Impact case study database

The creation of a monitoring tool using the underpinning statistical research with the commercial partner Dr Foster Ltd has helped the NHS improve care and save lives since 2007. This case study describes the impact since 1 August 2013, but we first give some important background.

Before the current REF impact period, our hospital monitoring system identified high mortality at Mid Staffordshire NHS Trust. The alert letters sent by Imperial to the trust and the national regulator, the CQC, helped trigger CQC inspections, which led to a public inquiry (Francis Inquiry). The resulting report [A], published in February 2013, notes Imperial’s and Dr Foster’s contribution: *“There is no doubt that, without the work of the Dr Foster Unit and Dr Foster [Ltd], comparative mortality statistics would not have been published as quickly, or as fully, as they now are.*” One of the consequences of the Francis Inquiry was the investigation of other high mortality hospitals, which led to the Keogh Mortality Review [B], published in July 2013. The Review used in part our monitoring tool’s HSMRs (measures of hospital death rates) to spot high-mortality hospitals, and 11 out of 14 high-mortality hospital trusts were put into special measures. In 2013, the 11 trusts had 570,000 admissions and 21,000 deaths.

This resulted in improvements in the quality of care, mostly in the period after August 2013. The CQC assessed the 11 hospital trusts in August 2014 and found many improvements [C]. For example, one of those hospitals, Sherwood Forest, put in place regular audits and sufficient handover time between shift changes. With higher-than-expected mortality in 2014, they proceeded to transform sepsis care as a direct response to our mortality figures. Improvements continued over the coming years – see Dr Foster online case study [D]: “ The Trust has seen a significant reduction in its mortality rates, with deaths below the expected level since April 2016....for the first time since 2010”. They have around 50,000 admissions and nearly 2,000 deaths each year; NHS Digital’s SHMI web pages report their relative risk (the risk-adjusted rate compared with the national average, known as the SHMI) as 1.10 for Jan-Dec 2012, falling to 0.95 for Jan-Dec 2016.

To investigate the impact of the monitoring system beyond those 11 trusts, in 2018 Imperial staff evaluated the monitoring tool in a peer-reviewed report to NIHR [E], including interviews with and quotes from staff at site visits plus a national survey. Although the study time period straddled August 2013, it provides a robust summary of the monitoring system. The study included 532 alerts sent to 139 hospital trusts; 71 trusts responded to the survey, and 11 hospitals were visited as case studies. The evaluation found:

• Quality of care was cited as a factor in 70% of investigations into the alerts

• On average, the relative risk of death fell by 58% during the 9-month period immediately following an alert and then levelled to a slow decline

• Full action plans were created in 77% of trusts investigated, and several hospitals reported positive changes in culture. The tool changed how some hospitals respond to information such as death rates, leading to changes in their processes. For example, before receiving our alert regarding heart attacks, one site reported poor communication, and one doctor had been disciplined for speaking out about poor care. As a direct response to our alert letter, a new mortality committee was set up, reviewing every death. A chest pain pathway was introduced across the trust, and new coronary care facilities and more consultants were approved.

This impact had significant reach between August 2013 and December 2020: we sent out 1,312 alert letters to hospitals, covering nearly 41,000 deaths during this period.

Many hospitals report the HSMR for specific patient groups in their annual Quality Accounts and set targets for the following years: the source of these figures is our monitoring tool. An example is sepsis at Oxford University Hospital in 2017/8, with reports of improvements in both care processes and the HSMR for sepsis in 2018/19 [F]: the trust had 1,503 inpatients with sepsis in 2018/19.

Besides the public health impact, there are financial impacts. Dr Foster benefit financially from the underpinning research, which they sell, together with further analysis and support undertaken by their staff, to NHS organisations and others: in June 2018, their annual turnover was £6.5m, with 67 employees [G]. Telstra Health acquired them in 2015, a deal reportedly worth 25-30 million Australian dollars [I]; the monitoring system developed with Imperial and the expertise provided by the Imperial unit were important elements of that deal [H]. Dr Foster were the first organisation worldwide to publish hospital-level death data (as HSMRs) in national newspapers, working with hospitals to understand and improve their performance. As UK pioneers of healthcare analytics, Dr Foster Ltd led the way in the use of HES data and statistical methods, which was then followed by competitors such as CHKS and HED and helped create a market now worth $2.7bn in Europe alone [J].