Palliative coding surge raises death rate worry

Professor Sir Brian Jarman last week told the Mid Staffordshire Foundation Trust public inquiry the trust was one of three in the region where the number of patients recorded as receiving palliative care shot up between quarters one and three of 2008.

By the end of the period Mid Staffs was coding about 30 per cent of patients as palliative, George Eliot Hospital Trust in Warwickshire almost 40 per cent and Walsall Hospitals Trust 78 per cent.

“The only way you could get dramatic changes like that would be if the three trusts suddenly became terminal care hospitals overnight,” Dr Jarman told the inquiry.

The trusts’ coding changes came a year after the rules were altered to allow patients with incurable conditions to be classified as palliative, which Dr Jarman told the inquiry would allow trusts to include rheumatoid arthritis and diabetes.

In his evidence, Professor Jarman questioned why the change to coding in the West Midlands had come a year later than the rule change and coincided with the launch of the Healthcare Commission’s investigation at Mid Staffs.

He told the inquiry the trusts were effectively “removing deaths” which would have the effect of lowering the hospital standardised mortality ratio.

Increasing the number of patients classified as palliative increases the number of expected deaths at a trust, explained Professor Jarman, one of the founders of the Dr Foster Unit at Imperial College London. The HSMRs used by health information business Dr Foster are calculated by working out the difference between expected deaths and actual deaths.

Professor Jarman said he believed the coding changes were a result of a “concerted effort” in the region.

NHS West Midlands declined to comment on whether it had encouraged the approach but told HSJ all trusts were now looking at their coding from 2008 to “ensure their data is accurate”.

Professor Jarman told the inquiry the number of patients recorded as palliative had increased across England since 2007, from which time mortality rates appeared to fall faster than in comparable countries.

Rules on coding changed again in June 2010, when the category was split into specialised and general palliative care. The summary hospital mortality index was delayed by disagreements about methodology. In evidence to the inquiry last week, NHS Information Centre chief executive Tim Straughan said it would be produced in October.