A loaded question if I ever have heard one. On one hand, it tends to convey the feeling that mortality is not a problem outside of the NHS. On the other hand, it seems to construe that the NHS is somehow pathologically responsible for every mortality that happens under its kind patronage.
"Ageing is a problem in the NHS". Does that convey the inevitability of the problem? Does it make you say, "where is it not"? So why is it that when we talk about the Damocles sword of mortality, we tend to forget the inevitability of the same? Everyday, the public seems keen to prove that doctors are not gods as the doctors seem to think, but when it comes to mortality, they seem to expect doctors to be Gods and avert mortality at every instance? Or is the confusion due to the fact that we casually state "mortality" without qualifying if further?
Mortality comes in two forms. "Expected" and "unexpected" mortality with the latter being the one that all of us are concerned about. Yet when it comes to number crunching on the national scene by Dr. Foster or CHKS databases, all this is thrown to the wind and it all comes down to just "mortality" as far as the public is concerned. In the thick of discussions in NHS trusts also this distinction can get easily blurred with loss of focus of what really matters and what really needs to be done.
"Needless Deaths". Another trending word for the tabloids and department of health. Yes, I did use them in the same sentence . Attention grabbing is what both of them do as and when they need someone to listen, what else gets the attention of daily mail readers than "needless deaths"?. "Needless " just seems to be a ridiculous word to portray what happened, giving a feeling that there are needed deaths. I won’t go into aspects of euthanasia on this blog! Newspaper flash: "2000 needless deaths might have happened at the Killthemall NHS foundation trust". Might have happened. If that is not scaremongering, I don’t know how you do it better.
Coming back to "expected" versus "unexpected" deaths. So apparently there is a mechanism to decide which deaths in hospital are expected. Any event that does not meet the requirement of that risk assessment formula is "unexpected". 99 year old Jones comes into hospital with a cough. Mr. Jones had no expectation of death. Neither did his family who was confident in the NHS's ability (after all NHS does world class commissioning whatever that is, so the care must be world class, better than first class if you ask me)to keep him going forever. They would not have dreamt that he could die suddenly a day after admission. Unexpected Death. What about the Medics who admitted him? They see an old man (don’t accuse me of ageism, just stating the facts as medics see him for the sake of discussion) coming in with the old man's friend, good ol pneumonia with the very high potential for dying on this hospital admission. They don’t want to shock the family out of their optimism and Mr. Jones gets put on room 101a. He dies the next day and doctors take annual leave and scramble for their defence union phone numbers to get help with answering the letters of complaints from well-meaning relatives who appear from all over the world. Works better than Facebook for family reunion. Anyway, staying on track, this has the potential to become national news, with the hospital's outlying mortality rate suddenly coming into heavy scrutiny in the local echo and the daily telegraphs as relatives from Timbuktu pour out their hearts. Just because it was unexpected.
What if I told you that Mr. Jones came in with a severe pneumonia renal failure, atrial fibrillation and heart failure and being bedbound due to previous stroke he had no chance of getting past this septicaemia at 99 years of age? Has your expectation changed? If all of this had been explained to the family and the worst outcome prognosticated, would the unexpected become the expected? Root cause analysis and many wasted man hours later, recommendations come out that communication with relatives was the main problem. You didn’t see that coming did you?
That was an easy one. Consider Mr. Jones coming in at the penultimate year of potential receipt of the royal birthday card. In the pink of health as Joneses tend to be, enjoying life, living life to the fullest, never been sick in his life, he has a mild cough. Chest infection. Everything looks ok. Chest x-ray ok, ECG ok, Kidney tests and liver tests very reasonable. Next day he dies on ward 101b. Totally unexpected death. Found dead in the morning no less. Outrage. Letters from Timbuktu as before. What do we do? What do medics do? What do trusts do? What do foundation trusts do? What do trusts that already have a high SHMI (Summary hospital-level mortality indicator) do? They don’t have a leg to stand on. Tabloids print the front page news of the unexpected death of a 100 year old man. At the hands of high-earning overpaid NHS doctors again. The following day, the papers get more details on how the poor Mr. Jones was not even offered lifesaving CPR (cardiac resuscitation) as he was found dead in his bed, passing away silently at night, all alone in a dark corner of the monolithic NHS. Our citizens deserve better. They should pass away more slowly on noisy wards after many more blood tests and imaging and a cocktail of the latest antibiotics or chemotherapeutic agents and ideally even a brain transplant if possible. Public expectations. That is what much of this is about. Not about expectations of death, but expectations of the public. But irrespective of the feelings of the relatives and the local news papyrus, the good Mr. Jones may have unwittingly increased the needless death for the hospital on the national scene.
Imagine 90 year old Mr. Jones has a cough and stays at home and passes away in his sleep at home. Not too different scenario, except for the bed sheets stamped with NHS logo and the hospital food. (don’t go there, at least not for now). Not worthy of news. Mr. Jones gets a silent funeral for being the greatest father and grandfather of all time and such. Local Hospital SHMI stays low, Relatives save on phone charges from Timbuktu and newspaper columnists hope for war in the middleast to fill their columns tomorrow.
The point I have been trying to make was that if a patient dies outside the hospital, the local hospital has a low mortality rate. Simples. A major contributor to SHMI when it comes to unavoidable deaths in frail patients with total expectation of death. Not the only contributor, but the single major contributor in many places. How is your local community working? Is every unwell 100 year old being sent to hospital just because passing away peacefully at home continues to be an unthinkable event? Are all relatives clamouring for hospital admission for all their grand, grand parents because they don’t trust the local GP, PCT or CTP or CCGs's ability to facilitate a peaceful death at home for their relative with terminal cancer? Is every patient with advanced dementia in a nursing home being carted to hospital at the middle of the night just because the bank nurse did not have a clue about what else to do out of hours? Has every institutionalised person or older person had a end of life decision discussed with him or her to avoid unnecessary admission to hospital with all the distress that it entails? Has every person been given a chance to express their end of life wishes to contribute or not contribute to their local hospitals’ naming and shaming ceremony? Forget trying to focus on SHMI numbers till you get those facts right. If you care about your local hospitals staying open, act now!