Thursday, 26 September 2013

In search of immortality

The media screams out relentlessly on excess deaths, avoidable deaths, harm, on how many lives can be saved if healthcare did this, that or the other right. In fairly cynical mood I thought, if I added up all the number of lives the media says we could save the people in UK could become immortal. Thus started my quest for immortality.

Here is the list and total of how many lives the media thinks healthcare can save.

Preventable DVT deaths 25000
Kidney function tests 42000
Addiction deaths 150000
Child deaths 2000
 Learning disability 1200
Cancer deaths 11500
 Maternal deaths 50
Not taking tamoxifen 500
Dehydration in the elderly 130
10  Wrong medication deaths 11
11  Sepsis 15000
12  Flu jab 7000
13  Trauma admissions in hospital 600
Total  254991

I am sure you the reader can add a few of your own categories to this list.

The total number of people dying every year in UK 428367. If we can save 254991 that means we will be 60% of our way to making UK immortal.Obviously there are undefined overlaps between the categories and I sure double or triple or multiple counting makes all that number attract attention.

Let us get a little real now. No one thinks they are going to to be immortal. Everyone knows there is avoidable/preventable mortality in healthcare delivery. The point is to try to admit, then identify avoidable deaths, followed by measures to reduce avoidable deaths to zero or awfully close to zero.

Would that be possible? 

The above media based list includes untimely or early deaths due to life style and behavioral choices. While solving that would also be possible, I am not talking about that. I am talking about deaths that can be avoided by delivering the healthcare in a way that we intended it to be delivered. 

United Kingdom has an amenable mortality of 102 per 100000 population (which works out to an approximate 65000 people) compared to France's 64 per 100000. It seems like a 40% reduction in amenable mortality should be possible. Since France's 64/100000 mortality is also amenable to healthcare it means we will have a lot of smart work to do for quite some time to come.

Can it be done?

We have already set the background by talking about HSMRs as an indicator, we have discussed the broad ideas around methodology in Hemadri's Four Fundamentals (, the issue of learning facts yet practising opinion and how to over come it in Letter to my nieces (

The current argument in UK is on how to actually identify the avoidable deaths. Individual case note reviews is thought to be the method. It may well be. There is a specific way of performing these individual case note reviews. 

Watch this space. The blog with some ideas on performing case note reviews will be here soon.

The quest for immortality - no that does not continue. The quest for eliminating avoidable deaths continues.................................


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Weblinks for each of the 13 headings which are listed above:


Sunday, 22 September 2013

NHS Hospitals with Doctors on the board of directors have better outcomes

NHS Hospitals with Doctors on the board of directors have better outcomes

Amanda Goodall has shown that hospitals with doctors as chief executives have 25% better clinical outcomes (statistically significant) in US hospitals. This is seen in other areas where 'expert leaders' have better outcomes. Kirkpatrick and Veronesi have looked at the board composition and found that in general boards of directors having more clinicians have lower HSMRs. Very specifically they found that boards of directors with more doctors in them clearly have a lower HSMR, higher CQC rating (actually their predecessor the healthcare commission's ratings) and higher patient satisfaction.

This prompted me to look at the Keogh 14 NHS Trusts that have been identified by the Department of Health and others as having problems mainly as a result of higher SHMI. The findings are of course compatible with the published research. 

All the 14 Keogh Trusts put together have only 3 doctors in their boards apart from their medical directors. Since medical directors on boards are statutory they are a common factor in all boards anyway.  So if medical directors are excluded from the calculations then the 

Keogh 14 trusts have 3 doctors (excluding Medical Directors) out of  184 board directors 1.63% of the board are doctors excluding MDs

Compare that to the 14 hospital trusts  with the lowest SHMIs (as of 2011) who have 15 doctors (excluding medical directors) out of 195 board directors 7.69% of the board are doctors excluding MDs

If we looked at HSMR (as of 2011) and compared high 14 and low 14 HSMR hospital trusts (the 14 is simply a number to match Keogh - there is no real logic or magic on the use of the number 14 here) a similar picture emerges:

NHS Hospitals with highest 14 HSMRs - 5 doctors (excluding Medical Directors)amongst 189 board directors  2.64% of the board are doctors excluding MDs

NHS Hospitals with lowest 14 HSMRs - 16 doctors (excluding Medical Directors) amongst 191 board directors. 8.37% of the board are doctors excluding the MDs

Medical directors as already mentioned are a mandatory appointment. Any other doctors appointed to the board is a sign of the value and recognition  by the trust and the appointment committees either on the basis of what the trust thinks that doctors bring to the table or as a recognition of research findings that expert led organisations do better. It is very clear that more doctors on the board of directors is associated with better outcomes.

It may not be politically correct to say so but it simply makes sense to appoint more doctors to the board of directors. 

What is important is that increasing the number of doctors in the board in the high SHMI or high HSMR hospitals must not be done as a matter of ticking the box - that will be very disrespectful to the concept. It should come out of a recognition of the value that the medical profession brings to the system as borne out by the findings above. 

It is also possible that when we cynically manipulate the undeserving into boards or when all boards have a higher number of doctors there will still be a difference between low and high performing hospitals. That is a different and new issue to be dealt with as it emerges. However in the meanwhile if as a result of increasing doctors in the boards we get better results we should respectfully and gratefully accept that.

It makes sense to have doctors on boards - let us do it.

Additional information added on 25 May 2015 - The difference in doctors in the board of directors between the Keogh 14 trusts and low SHMI trusts mentioned above is statistically significant with a p value 0.0081 (significant at p < 0.05 ) using a chi-square test

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The trust boards listed above were identified from their respective websites accessed on 21 September 2013

Kirkpatrick and Veronesi's article on Clinicians in Boards:

2012 low 14 SHMI trusts list is quite similar to 2011. I used 2011 since it was easier to access.

There were 7 BME board directors in Keogh 14 trusts and 7 BME board directors in 14 lowest SHMI trusts  

Keogh 14 Trusts
Basildon and Thurrock
Dudley Group
East Lancashire
George Eliot
North Cumbria
Sherwood Forest
United Lincoln

14 Low SHMI Trusts (2011)
West Middlesex
North West London Hosp NHS FT
James Paget
Chelsea & Westminster
St Georges
Royal Free

14 Highest HSMR trusts (2011)
Morecambe Bay
Isle of Wight
Hull & East Yorks
North Cumbria
George Eliot
Dartford & Gravesham
University Hosp of North Staffordshire
Northampton General Hospital
Dudley Group
Shrewsbury and Telford
Sherwood Forest

14 lowest HSMR trusts (2011)
Chelsea & Westminster
Kings College
Guys and St Thomas
Frimley Park
St Georges
Royal Free

Tuesday, 3 September 2013

How to do a ward round

Till recently there were no accepted method, standard, process, protocol or parameters on how a doctor should do a ward round for in-patients. We generally turn up, see the patient, sort problems and when the patient gets better we discharge the patient. In recent times there are emerging opinions which have led to some recommendations on ward rounds.
I describe my personal experience of one of the best ward rounds that I had the privilege to be a part of during my training days. I describe the ward rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants emergency takes, outliers and consultation requests from other consultants
- Write in the patient notes the results of investigations or have the investigation results on hand ready to be written in the notes
- Deal with any really dire emergencies where the physiology was really poor

Registrars should come in at 8.30 am and had till 9 am; their job was defined:

- Help the house surgeon deal with dire emergencies if there were any
- Talk to the nurses to identify any issues that arose overnight for the in-patients

Mr Desai would arrive at 9 am to the male ward. If there were any dire emergencies the registrar (and not anyone else) would continue to deal with it. Otherwise the whole team started the ward round. The whole team included the ward sister and the nurse who looks after the patient apart from the house surgeon, medical students if any, clinical attachment doctors if any and other healthcare staff as relevant. What I call a ward round kit followed the team - this included the notes trolley, all investigation request forms, a dictaphone, gloves, gel, stationery (continuation sheets, consultation request forms), some house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant. 

Everything that the patient needed as a result of the consultant visit was completed before moving on to see another patient.

If a patient needed bloods to be repeated immediately it was done right there in front of the consultant, bloods need to be repeated in the afternoon or the next day the forms were done right there, any other test requests (X-ray, CT, ECG, etc) were done then and there. Any communication with other teams/speciality's consultants/registrars they were bleeped or rung, spoken to or if they were not available a message was left with their secretaries. Letters needing dictation though this was rare was done right there. A canula that needed doing was done then and there. Every work that was generated as a result of Mr Desai's ward round was done in the presence of Mr Desai or if appropriate by Mr Desai himself as soon as it was generated before moving on to the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds took less than an hour (which was reasonable by surgical standards), Mr Desai's ward round took all morning (his ward rounds were in the morning). It was initially frustrating. But soon junior doctors realised that there were not many 'to do lists' not many things to actually pending. We were not running like headless chicken after the ward round. We ended up having more time for the doctors mess, more time for learning, more time for everything else.

Any really abnormal results were acted upon at the earliest as anyone would. The next time the house surgeon had any serious work was at 3.30 pm to check on any changes to patient's status which were not already informed and to check on investigation results that were not direly abnormal and to act on it. Barring a late finish in theatres Mr Desai would always visit the wards and speak to the senior nurse at 5 pm every day and conducted the equivalent of a board round. Any patients that needed to come to the attention of the on-call teams were noted - Mr Desai would speak to the on-call consultant and Mr Desai's registrar would speak to the on-call registrar. 5.30 pm we were gone.

I do not know the precise results of Mr Desai's work. All I know was that everyone including me was of the impression that his work was good. It was organised, it was thorough and all elective work was directly consultant delivered or delivered in the presence of a consultant. An aside which could be a nugget as a mark of the quality of his work: all his patients who were having elective major surgery were seen by the physiotherapist with a special emphasis on chest physio - blowing balloons et al - it was no wonder we thought his patients did well.

I did not know about lean concepts in 1994. When I later became aware of lean I realised that this is a single piece flow ward round if there was ever such a thing described.

I recommend it.

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PS: I have heard a number of patients credit Mr Desai with commencing gastrointestinal endoscopy, vascular surgery, endo-urology and triple assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise him.