UK Government

Department of Health (National): Experts Agree New Mortality Indicator for the NHS

Press Release   •   Nov 04, 2010 10:54 GMT

Changing the approach to calculating NHS mortality rates will lead to greater clarity

The method for calculating and using hospital mortality ratios across the NHS in England will change following a national review.

The new method, published today by the NHS National Quality Board, is called the Summary Hospital-level Mortality Indicator (SHMIs). The indicator can be used by hospitals to help them better understand trends associated with patient deaths.

Hospital mortality ratios are complex indicators, and there has been international debate over how they should be calculated and used. The variation among existing methodologies and the complex nature of the issue has also caused confusion among NHS managers, clinicians and patients.

The Francis Review into Mid Staffordshire NHS Foundation Trust shed new light on this debate and recommended a national review so that variations and trends associated with hospital deaths could be better understood.

This resulting review, led by Ian Dalton as Chief Executive of NHS North East, was carried out by a wide range of the experts on mortality ratios and relevant organisations. These include the Academy of Royal Colleges, the Care Quality Commission, the NHS Confederation, Dr Foster Intelligence, CHKS, National Patient Safety Agency and Professor Sir Brian Jarman from Imperial College.

The review group reached a consensus on the best methodology for the NHS to use and how to use it. It found that an SHMI is only one of a number of indicators that provides information about a hospital and its quality. While it can help to shine a light on potential areas for further analysis or investigation, it cannot be used as a standalone indication of quality or to rank hospitals in crude league tables.

Instead, the SHMI is like a trigger or smoke alarm - they may go off when there is no fire to put out, but they can also indicate a serious problem and must always be examined. Hospital boards must consider their scores carefully and ensure that they are continuing to provide the highest standards of care.

The SHMI indicator will:
* help ensure patient safety by providing an early trigger to probe potential problems;
* cover deaths relating to all admitted patients that occur in all settings - including those occurring in hospital and those occurring 30 days post-discharge; 
* apply to all NHS acute trusts except specialist hospitals, and 
* adjust as far as possible for factors outside of a hospital's control that might impact on hospital mortality rates.

Professor Sir Bruce Keogh, who commissioned the review on behalf of the National Quality Board, said:

"We are the first country to make a systematic attempt to engage healthcare providers, academics, institutions of medicine and the commercial sector in developing a clear method for assessing expected hospital death rates. The methodology will be open to public and academic scrutiny and debate so that it improves and becomes more useful over time."

Ian Dalton, who chaired the review as Chief Executive of NHS North East and is now the Director of Provider Development at the Department of Health, said:

"This is a huge achievement - we now have a wide-ranging consensus not only on the best way to measure mortality but also on how this measure should be used.

"A high SHMI on its own is not an indication of poor standards of care but it is a trigger to take action. Hospital boards across the country have a responsibility to pursue questions the SHMI might raise and quick action will help to ensure safe care for patients at all times."

The method will now be subject to rigorous independent testing and analysis before being formally introduced to the NHS by April 2011.


Notes to editors

1. Summary Hospital-level Mortality Indicators are intended to compare the observed number of deaths that actually occurred at a hospital with a statistical estimate of the number of deaths that might have been expected, based upon national average death rates and the particular characteristics of the patients treated in each hospital.

2. The review and the consensus statement can be accessed at:

3. Members of the HSMR Steering Group and its subgroups include:

Veena Raleigh, Associate Fellow at the Kings Fund
Brian Derry, NHS Information Centre,
David Rosser, University Hospitals Birmingham
Chris Welsh, Yorkshire & Humber SHA
Brian Jarman, Imperial
Roger Taylor, Dr Foster Intelligence
Paula Whitty, NE Quality Observatory System - chair of the Technical Group
Hugo Mascie-Taylor, NHS Confederation - chair of the Presentation Group
Paul Aylin, Dr Foster Intelligence
Sue Eve-Jones, Director of the Professional Association of Clinical Coders,
Richard Hamblin, Care Quality Commission
Robert Cleary, NHS Choices
Robert WInter, East of England SHA
John Williams, Academy of Medical Royal Colleges
Jason Harries, Managing Director, CHKS Limited
Ian Dalton, Chief Executive of North East SHA and DH managing director of provider development 
Bruce Keogh, NHS Medical Director, DH Monitor

A full list is available on page 31 of the report

3. The National Quality Board (NQB) is a multi-stakeholder board established to champion quality and ensure alignment in quality throughout the NHS. The Board is a key aspect of the work to deliver high quality care for patients.

The Department of Health held a number of stakeholder events to shape the design of the NQB. Stakeholders' views have shaped the NQB membership, its recruitments process and its role to provide strategic oversight and leadership in quality across the NHS
4. The Francis Review recommended that:

"In view of the uncertainties surrounding the use of comparative mortality statistics in assessing hospital performance and the understanding of the term 'excess' deaths, an independent working group should be set up by the Department of Health to examine and report on the methodologies in use. It should make recommendations as to how such mortality statistics should be collected, analysed and published, both to promote public confidence and understanding of the process, and to assist hospitals to use such statistics as a prompt to examine particular areas of patient care. "

5. NHS organisations can currently use a number of different approaches to monitoring mortality. Most use variations of tools such as the Hospital Standardised Mortality Ratio (HSMR) and the Risk Adjusted Mortality Indicator 

6. The White Paper Equity and Excellence: Liberating the NHS, was published on 12 July 2010 and set out the Government's strategy for the NHS.

7. For more information, please contact the Department of Health press office on 020 7210 5221.


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