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Despite the fact that this indicator was hailed as "experimental" and a "smoke alarm" rather than a "fire alarm", it was only a matter of time before those trusts with the higher SHMI figures would be highlighted with the suggestion of poor performance. Even this report highlights that 3 of the trusts were as expected under HSMR. I am all for transparency but in an environment that wants to judge performance, indicators will always end up as performance management tools rather than improvement tools. It may well be that those with high palliative deaths are as a result of poor hospice provision locally or even that because they care so compassionately for the dying that people choose to die in that environment.