Quality of care and patient safety in the UK: the way forward after Mid Staffordshire.

In the past decade, quality of care and patient safety in British hospitals have become the focus of increasing public, professional, political, and regulatory concern. The 2001 inquiry into paediatric cardiac surgery at Bristol Royal Infirmary concluded that the Department of Health was unable to respond to an issue of quality of care, even though the Department of Health accepted that ultimate responsibility rests with it and the Secretary of State for Health. The Bristol Royal Infirmary Inquiry warned that quality of care problems could recur in the National Health Service (NHS) in future. After the recommendations of an external investigation of Bristol were implemented, the adjusted death rate at the paediatric cardiac surgery unit dropped from 29% to 3% within 3 years. The families of children who underwent cardiac surgery at Bristol should have been told of the lower mortalities at other units. In 2001, the Dr Foster company published the first of their annual Good Hospital Guides in UK national newspapers: these included hospital standardised mor­ tality ratios (HSMR). The HSMR is the ratio of the number of observed deaths in a hospital over a certain time to the number that would be expected if the hospital had the national death rate accounting for the adjustment factors, such as age, sex, diagnosis, and emergency admission. Although it has limitations, the HSMR is a trigger to ask hard questions and understand where performance may be falling short. Since 2003, the Dr Foster website also reported monthly mortality alerts for particular diagnoses or procedures for NHS organisations and professionals. From April 2007, these alerts were sent by letter from Imperial College London to the chief executives of any English NHS hospital trust that was found to have a risk­adjusted death rate for a particular condition that was double the national rate in the preceding 3 months, and the chance of it being a false alarm was less than 1 in 1000. The letters were copied to the hospital regulator, the Healthcare Commission (and now to its successor the Care Quality Commission [CQC]). In 2007, when the Mid Staffordshire General Hospitals NHS Trust was supported by its oversight Strategic Health Authority for Foundation Trust status, its HSMR published in the Good Hospital Guide was the fifth highest of English acute trusts. The Department of Health cautioned the public against using HSMRs to judge the relative safety of hospitals. The Department of Health was not informed of the high HSMR or mortality alerts at Mid Staffordshire when they agreed, in June, 2007, to approve the trust’s application to Monitor, the Foundation Trust regulator, for final approval. Monitor was told by the trust that Mid Staffordshire’s apparently high HSMR was an artifact of coding. David Nicholson, initially Chief Executive of the Strategic Health Authority and later of the NHS, said the data that were available to the regulators did not indicate a problem at Mid Staffordshire, even though the trust had logged on and seen its mortality alerts 847 times. Nicholson considered Mid Staffordshire “singular” and not illustrative of a systemic problem, an attitude described by the Mid Staffordshire NHS Foundation Trust Public Inquiry Counsel as very dangerous and not supported by evidence to the Inquiry. The trust is now considered by Monitor to be neither clinically nor financially sustainable. Robert Francis’ inquiry into the problems at, and regulation of, Mid Staffordshire NHS Foundation Trust found a widespread culture of denial, and he, his Harvard experts, and Bruce Keogh, Medical Director of the NHS, all considered that monitoring HSMRs had provided