Category Archives: Mortality

Measures of mortality andt heir significance

Life tables 1841 -2011

The first English Life Table was based on data collected around the census year of 1841 and gave female life expectancy as 42 and male as 40.[1] By the sixth table, in 1891, life expectancy for women in England and Wales was 48 and for men 44. Many people lived longer than this, but so many babies died in their first year of life that it brought the average down. Public health reforms during the 1890s meant that by 1901 life expectancy was 52 for women and 48 for men.[2] Four years each, gained in just ten years. The turn of the century brought a dramatic drop in infant and childhood mortality as sanitation and living standards improved. By 1921 women were expected to live to 60 and men to 56. Eight years each, gained in just twenty years. By 1951 women’s life expectancy was 72 and men’s 66. Women gained 12 years to men’s ten over this thirty-year period as a result of better maternity care, partly due to the new NHS, and a higher proportion of women being non-smokers. This rise, of more than a year every three years, took place despite war, rationing and austerity.

Improvements slowed in the 1950s. Most of the easy victories had been achieved. In 1956 the Clean Air Act was passed, four years after the Great Smog caused excess deaths that Harold Macmillan tried to blame on influenza.[3] By 1971 life expectancy for women was 75 and for men 69. Three years more each, achieved in twenty years. In the 1970s the rate of improvement in life expectancy accelerated again. Social progress in that much maligned decade meant that despite cutbacks in healthcare and public services in the 1980s under Margaret Thatcher, by 1991 women were living to 79 and men to 73. Four years each, achieved in twenty years.

Over the next twenty years, men caught up a little with women: since more men smoked there were more male smokers who could give up. By 2011 women were expected to live to 83 and men to 79. In those twenty years women gained three years and men five. The six-year gap that had opened up by 1951 was back to four.

Since 2011, under David Cameron and Theresa May, life expectancy has flatlined. The latest figures, published by the Office for National Statistics in September, are for the period 2014-16. Women can now expect to live for 83.06 years and men for 79.40 years.[4] For the first time in well over a century the health of people in England and Wales as measured by the most basic feature – life – has stopped improving. Just as Macmillan had done, the government initially tried to blame the figures on flu deaths. But as the years have passed and life expectancy continues to stall it has become clear that flu isn’t the culprit. The most plausible explanation would blame the politics of austerity, which has had an excessive impact on the poor and the elderly[5]; the withdrawal of care support to half a million elderly people that had taken place by 2013; the effect of a million fewer social care visits being carried out every year; the cuts to NHS budgets and its reorganisation as a result of the 2012 Health and Social Care Act; increased rates of bankruptcy and general decline in the quality of care homes; the rise in fuel poverty among the old; cuts to or removal of disability benefits. The stalling of life expectancy was the result of political choice.

The first to be affected were elderly women living alone in the poorest parts of the UK. Their areas had been targeted by the last Labour government for interventions aimed at improving health. All those schemes were cancelled in the years after 2010. By 2016 cuts in welfare spending, especially those affecting older pensioners, had been linked to a rise in deaths. Public health experts writing in the British Medical Journal called for an inquiry, but the government refused.[6] Instead officials continued to claim that ‘recent high death rates in older people are not exceptional.’[7] An even higher rise in the death rate was recorded for Scotland, but again there was no serious response.[8] By July 2017 Michael Marmot’s Institute of Health Equity was linking NHS cuts to the rise in deaths among those with dementia and to faltering life expectancy.[9] A paper I co-wrote with researchers at Liverpool, Glasgow and York connected the rise in mortality rates with delays in discharging elderly patients from hospital because appropriate social care was not available.[10] The Financial Times reported that the slowdown in life expectancy had cut £310 billion from British pension fund liabilities, and these figures included only a few pension schemes.[11]

Life expectancy for women in the UK is now lower than in Austria, Belgium, Cyprus, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Liechtenstein, Luxembourg, Malta, the Netherlands, Norway, Portugal, Spain, Sweden, and Switzerland.[12] Men do little better.[13] In almost every other affluent country, apart from the US, people live longer than in the UK, often several years longer and the best countries are pulling away. Between 2011 and 2015 life expectancy rose by a year in both Norway and Finland.[14] It rose by more than a year in Japan, despite the Japanese already having the highest life expectancy in the world.[15]

Extra deaths now projected to occur every year in the UK from 2016 to 2058, by ONS – 2016-based projection as compared to the 2014-based projection

 Extra      Cumulative       Time Period

‘in year’

deaths

39,307             39,307             2016 – 2017

25,668             64,975            2017 – 2018

27,246             92,221            2018 – 2019

28,521             120,742          2019 – 2020

29,581             150,323          2020 – 2021

307,031           457,354          2021-2030

 246,302           703,656          2031-2040

 178,483           882,139          2041-2050

17,310             882,139          2050 – 2051

17,463             899,602          2051 – 2052

17,582             917,184          2052 – 2053

17,650             934,834          2053 – 2054

17,600             952,434          2054 – 2055

17,404             969,838          2055 – 2056

17,050             986,888          2056 – 2057

16,524             1,003,412       2057 – 2058

Source – calculated directly from ONS tables of expected deaths by age and year.[16]

In the UK official projections have now been altered because of the tens of thousands of people who have died earlier than expected. If you subtract the latest ONS figures from the figures published two years ago, you can see that a further one million earlier deaths are now projected in the next forty years (the ONS itself doesn’t publish this number – it is shown in the table above).[17] What has happened is no longer being treated as a decline; it is the new norm. On 26 October the Office for National Statistics announced that it estimates that, by 2041, life expectancy for women will be 86.2 years and for men 83.4. Both figures are almost a whole year lower than projected in 2014.[18]

Superficially this might appear a small adjustment that will only have an effect many years in the future. But its implications are huge.[19] Already in the year from July 2016 to June 2017 an additional 39,307 people have died. Seven per cent of them were people between 20 and 60: almost 2000 men and 1000 women. Well over four-fifths of the premature deaths projected by the ONS will be of people who are now in their forties and fifties.

These extra deaths are not linked to more migration to the UK: the ONS now projects less in-migration. They are not due to a rise in births: the ONS now projects lower birthrates. They are simply the result of mortality rates having risen in recent years.[20] The ONS believes this will have a serious effect on life expectancy and population numbers for decades to come. It does not say why the change has happened or even point out how exceptional it is.

The UK government accepts that air pollution, a reversible cause, results in 40,000 premature deaths a year.[21] There are complaints and headlines about that, but not about the fact that there were almost 40,000 more deaths than expected in the year up until June 2017. It is projected that there will be an extra 25,000 deaths between July 2017 and June 2018; an extra 27,000 in the year after that, more than 28,000 extra deaths in the 12 months after that, then another 30,000 (see table above). And on and on and on, and still the government has given no explanation.

Whatever has happened has happened in a country where the official statisticians feel they can only point out in the seventh note[22] attached to a press release that some figures have been adjusted. It is not difficult to guess the likely cause of the sudden deterioration in the health of the nation. If we do not address the policies that have caused these changes, the ONS projections will become reality.[23]

References

[1] ONS (2015) How has life expectancy changed over time? London: ONS, September 9th, https://visual.ons.gov.uk/how-has-life-expectancy-changed-over-time/

[2] Dorling, D. (2006) Infant Mortality and Social Progress in Britain, 1905-2005

In: Eilidh Garrett, Chris Galley, Nicola Shelton and Robert Woods (eds), Infant Mortality: A Continuing Social Problem: A volume to mark the centenary of the 1906 publication of Infant Mortality: A Social Problem by George Newman. pp 223-228, available here: http://www.dannydorling.org/?page_id=2442

[3] Dorling, D. (2014) Why are the old dying before their time? How austerity has affected mortality rates, New Statesman, February 7th, https://www.newstatesman.com/politics/2014/02/why-are-old-people-britain-dying-their-time

[4] ONS (2017) National life tables: England and Wales 2014-2016 released on September 27th 2017: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/datasets/nationallifetablesenglandandwalesreferencetables

[5] Loopstra R, McKee M, Katikireddi SV, Taylor-Robinson, D, Barr B and Stuckler D. (2016) Austerity and old-age mortality in England: a longitudinal cross local area analysis, 2007–2013. J R Soc Med;109: 109–116.

[6] Hawkes N. (2016) Sharp spike in deaths in England and Wales needs investigating, says public health expert, BMJ; 352: i981.

[7] Hawkes N. (2013) Recent high death rates in older people are not exceptional, says Public Health England. BMJ 2013; 347: f5252.

[8] Dorling, D. (2016) The Scottish Mortality Crisis, The Geographer (Newsletter of the Royal Scottish Geographical Society), Summer, pp.8-9, http://www.dannydorling.org/wp-content/files/dannydorling_publication_id5595.pdf

[9] Marmot, M. (2017) Marmot Indicators Briefing, Embargo: 0001hrs Tuesday 18th July, London: Institute of Health Equity,  http://www.instituteofhealthequity.org/resources-reports/marmot-indicators-2017-institute-of-health-equity-briefing/marmot-indicators-briefing-2017-updated.pdf

[10] Green, M.A., Dorling, D., Minton, J., and Pickett, K.E. (2017) Could the rise in mortality rates since 2015 be explained by changes in the number of delayed discharges of NHS patients? Journal of Epidemiology & Community Health, Online First: 2nd October 2017 doi: 10.1136/jech-2017-209403

[11] Combo J. Life expectancy shift ‘could cut pension deficits by £310bn’, The Financial Times, 2017 [updated 4 May 2017; cited 2017 8 August]. Available from: https://www.ft.com/content/77fa62fe-2feb-11e7-9555-23ef563ecf9a.

[12] Eurostat (2017) File: Life expectancy at birth, 1980-2015 (years), Brussels: Eurostat, http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Life_expectancy_at_birth,1980-2015(years).png

[13] Ibid.

[14] Ibid.

[15] Otake, T. (2017) Continuing streak, Japan leads world in life expectancy, WHO report says, The Japan Times, May 17th, https://www.japantimes.co.jp/news/2017/05/17/national/science-health/continuing-streak-japan-leads-world-life-expectancy-report-says

[16] ONS (2017) National Population Projections: 2016-based statistical bulletin, London:ONS, Oct. 26th, https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2016basedstatisticalbulletin

[17] To calculate these figures yourself you need to download the principal variant projections of 2014 and 2016 based by single year of age from here: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/z1zippedpopulationprojectionsdatafilesuk

[18] ONS (2017) National Population Projections: 2016-based statistical bulletin, London: ONS, October 26th,https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2016basedstatisticalbulletin#changes-since-the-2014-based-projections

[19] For the UK, at is makes up just under 1% of the global population, the implications are on the same order of magnitude as Sen’s findings of 1990 for the world but about the future, not the past: Sen, A. (1990) More Than 100 Million Women Are Missing, New York: The New York Review of books, December 20th, http://www.nybooks.com/articles/1990/12/20/more-than-100-million-women-are-missing/

[20] Dorling, D. (2016) Public Health was declining rapidly before the Brexit vote Public Sector Focus, July/August, pp.20-22, http://www.dannydorling.org/?page_id=5639

[21] Roberts, M. (2016) UK air pollution ‘linked to 40,000 early deaths a year’, BBC News (Health) February 23rd, http://www.bbc.co.uk/news/health-35629034

[22] ONS (2017) Note ‘7. Changes since the 2014-based projections’, London: ONS, https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2016basedstatisticalbulletin#changes-since-the-2014-based-projections

[23] There are numerous examples of where projections have not held true in future because people react to the projections and ten improve things before all the harm projected to occur if we can on as usual, can occur. See: Dorling, D. and Gietel-Basten, S. (2018) Why Demography Matters, preliminary details are here: http://www.dannydorling.org/books/demography/

First published by the London Review of Books

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Preparing for the end of someone’s life; be it our own or a loved one’s, is possibly the hardest thing we will have to do. Aside from decisions you have to make, you may need to draw up different documents, and discuss your or your loved one’s final wishes. Final arrangement also need to be discussed, like whether or not you wish to be buried, interred in a mausoleum, or cremated and then turned ashes into a living memorial diamond.

No one knows when death will come and break the calm and happy life.

However, it does get easier when you are willing to start the process long before the time ever comes. This gives you plenty of time to decide on the available courses of action instead of when the actual time comes, making it easier on the loved ones left behind. They will know what the final wishes were, have all the documents in order, and there shouldn’t be any surprise decisions to make because all the final arrangements have already been made.

Final Decisions

When it comes to final decisions, it’s safe to say that not all situations can be accounted for, but having had some prior conversation should make those decisions more bearable. Almost everything can be planned for and this listing is not meant to be all inclusive.

Here a few things you need to discuss with your loved ones to prepare yourself for end of life.

Health Care

While no one expects to pass on while in a hospital or nursing home, it would be prudent to find out what the protocol is for them in your area. While they are prepared to handle such events, knowing what will happen, helps you make appropriate arrangements in the event that you disagree with something.

Use of Hospice

This option is a god send for some, and a burden for others. While those whom work in the hospice industry are typically trained to help and aid both the family and those whom are terminal, it forces mindsets that can be quite hard to swallow. Again, being prepared for what should be done in these instances goes a long way.

Medical Procedure

Confer with loved ones what your beliefs are for medical help. While not quite the same as what health care protocols involve, make sure loved ones know and understand if and why there is a DNR in place, or how long to wait and under what circumstances they are to pull the plug on life support.

Important Documents

There are a number of different documents that should be accessible when the worst starts to happen. Documents like a living will, medical information release, and power of attorney, will prove quite useful. Provided that each set of documents is kept up to date, there shouldn’t be much in the way of added stress.

Each country will more than likely have their own version of the following documents, and this listing is not exhaustive to the number of documents you can have, or should. Please consult your doctor and lawyer long before you ever have to worry about this situation.

Living Wills

Living wills are legally binding and speak on your behalf for your end of life care. They do so when you are unable to do so for yourself. They also minimize confusion or added stress on your loved ones by pointing out what your final medical wishes are, such as a DNR or DNI orders. If you talk with your doctor about your wishes, they can draw up your DNR and DNI orders and have them in your medical file for you without the need for a living will.

Medical Information Release

Due to the nature of medical care, it is important that you have a legally binding release of information or you may find yourself unable to get information. This can extend to medical insurance policies; so it would be wise to have one should the need arise. A legally binding release of medical information allows those designated by you to receive information about your condition and prognosis as well as deal with the insurance company if needed.

Power of Attorney

A power of attorney is quite important and it will allow a person you designate to operate on your behalf when you are unable to do so; for a great many things. While a general power of attorney form encompasses a very broad range of things, you can also be quite specific in who can do what where, and how.

Final Wishes

These are more of a personal nature, and should be discussed at length with your family. In most countries, it may be customary to hold a funeral and a wake, but it may not be quite what you want. Things to consider for your final wishes include how you want your remains handled, specific instructions for the family, and how you would like to be remembered, such as turning your cremated remains into an ever-lasting diamond.

Turning ashes into diamonds and setting it on memorial jewellery become new trends to commemorate a beloved.

Your religious beliefs and life beliefs will play a large portion of this, and can only be carried out if your family knows about it. Otherwise, you will be left with what they think is best at the time. Most family members will gladly follow your last wishes if they know them, so be candid with them and what it is that you would like done when the time comes. Then, they can be assured that what they are doing will make you happy in the afterlife.

Final Arrangements

Almost all of your final arrangements will be cost intensive. You may want to be buried in the back yard under your favorite tree with your favorite book; but there may be laws in place that would prohibit such actions. There are also many laws in place about the spreading of ashes. Please research your area’s laws on the matter before making a final decision.

Cremation

Probably the second most opted form of final rest, cremation reduces the need to purchase a plot at a graveyard or within a mausoleum. Ashes can be kept and quietly displayed at home, or used for living memorials for the remainder of the family. Turning ashes into memorial diamonds can provide loved ones with a unique and special way of keeping someone they’ve lost close by.

Burial

Typical burial is quite possibly the most common form of a final resting place. However, along with the costs of conducting a funeral, you will need to weigh in the cost of a casket and burial plot. Often, a burial plot can be purchased years in advance, but bear in mind that you must read the fine print for the grounds you wish to be laid to rest in.

Entombment

If you feel that being in a graveyard is not to your liking, you can also look into being interred at a mausoleum. While you will still have to purchase a plot, it offers a more accessible way for your family to visit over a grave.

Graveyard – another home to return.

Final Thoughts

Being prepared means knowing what to do in any given situation. Preparing for a loved one’s or your own demise is never at the top of our priority list. But, it is far easier to prepare for long in advance before we may ever enter that typical stage of our lives.

The final decisions one must make are hardest to make when you are not able to. Hospitals and nursing homes may have their own protocols that they must follow to be within legal limits. Hospice services may not always be an option, as they can be costly and lengthy while we struggle to retain life. We may or may not want specific medical procedures carried out on us or our loved ones, so it must be discussed at length.

Have as much documentation readily available when the time comes for your loved ones. This way, they will be able to administer your wishes as you wish. Do not get caught in a position where you are unable to legally know what your medical status is, or deal with other agencies like the insurance company or bank.

Your final wishes and final arrangements should be discussed long before you get to that bridge. There are many options that are available, such as memorial diamonds made from ashes of your loved ones that can be added alongside the customary burials or cremations. Remember that the more prepared you and your loved ones are, the more likely it is that your wishes will be respected and carried out.

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Grenfell demonstrates it. The NHS exemplifies it.

“I seem, then, in just this little thing to be wiser than this man at any rate, that what I do not know I do not think I know either..”
Socrates

Apology by Plato

The events of the last week will undoubtedly shape the future of Britain in a monumental fashion. First, an election like none we have seen for fifty years. Called in hubris, led to nemesis, won, in truth, by no one. History-making nonetheless. The prevailing wind of politics has changed, now blowing Left of centre for the first time in nearly a decade. Corbyn has an approval rating of +6, Theresa May a disapproval rating of -34, nearly mirror opposites of where they stood in November. Who knew?

Theresa May and the Conservatives struck a conciliatory tone. “Austerity is over” they said, in radio interviews, in leaked excerpts from backbencher committee meetings. The “mood has changed” they said.

And then Grenfell Tower happened. And the mood changed again.

As details drip out of what will undoubtedly be known as the biggest domestic disaster since Hillsborough, a hazy but consistent picture coalesces. The fire began reportedly in a fourth floor flat, starting with a fridge. The residents had campaigned for years before about power surges in the building, about the risk of a lethal fire with appliances, but sadly, were ignored. Within minutes, it is reported, the fire had spread out of a window and roared up the side of the tower, consuming the external cladding system as one resident described “like matchsticks”. This external cladding had been part of a recent £8.7 million refurbishment, subcontracted by the private enterprise managing the tower, KCTMO, to update the insulation and aesthetic aspects of the outer structure. In the Times today, it is reported that the cladding material used is illegal in structures greater than 18 metres, is flammable when an alternative fire resistant material would’ve cost just £5000 more, and is illegal in Germany and the USA. Sky News’ Faisal Islam shared a BRE presentation this weekend, a diagram of exactly the kind of disaster that befell Grenfell, dated June 2014, three years ago exactly. In summary, we await the public inquiry that must happen, but it seems 58 (at time of writing) people died in a preventable disaster, that was forewarned, already forestalled in other countries, and seems to have been the result of thoughtless (one hopes) cost cutting from a private company.
But, as Damian Green stated in an extraordinary Radio 4 interview, “we must await the experts”.

Which struck a chord with me.

The mantra “prevention is better than cure” is as true in medicine as it is in fire fighting. Much of what we do, day to day, is about preventing future disease, rather than treating it’s corollaries. We use safety cannulas for preventing needlestick injury, we campaign to stop smoking to prevent lung and other cancers, we screen and treat alcoholics on admission to hospital to prevent deadly withdrawal seizures. When we see impending disaster threatening human life, we have a duty to act, as best we can.

A disaster likely already happened in the NHS, and I cannot help but see the parallels with Grenfell. In February of this year a Royal Society of Medicine Report looked into what was explained away by the government as a “statistical blip.”. Since 2010 the death rate in the U.K. was rising, for the first time in fifty years. More people were dying. To be exact, 30,000 “extra” people died in 2015 compared to what was expected. This study attempted to explain where these extra deaths came from. Was it a subpar flu vaccine one season , as Jeremy Hunt, once and current Health secretary, had claimed? No, the study concluded, the only explanation that fit the data was that 30,000 excess deaths were most likely a direct result of cuts to health and social care services.

Let that sink in.

30,000 men and women, potentially your grandmother or father, sister or uncle, whose deaths were in some way contributed to by cuts to services in the name of “austerity”. Like Grenfell, cutting corners and saving pennies, led to a national disaster. Like Grenfell, multiple agencies have limited oversight over the system as a whole. Yes, the buck stops with the government, but I’m sure they can pass it through any number of government and non-government subsidiaries. Like Grenfell, this essential public service, is sub-contracted in places to private companies, beholden to shareholders as much, if not more, than to the public they are supposed to serve. And like Grenfell, warnings about impending disaster, from “experts” and public alike, have fallen on deaf ears. But unlike Grenfell no one saw these deaths for what they were, a national disaster on a behemoth scale.

Austerity kills. It has already potentially killed 30,000 men and women in health and social care. It has killed at least 58 in Grenfell last week. It has killed thousands of disabled people whose benefits were removed just months before they died. Who knows where else this cost-cutting at any cost has cost lives to save pennies?

If you think I’m politicising this tragedy, you have it backwards. The politics came first, then the tragedy.

Which brings me back to where we started. “Austerity is over” they said. The “mood has changed” they said. As if austerity were always a fanciful choice, a frivolity that was chosen on a whim, as one might decide on a suitable tie, or a wallpaper for the living room. I don’t remember anyone claiming austerity was a “mood” when Osbourne and Cameron were laying waste to health and social care budgets, schools and police funding. Austerity was essential, they said. We have to “live within our means” they said. Except some of us didn’t manage to. Potentially as many as 30,000 of us, our most vulnerable.

So now austerity is over. Was it ever actually necessary? The short answer is no. The long answer is, perhaps for a while, but ultimately still no. Despite what the Mail and Sun has peddled for half a decade, the idea the economy is akin to a household budget is laughable. Pretending we only have control of spending in a government trying to “balance the books” is patently stupid; a government sets it’s own revenues, through tax and VAT, NI and council tax, levies and custom duties, subsidies from other countries, like the EU. Austerity was harmful to our economic recovery. This isn’t left wing socialist claptrap, this is mainstream economics. The IMF agrees as did a large backing of the UK’s top economists. This is economic theory that goes back a hundred years. Any economist could’ve told you that. But of course, we had had enough of listening to “experts” then.

Apparently that’s all changed now.

If we are listening to architects and fire officers again, perhaps we could list to economists and health experts again too, to teachers and police federations. To paraphrase Socrates, wisdom is knowing what one does not know. As a doctor I’ve begun to understand this more and more. Being conscious of the limits of my knowledge makes me safer, means I can operate with uncertainty and know where I need a colleague’s advice, or my boss.

In the age of the internet it seems we now know everything, but understand nothing. For too long we all “knew” that austerity was necessary, that “too much red tape” was throttling business and enterprise, that the NHS was “bloated” and spending “too much money”. Did any of us examine where this “knowledge” came from?

Now we see we knew nothing at all. I hope from these tragedies we can salvage some wisdom.

In an impassioned interview, the MP David Lammy spoke about the “safety net” of schools and hospitals, of decent housing, that is falling apart all around us. Austerity has shredded that safety net, and many have died slipping through the gaps.

Austerity is over, they say. I think we can rebuild this safety net, I hope we can fix the NHS.

But then, what do I know?

First published on the Juniordoctorblog

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The lifetime risk of death is 100%. As every Terry Pratchett fan knows, if we do somehow elude cause A, on date A, in place A, the Grim Reaper will probably reschedule soon enough.

We know the main causes and places of death in the UK, and they don’t really fluctuate much. Almost half a million of us die annually; usually when we are quite old.  In this beautiful infographic, our causes of death look almost floral.

Mortality statistics England & Wales: 2009  with thanks to the Guardian

Most of us take our last breaths in a hospital bed, succumbing to cardiovascular, cancer or respiratory causes- typically after spending 12.9 days in hospital, and often via an emergency admission.

Some of these deaths might have been postponed if we had had optimal hospital care; relocated if we’d had alternatives to admission; coded differently if someone else had certified us dead; rescheduled if we were ‘hanging on’ for Auntie Vera; inappropriately delayed if we were ventilated against our wishes.

And some of our deaths could have been ‘prevented’ for many years; maybe if we had phoned the Samaritans on that fateful day; if we’d taken our statin/ Bblocker/ ACE/ aspirin; if we hadn’t had the systematic disadvantage which faces poor, black, learning disabled or mentally ill citizens; if we’d managed not to get addicted to nicotine; if we’d been the right age for a vaccine.

If pigs could fly; if we’d tackled social determinants of health; if we’d had a well-led, funded, genuinely evidence based healthcare system. Or if we hadn’t walked under that ladder to avoid that black cat… as that brick fell.

In summary:

Mortality is a whole-population risk. The onset of our final illness is likely to precede our final admission by some considerable margin, and many factors influence when we end up calling 999.

If we really want to know whether service configuration is killing us, we need to use the real denominator: the population, and ONS data about day of death.

Because if the doctors’ reluctance to work ever-harder for reduced pay is linked to mortality, the main victims will be those who never get admitted in the first place.

Use of an artificial (and heavily lead-time-bias-susceptible) moving feast of variably defined “weekend admission” comparison in a series of widely-derided scientific papers would not be my method of choice for this question.

But we’ll never find out.

Which is a real pity.

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A repeated claim made by politicians and a justification for the Health and Social Care Act 2012 is that the NHS is ‘unsustainable’ in its present form because the UK’s ageing population is increasing costs to levels that we can no longer fund from taxation. But this is a myth. While the proportion of the population aged over 65 years is increasing in most of the developed world as people live longer, there is no evidence for the claim that ageing itself will lead to a funding crisis. Rather, the NHS funding crisis is due to cuts in funding for the NHS and social services coupled with the high costs of marketisation and privatisation leading to service closures such that NHS funded services including GP services and out of hours services and hospital services are no longer meeting needs.

Reductions in funding and budgets for social services and long-term care and reductions in local authority provision add to the strain on NHS services. The volume of services provided is shrinking and these are not keeping pace with need. The amount spent on social care services for older people has fallen nationally by £1.4 billion (8.0%) from 2010-11 to 2012-13. The number of people receiving state-funded care fell from 1.8 million in 2008-9 to 1.3 million in 2012-13.

According to Age UK, in the three years between 2010-11 and 2013-14:

  • Numbers of older people receiving home care have fallen by 31.7% (from 542,965 to 370,630).
  • Day care places have plummeted by 66.9% from 178,700 to 59,125.
  • Spending on home care has fallen by 19.4% from £2,250,168,237 to £1,814,518,000.
  • Spending on day care has fallen even more dramatically by 30% from £378,532,974 to £264,914,000.

Older people are living longer, healthier and more productive lives

The extent, speed, and effect of population ageing has been exaggerated by the government because the standard indicator—the old age dependency ratio  ( The old-age dependency ratio is the ratio of people older than 64 to the working-age population, aged 15-64) — does not take account of the fact that people aged over 65 years are younger, fitter and healthier than in previous decades. In fact older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years.

Currently over one million older people are still working, mostly part time, many with valuable experience or specialist knowledge. The spending power of the ‘grey pound’ has risen inexorably. Many do volunteer work vital to the third sector or look after grandchildren.

Older people aged over 65 contribute more to the economy than they take out. It is estimated that taking together the tax payments, spending power, caring responsibilities and volunteering effort of people aged 65-plus,older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services.

Most acute medical care costs occur in the final months of life, with the age at which these occur having little effect. It is not age itself, ‘but the nearness of death’ or health status of the individual in the ultimate period in the last few years or even months before death that matter most. According to this hypothesis health expenditure on older age groups is high, not so much because their morbidity or disability rates are higher, but because a larger percentage of the persons in those age cohorts die within a short period of time.

Similar findings have been reported in other European countries where by 2008 it was shown that ‘contrary to popular belief, ageing is not an inevitable and unmanageable drain on health care resources.’ Indeed one study suggested that the cost of death declines with age because older ‘people tend to be treated less intensively as they near death.’ In fact, it is those dying between the ages of 50 and 60 who cost the most. If the cost of death declines with age then an ageing society could lead to lower health care costs.

Life expectancy is an estimate of average expected life span, healthy life expectancy is an estimate of the years of life that will be spent in good health. The trend for healthy life expectancy at 65 in England for males and females has increased approximately in line with overall life expectancy at 65. For example, between 2006 and 2009, healthy life expectancy increased by 0.8 years for females and 0.5 years for males while overall life expectancy grew by 0.6 years for females and 0.7 years for males. This suggests that the extra years of life will not necessarily be years of ill health. There are important socio-demographic differences in healthy life expectancy. Not only can people from more deprived populations expect to live shorter lives, but a greater proportion of their life will be in poor health.

When measured using remaining life expectancy, old age dependency turns out to have fallen substantially in the UK and elsewhere over recent decades and is likely to stabilise in the UK close to its current level. It is not age but nearness to death that accounts for health expenditure.

Increased life expectancy means more years lived in good health.

Politicians must stop blaming older people for their decisions to cut funding and close services

The false premises of the ageing hypothesis provide a technical rationale for starving the NHS of funds. In July 2013 NHS England warned of a funding gap ‘of around £30 billion between 2013-14 and 2020-21’. A Lords select committee , the Office for Budget Responsibility , the Nuffield Trust and the Institute for Fiscal Studies published health spending projections on the assumption that ageing is a main driver of cost rises. The studies mainly relied on simple population projections. The connection between ageing and costs and chronic illnesses was simply assumed. They did not consider the fact that people are living longer, healthier and more productive lives.

So the most remarkable thing about the ageing hypothesis or ‘demographic time bomb’ is its survival. The Canadian economist Robert Evans has described it as a ‘zombie theory’, one that refuses to die. It survives today only as a reason for explaining politicians’ bad policy decisions which have resulted in pressures on the NHS: as an alternative to the real reason which is the cutting of health budgets, and services for health care.

In the UK, both the Royal Commission on Long Term Care (the 1999 ‘Sutherland report’) and the Wanless Inquiry (2001-04) rejected the ageing thesis. The 1999 Royal Commission found that, even though ‘the population aged 80 or over is growing rapidly and appears likely to continue to do so’, the UK was not on the verge of a “demographic time bomb” as far as long-term care is concerned and as a result of this, the costs of care will be affordable.’

Wanless concluded: ‘Despite this significant ageing of the population, demographic changes have so far accounted for a relatively small proportion of the increase in spending on health care in the UK. While overall spending (between 1965 and 1999) grew by 3.8 per cent a year in real terms, the demographic changes alone required annual real terms growth of just 0.5 per cent a year. Less than 15 per cent of the growth in health care spending over the past 35 years can therefore be attributed to the cost of meeting the needs of an ageing population. This is in keeping with findings from other countries.’

In Canada the Evans paper on the Romanow report into future health care costs declared: ‘All studies come to the same conclusion. Demographic trends by themselves are likely to explain some, but only a small part, of future trends in health care use and costs and in and of themselves will require little, if any, increase in the share of national health resources devoted to health care.’

The European Commission report of 2010 found that it was ‘the health status of an individual (and – in aggregate terms – of the population), rather than age itself, which is the ultimate driving factor’ behind cost rises. Furthermore, ‘Over time, there is no clear link at the aggregate level between levels of spending on health care and the demographic situation of societies. In fact, several studies have found that the impact of ageing on increase in health expenditures is limited to as little as a few percentage points of this increase.’

The connection between ageing and health care costs has also been rejected in studies and parliamentary reports in the USA, Canada, Germany and Australia.

Examples of the ‘Zombie theory’ and how it is used to justify policy choices:

“We’ve got a growing and ageing population now and this is having a significant impact. It’s down to the policy-makers to decide whether to change the policy or not.”  Rupert Egginton, director of finance at the Nottingham University Hospitals NHS Trust

“An ageing population with more chronic health conditions, but with new opportunities to live as independently as possible, means we’re going to have to radically transform how care is delivered outside hospitals.” Simon Stevens, Chief Executive of NHS England

“However, if the NHS is to meet the needs of an ageing population we need it to be more efficient so it can provide more and better treatments.” Lord Howe, Parliamentary Under-Secretary of State for Health

Trends in numbers of people aged over 65 years and mortality rates and number of deaths:

ageing population

Figure 1: Age-Specific Mortality Rates, 1963 and 2013, England and Wales (Source: ONS24

Figure 2: Age-standardised mortality rates (ASMRs) in England and Wales, 1942-2012 (Source: ONS25)

Figure 2: Age-standardised mortality rates (ASMRs) in England and Wales, 1942-2012 (Source: ONS)

ageing population

Table 1: Number of deaths registered in England and Wales, 2004-2013 (Source: ONS)

Age structure of the UK: 2011 Census data

  • Aged 65 and over: 10.376 million
  • Aged 85 and over: 1.394 million
  • Total population: 63.183 million

This was first published by the Campaign for the NHS Reinstatement Bill

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2015 and 2030 compared

mortality infographic medigo

This infographic displays data from the World Health Organization’s “Projections of mortality and causes of death, 2015 and 2030”. The report details all deaths in 2015 by cause and makes predictions for 2030, giving an impression of how global health will develop over the next 14 years. Also featured is data from geoba.se showing how life expectancy will change between now and 2030.

All percentages shown have been calculated relative to projected changes in population growth.

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This evidence review analyses data from the World Health Organisation’s Detailed Mortality Database, and summarises the literature to show that:

  • the leading causes of death change across the life course
  • there are marked social inequalities in each of the leading causes of death (within top 5 broad causes), by total number of deaths, across the life course
  • social and economic circumstances from birth accumulate and impact a person’s likelihood of an early death
  • different mortality rates for the leading causes of death are evident across comparative European countries.

This evidence is summarised for specific age groups across the life course below:

Stillbirths

The leading cause of stillbirth is short gestation and low birth weight. There are social inequalities in stillbirth associated with differences in:

  • access to care and early detection rates
  • termination rates (women from disadvantaged areas and from some ethnic groups are less likely to terminate a pregnancy affected by a severe congenital anomaly)
  • maternal lifestyle behaviours, such as unhealthy diet and smoking, which are associated with an increased risk of stillbirth
  • psychological stress, which is again positively associated with increased risk of stillbirth

Infants

(1.8% of all premature deaths, 2010)

Over half of infant deaths are attributed to conditions originating in the perinatal period, with the leading cause being short gestation and low birth weight. Congenital anomalies, birth asphyxia and Sudden Death Syndrome are other leading causes. There are social inequalities evident for all leading causes of infant death, such that increased risk of infant death is associated with risky lifestyle behaviours and lower uptake of health-protective behaviours. Mechanisms suggested as underlying these inequalities are differences in:

  • maternal lifestyle behaviours during pregnancy and breastfeeding rates
  • termination rates (see above)
  • uptake of recommended infant sleeping position (prone position).

Children, ages 1–4

(0.3% of all premature deaths, 2010)

‘Injuries and poisoning’ is the leading cause of death for boys whereas cancer is the leading cause for girls. Social inequalities are found in all leading causes of death among young children, including unintentional drowning and suffocation, and deaths from leukaemia, Hodgkin lymphoma and cerebral palsy. The mechanisms suggested as underlying these social inequalities include social differences in:

  • adherence to treatment
  • intake of vitamin, folate or iron supplementation
  • birth weight, linked to lifestyle behaviours

Children, ages 5–9

(0.2% of all premature deaths, 2010)

Cancer, particularly brain cancer, is the leading cause of death for both girls and boys of this age group, causing around one in four of all deaths. Deaths by injury and poisoning cause more deaths in this age group for boys than girls. Deaths from congenital anomalies and child homicide are other leading causes. There is limited evidence on social inequalities in childhood brain cancers. Research reveals socioeconomic inequalities in child homicide rates. The association between poverty, child maltreatment and homicide is most commonly explained by stress factors linked to unemployment, low income and depleted resilience, as well as prior experience of being a victim of or witnessing violence.

Children, ages 10–14

(0.2% of all premature deaths, 2010)

More than twice as many boys than girls die from external causes (particularly road crashes and unintentional drowning) between the ages of 10 and 14. Brain cancer and cancer of the blood, bone marrow and lymph nodes, as well as diseases of the nervous system, epilepsy and cerebral palsy are other leading causes of deaths for this age group. There is evidence of social inequalities in epilepsy and cerebral palsy, attributed in differences in short gestation and low birth weight, and infections during pregnancy. Variations in emergency admission rates, believed to be because of differences in the availability of communitybased support, effective ongoing management of conditions and thresholds for seeking admission, contribute to social inequalities.

Young people, ages 15–19

(0.6% of all premature deaths, 2010)

External causes of death – particularly road crashes, suicide and self-harm – are the leading causes of death for both sexes at this age. Other European countries, however, have comparatively higher rates of mortality than the UK. Socioeconomic inequalities in the leading causes of death for young people aged 15–19 are attributed to differences in:

  •  housing conditions and housing density
  •  proximity to traffic, exposure to hazardous or illegal driving
  •  parental mental health, employment, income, education/ skills and relationship status
  •  Exposure to stressful life events
  •  Adolescent mental health

Young adults, ages 20–34

(3.5% of all premature deaths, 2010)

Suicide and intentional self-harm is the leading cause of death for young adults. Compared with EU19 countries (the 15 EU countries prior to the accession of the 10 new members in May 2004 plus the four eastern European members of the OECD), the UK has the sixth lowest suicide and self-harm mortality rate for young adults (aged 20–34). Road crashes, brain cancer, cancer of the blood, bone marrow and lymph nodes, cervical cancer and breast cancer are the other leading causes of death. Social inequalities in these leading causes of death are attributed to differences in:

  • employment status/work quality
  • perceived acculturation (The degree to which ethnic-cultural minorities engage in the customs, tenets, principles and behaviours of their own culture versus the dominant)
  • mental health and self-harm rates
  • exposure to adverse experiences in childhood
  • lifestyle behaviours
  • use of preventive services
  • uptake of HPV vaccinations
  • tobacco use
  • alcohol consumption
  • early sexual experiences
  • screening rates
  • shift work

Adults, ages 35–64

(45% of all premature deaths, 2010)

Deaths as a result of disease and related causes, specifically cancer, ischaemic (coronary) heart disease, heart attacks, chronic liver disease and cirrhosis are the leading causes of death among adult men and women. Suicide and intentional self-harm remain a leading cause of death among adult men. Mechanisms posited as underlying social inequalities in leading causes of death in adults include social differences in:

  • diet and lifestyle behaviours
  • access to care and uptake of preventive services
  • childhood cognitive development
  • obesity
  • mental health, and physiological and psychological responses to adverse circumstances
  • social isolation/loneliness

Adults, ages 65–74

(48.4% of all premature deaths, 2010)

Cancer – particularly lung cancer and cancer of the colon, rectum and anus – and ischaemic (coronary) heart disease continue to be the leading causes of death among older adults. Cerebrovascular disease, chronic lower respiratory diseases and pneumonia emerge as other leading causes. The mechanisms suggested as underlying social inequalities in the leading causes of death in older adults include social differences in:

  • lifestyle behaviours – unhealthy behaviours associated with increased risk of early death
  • disease awareness, with lower awareness associated with increased risk of early death
  • health professionals’ cultural competence
  • housing conditions, with poorer conditions associated with increased risk of early death

Conclusion

This evidence review shows marked social inequalities for the leading causes of death across the life course. Risk factors associated with premature mortality are also known to accumulate over time. A sizeable proportion of the burden of disease and premature death is therefore estimated to be a result of social inequalities throughout life, and differences in access to and use of healthcare services, which are amenable to policy and practice interventions. Social inequalities in mortality are unjust. It is unacceptable that we can identify which children are more likely to have an early death because of the conditions in which they are born. Health care systems along with other sectors, including education, welfare, social care, employment, transport, community and voluntary, and the built environment, need to continue to work together to build on promising policies and practices to prevent early death across the life course, and from the earliest possible opportunity.

This report was written for the Department of Health by Jill Roberts and Ruth Bell of the UCL Institute of Health Equity.  Full report here.

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Avoidable deaths?  No such thing.   Death can only be postponed.

Will hospital mortality league tables  be a good thing?  Well the link between poor care and premature death seems to be weak.

My local hospital (Wythenshawe) did a case note review of all 1440 deaths in the hospital between July 2013 and July 2014. They concluded that there was a potentially preventable mortality  (grades 4-6 as per the BMJ paper) of 1.1%.  The clinicians (and I) thought this exercise was well worth doing, though there were substantial costs.

But 1420 of the people who died in the hospital had deaths which were pretty clearly not preventable.  The mean length of stay of those who died was 15.6 days.  So on the face of it more than  20,000 bed days were occupied by people who probably derived little benefit from being in hospital.  The review didn’t investigate at what stage it became clear that they were going to die, and I suppose that varies quite a lot.  But there seems general agreement that many people arrive at hospitals in a condition where death is the obvious outcome.  And not many people think that a busy acute medical ward, or a casualty department is a good place to die.

In 2013 about half the people who died in England and Wales died in hospital. If Wythenshawe is at all typical they took up about 7 million bed days.  If we could reduce that figure by even 10% then we might not have a crisis in casualty departments across the country.

Place of death

Place of death2013
Total506,790
Home113,071
Care homes107,090
Hospices27,102
Hospitals248,238
Elsewhere11,289
Deaths registered in England and Wales

 

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These graphs show  international rates of “amenable mortality”—that is, deaths from certain causes before age 75 that are potentially preventable with timely and effective health care

Mortality Amenable to Health Care 1997-8

 

Mortality Amenable to Health Care 2002-3

 

From E. Nolte and C. M. McKee, “Measuring the Health of Nations: Updating an Earlier Analysis,” Health Affairs, Jan./Feb. 2008 27(1):58–71.

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It is surprising that the Guardian gives any credence to the statistics of hospital mortality promoted by Sir Brian Jarman on Channel 4. Hospital death rates, particularly if followed over time, can give useful warning of problems, as Sir Bruce Keogh has stated. However comparison of such data internationally is fraught with difficulties, as we found when we first published the European Atlas of Avoidable Deaths in 1988. Since total mortality rates in the UK are similar, or lower, than in the United States, as a large proportion of the population in both countries die in a hospital such a difference seems unlikely.

momento moriTo compare hospital mortality rates between hospitals, whether in one or more countries , it is necessary to take into account such factors as length of time in hospital, availability of discharge facilities, e.g. hospices, hospital admission criteria and many other procedural and cultural factors. Comparison of outcomes for individual conditions is even more difficult because of differences in diagnostic and coding procedures which have been illustrated many times. Unfortunately the data presented by Jarman in both your paper and Channel 4 is inadequate to determine the validity of the conclusions or the methods used. This is a striking media story but, unfortunately has not been subjected to proper scrutiny.

Walter Holland.

MD, FRCP, FFPH

Visiting Professor

London School of Economics

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My interest in mortality goes back 40 years to when I trained as an actuary and carried out medical underwriting.  I have written before about how early on in my NHS career I suggested applying some of the rigour we used in the insurance industry to mortality studies. I was interested in mortality rates and Hospital Standardised Mortality Ratio; it was familiar territory.

Some years later I have grave concerns about the misuse of Hospital Standardised Mortality Ratio, based in part on the academic papers often cited which raise methodological issues.  I am also aware that the different methods to derive an Hospital Standardised Mortality Ratio using the same underlying data can produce different answers.

So I disliked the adoption of one flavour of Hospital Standardised Mortality Ratio as a commercial product, touted by the DH as vital to good management in its role as some kind of business partner.  I disliked the use of ratings for league-table like simplistic denunciation of trusts.  But I was warned (in 2008) for speaking publicly against the abuse of mortality rates.

In recent months through Mid. Staffs. to Keogh we have blatant political abuse with ludicrous claims in various media about excess deaths derived from abuse of Hospital Standardised Mortality Ratios.  So, for example, the only thing we know for certain about the often quoted Hospital Standardised Mortality Ratio figures from Mid. Staffs is that they were wrong – not something you ever hear in the “media”.

None of these many misuses were ever challenged by those who knew better.  The ridiculously incorrect use of inaccurate information was actually given credibility by those who knew better.

But even before that shameful episode my own work had shown me why the way Hospital Standardised Mortality Ratio is used was flawed.  First it is easy to use the whole country figures to compare one year with another, and when I did that it suggested an 6- 8% improvement in mortality rates across the whole NHS in one year; clearly impossible.  Second, the annual ratings tables showed there were a number of trusts that improved their Hospital Standardised Mortality Ratio significantly but other information showed both the number of actual deaths and the case mix did not change; clearly impossible. Something was wrong.  Things have improved and we now have Summary Hospital-level Mortality Indicator which is a better indicator – but the issues remain.

All the indicators like Hospital Standardised Mortality Ratio and Summary Hospital-level Mortality Indicator depend on coding.  I observed coding taking place and compared the process with the rigour used 40 years ago for underwriting and found it was poor.  Often lightly trained clerical staff were trying to interpret incomplete information to get to the codeable diagnosis was only one of several obvious sources of potential error, but there were no serious systemic or even spot checks applied. The level of coding error and its impact on Hospital Standardised Mortality Ratio could easily be studied, but isn’t.

It is regularly claimed that high Hospital Standardised Mortality Ratio is an indicator of poor care in the organisation as a whole.  And so it is claimed that a high Hospital Standardised Mortality Ratio means more deaths than should be expected given the adjusted case mix.  This may even be true but no study has ever confirmed this.

If there was another universally accepted method which indisputably ranked trusts for the quality of their care then we could see how well Hospital Standardised Mortality Ratiocorrelated with the reality. Such a baseline study would not be impossible but would require some investment, but there has never been any kind of attempt to do this (still one outcome from Keogh is we are promised one).  Can we honestly claim we know the underlying reasons for variations in mortality rates?

Maybe we would also find that the higher mortality rates were linked to care quality but are mostly just simply correlated with levels of funding as some claim.  We don’t know.

Which leads on to something that we do know derived from proper clinically led non statistical studies into avoidable deaths.  The outcome is not just a figure: it is also a lot of information about why the figure is at that level – what the most common causes of avoidable deaths were.  This is something that is immediately transferable into action. Such studies are clinically intensive and do include (in some cases) actual involvement with the clinicians responsible for the care and even relatives and carers. The studies have greater reliability as there is no coding error or opportunity for gaming.

What we do know from studies of this kind is that the level of avoidable deaths is around 5-6%.  The statisticians tell us that this is a figure which renders the use Hospital Standardised Mortality Ratio to detect variations in this segment of all deaths is unreliable; it can’t get at this 5-6%, which is where the variation due to clinical quality comes from, in a meaningful way.

For those that are responsible for managing clinical quality, we know there are many things which should be done.  You should always do the clinical audit studies, do mortality investigations in an open and transparent environment, make sure your data is accurate, invest in analysis skills, do proper case note investigations, look not just at all deaths but also at near misses.  These are all real investments in quality improvement. We could in a collaborative NHS do far more to share information and best practice.

Why bother with Hospital Standardised Mortality Ratio at all?  Well, I am convinced that we have to find ways to use information better to provide early alerts of things which may be going wrong or to identify where (with perhaps the best intentions) current practice is falling behind best practice.  But until we have much better data, a much more sophisticated set of analysis tools, and competent analysts we will just get the fog generated by misuse of one tool which may actually be valuable if used properly.

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The general response to the Keogh review was positive; it showed how inspection and analysis could be used.   As many have already pointed out, it used a methodology similar to that used by the Commission for Health Improvement a decade ago (and found to be too expensive!).  The absurd pre publication hype about 13,000 avoidable deaths from the usual media sources was as predictable as it was disappointing.  It is about time some of those who passively condone this type of ridiculous reporting actually spoke out.

Bruce Keogh (Photo credit: Cabinet Office)

Bruce Keogh (Photo credit: Cabinet Office)

The review of 14 acute trusts with a recent history of high comparative mortality rankings (using either HSMR or SHMI) showed that in all of them there were serious issues; issues which had NOT been picked up by either regulators or performance managers.  It was accepted that many of the issues had been identified within the trusts but the rate at which remedial action was being taken was too slow.

Since there are no suitable benchmarks it is possible that such a thorough review would find issues at most trusts; and indeed may find trusts with, for example, weak governance but good mortality rankings.

The issues found in the 14 were a mixed bag – poor managerial and clinical leadership, weak governance processes and some technical failures (eg failure to maintain equipment) but the most obvious linking factor was lack of suitable staff at the right time in the right place.  The data appeared to show sufficient staff but the reality was they were not always in place: the most useful conclusion and the one most likely to be ignored.

But – the review did not say anything about excess or avoidable or unnecessary deaths.  The stories spun by the Tories and reported without critical analysis by some parts of the media were shown to be nonsense.

To further emphasise the point many of us have been making for years the report recommends that a proper study is done to see if there is any link between league table style mortality ratings and unnecessary deaths.  A proper evidence based study.

Then we need an evidence based study which shows why some trust have high ratings – we still do not know.  As a simple example one trusts of the 14 has had a higher than average crude mortality rate (deaths divided by activity – not affected by coding) for as long as records are available.  During this time it has had a complete change in management, completely different governance structures, completely different regulation and performance management – and it is still higher than average – so WHY?

The review also served as a test of methodology and it largely passed.  If sufficient resources can be mobilised then similar reviews could and should be made at every provider – not just acute trusts and not just NHS; with the results properly published.

So we get a more thorough approach using managerial and clinical expertise from within the NHS and also properly involving the public and patients.  It will not come cheap and you wonder how long such a regime will survive before someone says would it not be cheaper just to get a better quality of management and enough staff?

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