The Keogh Review Review.

You will all have been surprised that I waited so long before I Blogged about Sir Bruce Keogh’s (The NHS Medical Director) review of the 14 failing hospital trusts – it’s not like me. That’s because this needed some thought.

The Keogh Review, came about because of the public anger at the unneccesary deaths (600 to 1200) which occurred at Mid Staffordshire NHS Foundation Trust and in particular at the failure of the management, doctors and nurses to provide basic, compassionate care to the elderly, terminally ill and sick patients who were unlucky enough to be treated at this group of hospitals. I commented widely on the Francis report into this scandal in my other (rather silly) Blog at the time of publication:


The exposure of Mid-Staffs came about through the Dr Foster Unit based at Imperial College, London and headed by Professor Brian Jarman, who had been analysing mortality rates. The unit collated and published mortality figures for all hospitals so that they could be compared with what was expected. If the rate was too high, it was a cause for concern. It’s still controversial – you can ‘fix’ the figures by changing the way deaths are coded. I wrote a lot about that too. Some hospitals feel they are unfairly hit for serving high risk communities or undertaking more complex operations or treating high risk individuals. There’s a lot to argue about.

All the same, the result was the identification of 14 Trusts that gave cause for concern – too many deaths over a long period.

As a result, Keogh, his team and Pricewaterhouse went in, consulted and then analysed whether there was a problem and, if so, how to deal with it. The press seem to have looked only at his covering letter to the Health Minister, which is by way of a summary. We need to look a bit further.

My first point is that it’s a remarkably quick report – far too quick to be final but that’s really commendable. The patients in those areas have waited too long, things needed to change and quickly. I think that’s starting to happen.


Secondly, the most remarkable thing is how useless the management of the 14 Trusts are. They knew that they were going to be investigated, it wasn’t a secret. Not least, Keogh had a travelling consultation process which went to each trust area to talk to patients. That means they had plenty of notice of an inspection.

So, take a look at this damning passage;                

“3.2 Where we took immediate action to protect patients

The most important part of my remit was to take action to protect patients from harm where we found instances of poor care or risky environments or practices. We employed the ‘precautionary principle’ in undertaking this review. Where we found areas of concern, we acted immediately (we didn’t wait for a disaster so that we could be absolutely certain).

Actions taken included: immediate closure of operating theatres; rapid improvements to out of hours stroke services; instigating changes to staffing levels and deployment; and dealing with backlogs of complaints from patients.

1) The review had to shut operating theatres?

The only reason to do that would be that they were unhygienic or there was equipment unsuitable for use.

Was no one checking? Managers, Surgeons, Nurses?

2) Out of hours stroke services.

This simply means that those hospitals were not treating strokes out of hours because they didn’t have specialist staff available. If your stroke was at the weekend you waited in a bed till Monday.

Nowadays everybody knows that if you don’t treat strokes quickly, outcomes are worse, people are more disabled than they need to be and are more at risk of dying. Minutes count. Sometimes just taking Aspirin in time makes a difference.

3) Changes to staffing levels and deployment – not enough nurses and doctors.

All of this would have been obvious to the lowliest member of staff and to most members of the public – yet it took this review to sort it out.

I was very critical back at Easter about the way Leeds General Hospital’s Children’s Heart Unit was closed down. It happened the day after the campaign to save it had won a High Court Judgement declaring that the decision making process which led to proposals to shut it down had been flawed. At the time I felt this was badly handled by Keogh – I thought it was highly ‘political’.

I now realise that he was in the midst of this whole process of 14 hospital inspections and in some cases this was leading to emergency actions. I can imagine that he was appalled by what was being discovered and trying to do something quickly to sort it out. It’s in that context that interested and biased parties were lobbying him about Leeds.

I still don’t think it was handled well but I now understand the pressures that he was under at the time. His ‘mistake’ was one which was on the right side, compared with those made in the past which avoided the problems. He’s trying to make a new start.

It also isn’t right to look at this report without taking in the other changes that have been happening recently: last week, England’s new Chief Inspector of Hospitals, Professor Sir Mike Richards ordered investigations into Barts Health Trust as well as Barking, Havering and Redbridge; Croydon; and South London Healthcare, based on their appalling record in ‘never events’, the errors that should never happen.

There is a clear change in direction at the Care Quality Commission: how it does its job of inspecting trusts and care homes, although changing that will take time. In particular, inspections need to be carried out by people with some qualification and experience to do so.

I get the feeling that the clinicians have finally got the message that something very wrong was going on and that they had better do something to change it. I hope so, anyway.

Am I getting soft in my old age? Well, I am being won over, the question is whether I’ve just been schmoozed by this report or whether it’s for real. I’m going to be a bit more critical in the second part of this review.

                                           Part 2

At the conclusion of Sir Bruce Keogh’s letter to the health minister are these paragraphs;

“Finally, not one of these trusts has been given a clean bill of health by my review teams. These reviews have been highly rigorous and uncovered previously undisclosed problems in care. The rapid responsive review reports and the risk summit summaries make uncomfortable reading.

However, this is not a time for hasty reactions and recriminations. Any immediate safety issues we uncovered have been dealt with. It is a time for considered debate, a concerted improvement effort and a focus on clear accountability. So, I expect the carefully considered and agreed action plans to be enacted with serious consequences for failure to do so.”

I’ll be taking him up on that and here are a few issues for debate;

It’s clear that there were arguments raging amongst the people involved in the review, as these passages on mortality rates show:

“It is important to understand that mortality in all NHS hospitals has been falling over the last decade: overall mortality has fallen by about 30% and the improvement is even greater when the increasing complexity of patients being treated is taken into account. Interestingly, the rate of improvement in the 14 hospitals under review has been similar to other NHS hospitals.”

Which shows that the 14 had had some improvements, but they had started 10 years ago lagging behind and after the decade ended, they were still lagging behind.

The usual excuses didn’t explain what was going wrong, though;

“Factors that might have been expected – and are frequently claimed - to impact on high mortality, such as access to funding and the poor health of the local population, were not found to be statistically-correlated with the results of these trusts. The average for the 14 trusts is broadly the same as the England average in terms of funding and the socio-economic make-up of the populations they serve.”

This following passage says it all really – some of the failing hospitals were more concerned about explaining away the bad figures rather than improving patient outcomes. That makes it a management failure although nowhere in the report is there any mention of managers or boards.

“Clinical coding accuracy, and depth of coding, can in some cases impact on mortality indicator values for hospitals. Coding patients to make them appear sicker or identifying a higher amount of co-morbidities can improve mortality ratios. No statistical measure is ever perfect, but some organisations were not engaging in the message the data was giving as they felt it was wrong. Investigation into the signals that the data gives needs to be both about how data quality can be improved by clinician engagement and also clinical care and service delivery investigation to identify if improvements can be made. We found some trusts focusing too much time on the former and not the latter.”

This passage in the covering letter is an attack on government leaking a few days before publication – that 13000 had died needlessly in these trusts (a Lynton Crosby briefing, allegedly), which echoed leaks earlier in the year that 30,000 had died in the NHS as a whole, due to neglect. As I said back then, this was a political attack on the public ownership basis of the NHS and on its staff, who deserve better;

“the complexity of using and interpreting aggregate measures of mortality, including HSMR and SHMI. The fact that the use of these two different measures of mortality to determine which trusts to review generated two completely different lists of outlier trusts illustrates this point. However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths. Robert Francis himself said, ‘it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care’”

This next passage confirms what I have been arguing about for so long – that the Accident and Emergency is the heart of any hospital. Shut it down and you start the process of closing the hospital. If it isn’t working right, the problem is going to spread further:

“Over 90% of deaths in hospital happen when patients are admitted in an emergency, rather than for a planned procedure. It is not altogether surprising, therefore, that all of the 14 trusts we reviewed had higher than expected mortality in non-elective (urgent and emergency) care and only one (Tameside General Hospital) had high mortality for elective (planned) care. The performance of majority of the trusts was much worse than expected for their emergency patients, with admissions at the weekend and at night particularly problematic. General medicine, critical care and geriatric medicine were treatment areas with higher than expected mortality rates.”

Here he is saying that you have to look at the whole system and especially at staffing and staff morale;

“Understanding the causes of high mortality is not usually about finding a rogue surgeon or problems in a single surgical speciality. It is more likely to be found in the combination of problems that to a differing extent are experienced by all hospitals in the NHS: busy A&E departments and wards, the treatment of the elderly in and out of hospital, and the need to recruit and retain excellent staff. Such issues are complex and require a ‘whole system’ approach to deal with them. This is why it has been so important that this review has involved all the key players.”

                                          Part 3
The Good,the Bad and the Ugly
These are my conclusions about the report.
The Ugly
The 14 Trusts were failing 10 years ago, failing now and likely to be failing in 10 years time unless real changes are made.
A number of the trusts, despite prior warning of inspection, were still unsafe or not properly staffed when Keogh came calling.
If management couldn’t get its act together to sort everything out before an inspection, when would it?  Unless the management changes it is going to happen again, as soon as the Keogh spotlight has moved on.
The report doesn’t identify management or managing clinicians as a problem and it should have spelt that out. The problems start at the top even if they don’t finish there.
The managers get the big rewards, they should pay the price when things go wrong.
The Bad
Because it was so quick, the report does little except highlight areas of concern and raise good intentions for the future. These include;
The need to listen to patients.
Staff morale – every study indicates that low morale or alienation leads to increased mortality rates for patients.
Inadequate staffing levels – a danger for staff.
Too much reliance on agency staff or a high staff turnover to fill the gaps and ignoring the problems that forced staff to leave in the first place. Long service is a sign that people are happy. Happy people make happy patients.
Not enough consideration given to junior doctors and nurses – to tap their enthusiasm and idealism.
In short – too many question marks and too few answers.
The Good
As reports go, it was quick and decisive and Keogh identified the safety problems, taking action quickly.
As he says, after taking emergency action it’s time to debate what was going wrong and then check up on how the Trusts have acted following the review.
Plainly, managers need to be losing their jobs if it doesn’t improve – however much you argue about numbers, people have been dying. From the tone of the report, it is implied that there will be follow up action.
He wants Junior Doctors and Nurses to be involved far more than they currently are. The implication is that they are likely to be more up to date, more modern in their outlook, more committed and more concerned than their older, worn down colleagues.
He wants hospitals to listen to patients.
It gives every indication that Keogh wants to change things for the better. Let’s keep an eye out on what happens next.
My say;
For what it’s worth, my view is that there was too much time spent on whether the mortality figures are helpful or not – it’s a red herring. Mortality figures have proved to be a very useful indicator of problems, up till now. Unfortunately managers have realised that and have been massaging the figures, ‘gaming’ the codes. You can go on expensive courses to learn how to do it.
However, there are many other indicators and they are all of value.
Here’s three lists that the report took account of:
In-patient, Cancer survey, PEAT – privacy and dignity, Complaints about clinical aspects, Ombudsmans Rating, PEAT Environment, PEAT Food, Friends and Family test, Patient voice comments.
Then they looked at;
Harm incidents, ‘never events’, patient safety incidents, medical error, MRSA/ C-Diff infection rates, litigation, coroners concerns.
Then they looked at indicators of staff dissatisfaction and alienation;
Ratio of Nurses to beds, periods of working, vacancies unfilled, sickness rates, staff leaving rates.
As I found when I was analysing the never events, when you look at any one indicator it doesn’t obviously have much relation to any other indicator.
As I also found when I was comparing never events with mortality rates, a trust can succeed on some indicators, but failing on others can still be an indication that the trust is failing.
We need to be looking at the widest possible range of indicators, for patient outcomes, for staff alienation, for clinical excellence and pro-actively look for areas of concern.
The more indicators the better, the less likely they can be fixed. Broadly, if hospitals are failing on several indicators, its time to take a close look at everything else.
And that, I think, is what Keogh’s report is saying.
My big problem is that nowhere is there any mention of democracy – of democratic control. Once upon a time, we paid the taxes, the government ran the NHS and was responsible for any failures. When things went wrong a minister had to resign. Now, Foundation Trusts are independent, the government is off the hook and we have no control. Neither do the local authorities, whose elected representatives used to have some influence. It seems that all we have left is to stand protesting at the hospital gates. Or Blogging!
You don’t have to be very political – ‘No taxation without representation’, cuts across left and right. At the very least, we need to take back control and ownership of our NHS, because we could have done a better job.
There is no mention of democracy in the workplace.
No mention of the Trades Unions and professional bodies representing staff – they should have a role.
There’s no breakdown of the workforce and the role that inequality, prejudice and bullying plays in creating alienation.
As I keep saying;
1) The majority of NHS staff are working class.
2) The majority of NHS staff are women.
3) The majority of NHS staff are from ethnic minorities.
But this report does not discuss equal opportunities and fairness at work or the climate of fear and division that there is, right now.
There are managers, often with little or no experience of running hospitals - ordering clinicians about. Once upon a time, Doctors ran hospitals, helped by administrators, who ‘administered’. I know which I’d prefer.
It’s not just Doctors – there are nurses, care assistants and all kinds of specialists. A hospital is a whole collection of competing specialisms and interests fighting for scarce resources.
And that’s not even taking account of healthcare outside of hospital, fighting over the same money.
What Keogh has done is lay down a marker – a brand new start. He’s opened a debate and we need to dictate the form that debate takes. Because if we do nothing the agenda will be set by NHS bureaucrats, hospital managers, a biased press, Big Pharma, private finance initiative rip-off merchants, and private healthcare.
Then we really will be left standing at the gates.
Neil Harris
(a don't stop till you drop production)

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