29% of hospital bed days. This includes patients who could have been seen as day cases, patients who could have been treated in the community, and patients who have been readmitted within a week of discharge.
• The report highlights the fact that around 55,000 people were admitted to an acute hospital service with a diagnosis of dementia – a condition that it says should not be managed in hospital. Each admission represents a failure of care, according to the report. A similar failing was found in there being over 150,000 admissions for urinary tract infections – which in most cases, could have been prevented by higher standards in primary care.
• Patients over the age of 75 accounted for 50% of “avoidable” bed days.  

Inefficiency

Trusts that provide cost effective care by reducing length of hospital stays, avoiding emergency readmissions and using resources effectively can also achieve good outcomes, says the report. At a time when budgets are under pressure, the report says efficient care must be delivered, but not at the expense of quality.

Areas of inefficiency include readmissions, unnecessary admissions, patients spending too long in hospital, wasted outpatient appointments and little elective surgery being carried out at weekends. For example, it says that one million hospital stays are unnecessary – of little or no benefit to the patient or the taxpayer, and that:

• very few hospitals stand out as delivering efficient and high quality care
• four trusts score well on both efficiency and quality
• two trusts score badly on both efficiency and quality

Fair access to treatment

The report points out that the level of treatment provided to patients declines as they get older and medical intervention is less appropriate. However, the degree to which this happens varies and may reflect lack of access to services for older people, rather than the views of patients themselves. For example, older women who have a mastectomy may have less chance of being offered breast reconstruction surgery. However, over-treatment of older patients can be as much of a problem as under-treatment.

Variations in levels of treatment suggest they may at times be driven by availability of resources and the views of clinicians rather than those of patients.

High mortality rates persist

The report says that wide variations in hospital mortality rates persist. The report uses four measures of mortality (see below) as a warning sign that poor quality care may be leading to a higher than expected mortality and that further investigation is needed.

• five trusts did well on three out of four measures
• twelve hospital trusts did poorly on at least two of the four measures of mortality
• three trusts have had a consistently high Hospital Standardised Mortality Ratio – one of the four measures of mortality – for the past three years
• mortality rates for patients admitted at weekends are generally higher than weekdays
• five trusts had high mortality rates only at the weekend
• higher levels of senior medical staffing at weekends are associated with lower mortality rates and there has been a slight increase in weekend staffing since last year

How are hospital mortality rates assessed?

Dr Foster uses four different types of measurements to assess an individual hospital’s mortality rates, which are:

• hospital standardised mortality rates – a measure of how many deaths occur while a patient is in hospital care, based on the conditions that account for 80% of deaths
• summary hospital-level mortality indicators – a measure of any deaths that occur after hospital treatment in hospital or in the first 30 days after discharge
• deaths after surgery – the amount of patients who die due to a complication occuring during or shortly after surgery
• deaths in low-risk conditions – deaths in conditions in which patients would normally survive

The use of four separate measurements adds weight to the finding of the report’s analysis.

For example, a hospital may have a high rating in one measurement, such as deaths after surgery, for purely blameless reasons.

It could be the case that it performs a greater number of high-risk surgical interventions in severely ill patients, than most hospitals.

However, higher mortality rates than would be expected in two (or more) measurements would usually be seen as a cause for concern.

Does the report make any recommendations?

The report does not make formal recommendations, but it does highlight five main problems that need to be addressed by the NHS in order to improve both the effectiveness and efficiency of services.

Firstly, many of the people currently in hospital beds are there because of a lack of access to more appropriate treatment. Last year for example, nearly 55,000 people were admitted as emergencies with a diagnosis of “nothing more than dementia”. The report says that “hospitals are becoming refuges for those who have been let down by the wider health system”.

This then leads to the second problem highlighted by the report – bed occupancy rates, which in certain parts of the country and at certain times of the year, can be as high as 92%. Previous research has found that once bed occupancy rates rise above 85% it is more likely that problems affecting patient care will develop.

Thirdly, it says that there is patchy provision of care for elderly people, with some elderly people not being offered treatments (such as breast reconstruction surgery after a mastectomy) that would be offered to younger patients.

Fourthly, despite being a recognised problem for many years, the mortality rates during weekends are much higher than during the week. Hospital trusts need to do more to make sure that more senior medical staff work at the weekend.

Finally, there is a great deal more that hospitals can do to increase efficiency and savings without compromising patient care. They mention expensive MRI scanners going unused at weekends due to lack of staff, or hundreds of millions of pounds being spent on readmitting patients for problems that could have been avoided if recommended care protocols had been followed.

Dr Foster’s co-founder, Roger Taylor, says that much of what needs to be done to solve this rests with GPs, community services and social care. Nevertheless, he also says more could be done by hospitals to improve efficient use of resources by, for example:

• better use of day case surgery
• avoiding unnecessary admissions
• reducing the number of patients who have operations cancelled after admission
• making better use of hospitals at weekends by increasing activity and staffing levels