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Dr Foster identifies 13 trusts with high mortality ratios

Thirteen hospital trusts have higher than expected mortality indicator scores, according to an extract from the latest report by health analytics firm Dr Foster which has been shared exclusively with HSJ.

The company lists organisations which have a higher than expected score on two or more different mortality indicators: the hospital standardised mortality ratio, the summary hospital-level mortality indicator, deaths after surgery and deaths in low risk conditions.

The majority of trusts listed are district general hospital trusts but University Hospitals Birmingham Foundation Trust − a prestigious tertiary centre − is among those appearing.

Twelve of the trusts had higher than expected rates on two of the four indicators, Birmingham was an outlier on all of them except the summary hospital-level mortality indicator. None had a lower than expected rate on any of the four measures.

University Hospitals Birmingham − which itself offers a mortality indicator service available to other trusts, in competition with Dr Foster − made no comment on the report as HSJ went to press on Tuesday.

As in previous years, several trusts expressed doubts about Dr Foster’s methodology.

Northern Lincolnshire and Goole Hospitals Foundation Trust said the summary hospital level mortality indicator figures used by Dr Foster did not match official Department of Health figures.

Chief executive Karen Jackson said: “The trust’s Dr Foster scores have improved considerably compared with last year. However, I am concerned at Dr Foster’s decision to use a different interpretation of the SHMI that is at odds with the official nationally published figures. This is very confusing for both NHS staff and the public.”

In a statement Mid Cheshire Hospitals Foundation Trust said under a different mortality indicator, the risk adjusted mortality index, it was not an outlier.

It said its higher than expected rating on the summary hospital-level mortality indicator was the result of a “data recording issue [which] caused the SHMI to spike”.

The trust said the same data issue accounted for its higher than expected score on the hospital standardised mortality ratio.

It added that from October it had “doubled the number of consultant physicians who work over the weekend”, from one to two.

In Dr Foster’s report 20 trusts were lower than expected on two or more of the four indicators.

Eleven of the 20 were in London and one, Guy’s and St Thomas’ Foundation Trust, was lower than expected on all four measures.

NHS England has commissioned professors Lord Darzi and Nick Black to conduct a study into the relationship between mortality rates and actual avoidable deaths. This would then be used to inform a new measure based on clinical case notes and would supersede the measures currently in use.

Four of the 13 trusts in the Dr Foster list were also inspected this year by teams working for NHS England medical director Sir Bruce Keogh as part of the government’s response to the Francis Inquiry. These were: Medway Foundation Trust, North Cumbria University Hospitals Trust, Northern Lincolnshire and Goole and United Lincolnshire Hospitals Trust.

Trusts that are high on at least two of the four main mortality measures

Aintree University Hospital Foundation Trust

Blackpool Teaching Hospitals Foundation Trust

East Sussex Healthcare Trust

Heart of England Foundation Trust

Medway Foundation Trust

Mid Cheshire Hospitals Foundation Trust

North Cumbria University Hospitals Trust

North Tees and Hartlepool Foundation Trust

Northern Lincolnshire and Goole Hospitals Foundation Trust

Northumbria Healthcare Foundation Trust

United Lincolnshire Hospitals Trust

University Hospitals Birmingham Foundation Trust

West Hertfordshire Hospitals Trust

Readers' comments (27)

  • When will someone get to grips with this process of being hung, drawn and quartred in the court of Dr. Jarman? - which, by the way, is a very useful tacticto drive more work in the direction of the Dr. Foster commercial services?

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  • George Rook

    As an expert patient, let alone joe public, it is very difficult to know what these indicators mean, and then to have trusts coming back and saying something was due to data fault, or on another indicator they are not an outlier...

    Why can't we have one measure across all trusts? Tell us where we are more likely to die during or after treatment? Tell us which specialities are safe and which less so.

    So many organisations and measures and is out of hand and bewildering.

    Trusts need to just make their services safe and effective when we use them.

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  • What is clear is we are more likely to die in peripheral hospitals- we should all head for the leading Teaching Hospitals. Why on earth do people support their local cottage hospitals!

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  • 9.00am - you might want to google the trusts on that list. Can't see how the evidence backs your assertion.

    There are are big trusts on there and 4 have a title including the words "University" or "Teaching".

    Not sure that many of them can be called cottage hospitals.

    In my neck of the woods it's the big teaching hospital that most doctors would not want to go if they were a patient.

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  • UHB Birmingham is probably one of the biggest in the country, and the flagship Trust held as an example to us all. Money has been really spent there.
    I would be asking about the patient demographics of these hospitals. Average ages and severity of illness being treated. The tertiary care hospitals like UHB are likely to have very sick and complex cases coming in because they are designed to deal with these.

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  • This is old news for Keogh trusts. ULHT's rate is currently well below 100 and has been since April!

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  • I'm not sure whether UHB is the biggest Trust in Birmingham. If not the one that is bigger would be Hear of England Foundation trust. To be fair that does have a couple of DGHs as well as a huge site as well so will be a mix. Between UHB and HoEFT though they probably provide 70-80% of the tertiary care to the population of Birmingham.

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  • Can DFI please explain the methodology they have used to blacken (their colour) the SHMI.
    It looks like the poisson limits and not the official NHS methodology Over Dispersion. Hence choosing to increase the number of outliers.

    Aren't they are a member of the SHMI technical group, and agreed the correct methodologies? Or is that Doc Foster Research I get confused by the distinction.

    Also aren't DFI 50% owned by HSCIC and what are they doing to ensure that DFI follow the appropriate methodologies.

    We do not need commercial companies using inappropriate methodologies.

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  • This is rather poor journalism, even for a 'popular' non-academic publication. The different measures are not even described properly! You'd think it was a matter of politics which to choose.

    I don't like the toxic commercialism in health care any more than my colleagues above, but I really need to know how these measures operate and the funding of the organisation producing them doesn't seem germane here.

    Editor - how about a published clarification?

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  • Not suprising to see North Cumbria now pulling down HSJ Provider Trust of the Year - Northumbria Healthcare. Its all about common denominators!

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  • Stella, am confused, do you think I have mis-described or under-described the measures? And what do you mean "a matter of politics"? Leave a comment or email me
    There's a limit to how much of the methodology I can explain in a short news piece. Here are 10.8mb of methodology documents

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  • Stella, am confused, do you think I have mis-described or under-described the measures? And what do you mean "a matter of politics"? Leave a comment or email me
    There's a limit to how much of the methodology I can explain in a short news piece. Here are 10.8mb of methodology documents

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  • 10:58 – The SHMI technical group (leading the methodology for the SHMI) do publish the SHMI with 2 control limits (including the 99.8% one used in the guide) as they have been recognised to both have their use.

    For the Hospital Guide, all mortality indicators have been banded using 99.8% control limits. For the SHMI, we have used the 99.8% control limits as published by the Health & Social Care Information Centre at The use of 99.8% control limits is in line with advice from the Dr Foster Unit at Imperial College London to the SHMI technical group and is consistent with those used for other mortality indicators published in the Hospital Guide.
    SHMI figures by trust are published with two banding systems. One applies 99.8% control limits, consistent with our approach to all the other indicators in the Guide. The second banding system identifies a smaller number of outliers on the grounds that the data is over dispersed. In simple terms, the second approach assumes that the extent of variability between trusts is too high to be explained by variation in quality of care and applies additional statistical processes to set a higher benchmark for outlying status. The Dr Foster Unit at Imperial College has advised that, in their view, the degree of dispersion across the data does not warrant this further adjustment and that, since the data is being used as a ‘screening test’ to identify where it is more likely that quality of care may be an issue, it is not appropriate to adjust the data on the assumption that variability is not being caused by quality of care.

    This explanation was fully explained to the trusts prior to publication of the Guide.

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  • 10:18 – HSMR is not a crude rates metric but risk-adjusted one taking into account many criteria including demographics and co-morbidities. The full methodology on how HSMRs are calculated are completely transparent and published. You can download them on

    It is true that large teaching hospitals tend to have more complicated case mix than other hospitals; but it is also true that they tend to have a lower than expected mortality rate after risk-adjustment. UH Birmingham unfortunately does not fall into this category.

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  • Wonder how the 'failing' Burton Hospital and George Eliot feel about being 'buddied up' with UHB? Perhaps they should offer to buddy them instead?

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  • You may well ask that question 2.57. Why oh why are Dr. f and Jarman given all this air time when Bruce Keogh and his team are trying so hard to get some proper academic rigour into mortality stats and the link to excess deaths debate. The FTN are trying to get some sensible media response but yet again we see this rubbish in the media undermining public confidence and causing yet more confusion.

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  • No mater what the academic arguments the mortality data must be taken seriously. Interesting to note that the prime example of North Cumbria University Hospitals, already pinpointed as a big issue by the Keough review and taken over a couple of years ago by another poor performer with higher than average death rates, hse been outed by Dr Foster. So lets not just dwell upon methodologies but dig down to the facts that have already been exposed in a number of secondary care outfits right across the NHS. Stick with it Professor Jarman and of course you do have your former colleague Tim Kelsey now strategically placed in the Kremlin. Thank you HSJ for a balanced piece with I am sure more yet to come.

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  • North Cumbria and Northumbria didn't get as far as merging so their data are handled separately here. Northumbria appears on the list on its own merit (or otherwise). Ask Cure the NHS NorthEast what they think of Northumbria being HSJ trust of the year. The trust is well known for its spin and PR.

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  • Thanks to Ben Clover & Dr Foster for the helpful clarification!

    I'm sure others will read and enjoy too.

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  • I am not a statistician, but imho this seems to me to be selective negative reporting yet again...can't you print all the results in a funnel plot so we can see where all the Trusts lie and which are outliers positively and which are outliers negatively? For 13 hospitals that are worse than expected there must be 13 hospitals that are better than expected....or am I being statistically naive? Aren't we dancing on the head of a pin? Its all about deviation from a mean isn't it? Above or below. I want to see the whole picture, not just bits of it that make sensational headlines. What about the rest of the results to keep things in perspective?

    And why do Dr Fosters seem to operate according to their own timeline and agenda? How do they fit in with the work being done by Keough? Who commissions and quality assures their work? Is it peer reviewed before publishing?

    I am heartily sick of all this. As David Spiegelhalter said in his BMJ article after the last Professor Jarmine foot in mouth episode "the crucial fact is that both the SHMI and HSMR are standardised to recent national performance, and so we would expect at any time that around half of all trusts would have 'higher than expected' mortality, just by chance variability around an average" (BMJ 2013;347;f4893)...he adds later "it is enough to make a statistician sob".

    anon 4.44pm you say we should ignore the academic absolutely not. It would be throwing the NHS to the wolves to ignore academic evidence, and there are many wolves out there waiting for anything remotely negative to further undermine the public's confidence in the NHS, and its helped by one-sided reporting.

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