Mandatory VTE assessment hit 95% compliance. National outcome data tell a different story.

Quality improvement · NHS · Venous thromboembolism

Mandatory VTE assessment hit 95% compliance. National outcome data tell a different story.

Scope of this post: This article is about the assessment-based process — how it was mandated, measured, and rewarded — and why national data suggest it did not deliver the guideline's stated aim. It is not an argument against thromboprophylaxis itself; that is a separate clinical question, covered in a follow-up post.

In June 2010, England launched one of the most ambitious patient-safety programmes in its recent history. Every adult admitted to an NHS hospital would receive a documented assessment of venous thromboembolism (VTE) risk. Thromboprophylaxis would follow for those who needed it. Trusts would report compliance quarterly. Financial penalties would bite if performance fell short. NICE had already published its guideline — CG92 in January 2010 — setting out what good prevention looked like. The aim was clear: reduce deep vein thrombosis (DVT), pulmonary embolism (PE), and the deaths that follow from hospital-associated thrombosis.

Fifteen years on, the compliance charts look like a quality-improvement textbook. National assessment rates climbed from roughly 53% in mid-2010 to above 90% within two years. From April 2013, when the target was raised to 95%, the NHS met it and kept meeting it — quarter after quarter, trust after trust. By 2019, the figure sat at 95–96% and barely moved. On paper, the programme worked.

But paper is the problem.

The wrong scoreboard

The NHS did not make thromboprophylaxis mandatory in the abstract. It made documented risk assessment mandatory — and then treated assessment completion as the primary measure of national success. CQUIN payments, standard-contract clauses, and board-level dashboards all converged on one question: was the form filled in?

That is a process metric — not whether the right patient received prophylaxis, whether doses were administered, or whether fewer patients developed clots. Root-cause analysis was part of the policy bundle, but compliance with assessment drove behaviour and reputation.

When a system optimises for what it measures, it should surprise no one when the measurement diverges from the outcome.

HES tells a different story

Hospital Episode Statistics (HES) do not record "hospital-acquired DVT" as a discrete field. What they do record — reliably, at national scale, year on year — is whether a DVT code appeared as a secondary diagnosis on an admission episode whose primary reason for hospital contact was something else. That is an imperfect proxy. It may include some pre-existing clots. It will miss silent events never coded. It cannot distinguish community DVT from thrombosis provoked by the index admission.

It is, nonetheless, the closest thing we have to a ten-year national signal of DVT arising in the context of hospital care — and that signal is not comforting.

Secondary DVT rate (England, HES)

Period	Per 100,000 episodes
2012/13	~166
2019/20	~210
2021/22	~225
2020/21 (COVID)	~253

Source: Hughes et al., BMJ Open 2025. SPC analysis shows significant upward trend from 2013 — when assessment compliance was already above 95%.

That is a red flag. It is proof that the assessment-based process the NHS built around the guideline — mandatory forms, compliance targets, central returns — did not produce the epidemiological pattern you would expect if that process were reliably reducing hospital-context DVT at scale. The failure lies in what was industrialised, not in the existence of thromboprophylaxis as a clinical intervention.

Compliance up. Secondary DVT coding up.
Those two lines were never supposed to run together.

The death data make it worse

If the assessment process were reliably triggering effective prevention among the patients the programme was designed to protect, we should see that in hospital-linked VTE mortality — deaths in hospital or within 90 days of discharge among people with a recent admission, with VTE on the death certificate. That is NHS Outcomes Framework indicator 5.1 (I00675), the official national outcome measure aligned with NICE's hospital-associated thrombosis framing.

Here the official narrative and the epidemiology part company.

The published story (rate) 72.8 → 62 Fatal VTE per 100,000 admissions 2007/08 to 2019/20 (61.2 in 2023/24) ✓ Widely cited as success

The epidemiology (count) 8,106 → 9,087 Absolute hospital-linked VTE deaths 2007/08 to 2019/20 (+12% pre-COVID) ↑ Significant upward SPC trend from 2013

The rate fell because the denominator grew faster than the numerator — adult hospital admissions increased by roughly a third over the same period — not because England was clearly putting fewer people in the ground from hospital-associated thrombosis.

A metric that dilutes the truth

Why does a falling rate mislead so convincingly? Because NHS OF 5.1 spreads fatal events across a denominator far broader than the population where those deaths actually occur.

National linkage work by Catterick et al. (BMJ Open, 2024), using the same case definition as the outcomes-framework indicator, found that 86% of hospital-linked fatal VTE followed emergency inpatient admission. Planned inpatient and day-case pathways together accounted for only about 12% of deaths — yet they form a large share of all admitted activity.

The indicator dilutes high-mortality emergency pathways across millions of lower-risk admissions.
A rate can fall while the count of people dying does not — and even rises.

Day cases are included in both numerator and denominator of OF 5.1, so a day-case surge could artefactually lower the rate. HES data rule that out: day cases rose in number but held at about one-third of activity for over a decade. Fatal VTE stayed anchored in emergency inpatient care. The problem is a rate-based metric on a heterogeneous admission base, sold on the promise of fewer clots and fewer deaths.

Well meaning guideline failed in practice

NICE CG92 — later updated as NG89 — describes a pathway: identify risk, prescribe appropriate thromboprophylaxis for those who need it, consider post-discharge extension where indicated, investigate incidents, learn from harm. That is more than a tick-box.

What England actually mandated and measured was the first step — documented VTE risk assessment — and treated completion of that step as if it stood for the whole pathway. Form completion, central reporting, and a 95% compliance target became the national product. Thromboprophylaxis remained in the guideline text; it did not become the national scoreboard.

That substitution is why I regard the guideline as well meaning but failed in practice: not because prevention is futile, but because the assessment-based process given statutory force was the wrong proxy for it.

Process–outcome decoupling

Metric	What happened	Signal
VTE assessment compliance	Target met, sustained, celebrated	✓
HES secondary DVT	Upward trend through compliance era	↑
Fatal VTE (absolute deaths)	Flat to rising from 2013; SPC significant	↑
Fatal VTE (published rate)	Modest decline; cited as success	↘

We optimised documentation and called it prevention.

What should change

Assessment completion should be a gateway metric, not the finish line. Outcomes would be tracked in absolute terms and pathway-specific strata — emergency medical admissions first — with prophylaxis administration audited alongside forms. Secondary DVT in HES would be monitored as a sentinel, coding caveats acknowledged but not deployed to dismiss the signal.

The lesson generalises beyond thrombosis. When a guideline becomes mandatory NHS activity with financial teeth, ask which part of the pathway was actually enforced. If the answer is a single process step — here, risk assessment — you may get excellent compliance on that step and no superior clinical outcome on the harm the guideline was written to prevent.

Coming next: Thromboprophylaxis on its own terms — evidence, delivery, and outcomes. This post stops where the national programme stopped measuring: at the form.

The clinical intention was humane. The assessment-based architecture was not equal to it.

References

1. NICE. Venous thromboembolism in over 16s (NG89). nice.org.uk/guidance/ng89
2. NICE. VTE: reducing the risk for patients in hospital (CG92). nice.org.uk/guidance/cg92
3. Department of Health. Report of the Independent Expert Working Group on Prevention of VTE. 2007.
4. NHS England / NHS Digital. VTE risk assessment quarterly data and CQUIN specifications, 2010–2020.
5. Catterick MD, Hunt BJ. Impact of the national VTE risk assessment tool in secondary care in England. Blood Coagul Fibrinolysis. 2014;25(6):631–635.
6. Hughes F, et al. HES DVT/PE trends. BMJ Open. 2025. doi:10.1136/bmjopen-2024-090301
7. Catterick MD, et al. Who dies from VTE after hospitalisation in England? BMJ Open. 2024. doi:10.1136/bmjopen-2023-078898
8. NHS England Digital. NHS Outcomes Framework 5.1 (I00675). Feb 2025 release
9. Nuffield Trust. Blood clots following hospital care. nuffieldtrust.org.uk
10. NHS England Digital. Hospital Admitted Patient Care Activity (HES). digital.nhs.uk
11. Hunt BJ, et al. VTE prevention: UK experience. Res Pract Thromb Haemost. 2023. PMC9903667

Busting Myths in Healthcare Management

Busting myths in healthcare management

A dozen at a time

Myth 1

Quality can be measured

No

(But, Quality Improvement can be measured)

Myth 2

Publications and guidelines (national) are a good source of evidence (for QI)

No

(Often published evidence is invalid, not robust enough or gets outdated soon. Guidelines are rarely tried in their totality before being recommended)

Myth 3

Increasing Quality Increases Cost

No

(Improving Quality Decreases Cost)

Myth 4

Improving Quality Improves Safety

Often No

(Improving Quality Improves Quality, Improving Safety Improves Safety. According to definitions they are two different things.)

Myth 5

Management by Objectives/Targets are good (for QI)

No

(Targets especially mandatory ones are prone to scamming)

Myth 6

Above Average is a Good Indicator of Quality

No

(Averages are flawed. Averages are not real)

Myth 7

A high percentages of good things and a low percentages of bad things are good indicators of quality improvement

May be but not really

(Percentages could be misleading. Percentages are not real numbers)

Myth 8

Culture Can Be Changed

No

(Processes can be changed and that may change culture)

Myth 9

All Directors in the Board of Directors are Leaders

No

(Leaders are follower defined not position defined)

Myth 10

Management Principles are the same for Healthcare as in any other field

No

(The frontline in healthcare is unique and very different)

Myth 11

Errors can be eliminated (in healthcare)

No

(Errors can be reduced but cannot be eliminated. But harm can be eliminated.)

Myth 12

Human Factors is about Changing Behaviour

No

(Human Factors is about changing Design)

 You can learn more about these from many sources (eg. University of Hull http://successinhealthcare.blogspot.co.uk/2015/06/msc-in-healthcare-improvement-leadership.html or enquire about a bespoke course http://www.successatmedicalinterviews.co.uk/Courses.aspx )

©M HEMADRI

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M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Don Berwick Report

Don Berwick NHS patient safety report - will it work?

It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf). There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot

My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

© HEMADRI

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PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.

Revalidation - GMC must make it objective as soon as possible

The shortest overview of revalidation

GMC is commencing the process of revalidation for doctors in December 2012. The revalidation demands that we have evidence of 

1) Continuing professional development

2) Quality Improvement Activity

3) Significant events

4) Feedback from colleagues

5) Feedback from patients

6) Review of complaints and compliments

These six will populate the annual appraisal which apart from its main domains include the personal development plan, probity and health

Based on the above, the responsible officer will make a 'judgement' on whether the doctor can be recommended for revalidation. The GMC will then make a decision on whether the doctor has been successfully revalidated.

There is plenty of guidance on GMC website : http://www.gmc-uk.org/doctors/revalidation.asp

Concerns about the background for revalidation

While the issue of periodic quality assurance of licensed doctors has been discussed for a long time, the common view is that the current revalidation efforts commenced after the Bristol enquiry and gathered momentum after the Shipman enquiry. Bristol was an outlier, there was no trend that many hospitals or many cardiac surgery units were having unacceptably bad outcomes. Shipman was an outlier, there was no trend that many doctors were behaving or beginning to behave in a Shipman like manner. Outliers need to be analysed properly so that outliers can be stabilised to a performance level compatible with other performers within the general system. Quality principles would suggest that outliers should not trigger a process change for the whole system. Process change for a system could be triggered by an unacceptable trend (there are other reasons to change the process as well, but outlier is generally not one of them). To create a process change on the basis of outliers is thought to result in unnecessary expense and wasted effort.

This does not mean that we cannot learn from outliers, undoubtedly there are extraordinarily important lessons to be learned from Bristol and Shipman.

Linking the background to current revalidation method

Bristol is about performance and Shipman is about behaviour. We can safely assume that this is what the GMC seeks to assure. Quality assurance needs to be demonstrated in an objectively measureable manner.

Revalidation criteria - Not Objective

The six areas of evidence that the GMC asks for seem to be mostly subjective.

Continuous professional development (CPD) is generally accepted as a reflection of time spent on courses and conferences or other learning opportunities. It is certainly not a measure of the knowledge or skills gained or updated though that might happen. Some professional bodies have not defined the time needed to be spent on CPD. Hence while CPD is often measured and entered as a number it is a measure of time spent rather than a number to show the knowledge or skills gained. It could therefore be argued that CPD is either subjective or fit for purpose for revalidation if the intention was to validate or assure knowledge and/or skills.

Quality Improvement Activity: within this areas a range of activity is included. Activity is neither outcome nor achievement. Therefore activity is again time spent rather than gains (or losses) measured. An important point in quality improvement activity is that people fail more often than they succeed, that is the nature of quality improvement. Doctors, hospitals and the GMC should be comfortable with that. This could be potentially be an objective criteria but currently it could probably be considered unsure.

Learning from significant events and review of complaints and compliments are about self-reflection and reflective writing. It is obviously subjective. Feedback from colleagues and feedback from patients though done through validated tools by external or independent service providers is essentially the conversion of subjectivity into a scale to be able to measure.

Are subjective criteria relevant?

Absolutely yes. But only when looked along with objective criteria. Any form of quality assurance process must include subjectivity. The current criteria for revalidation seems mostly subjective and hence the concerns.

Why are objective criteria important?

We are talking about doctors who are essentially already very highly qualified and doing an extremely complex job under phenomenally varying conditions. We are taking about professionals on whom we have already spent somewhere between half-a-million to a million pounds before they are employed to do their role. Revalidation is about making a decision about their careers which could potentially be halted. To make such major decisions on mostly subjective criteria would not make sense. Further, there are planet loads of data already gathered and analysed and hence objective criteria are possibly already available if we wanted to use them.

Next is the issue of who may potentially be adversely affected to a higher degree than most. When subjective criteria are used there is a risk that often the weak, the easy targets and usual suspects may be affected. This has been seen in a few exam situations where certain sections of candidates pass the objective knowledge and skill components but fail the subjective elements of vivas, communication, simulation etc. There is a fear that it is possible that IMGs and BMEs (and SAS) doctors  would be affected by the level of subjectivity involved in revalidation.

There are good reasons behind these fears which relate to the culture and history of healthcare institutions and the culture and mind-set of BME/IMG doctors which is not explored here.

Increasing objectivity

Testing knowledge has traditionally been done by examinations. Americans revalidate their doctors on the basis of an objective examination of knowledge. This while reducing bias increases the validity of assurance of knowledge. Skills assessment could quite relevantly be based on performance data. Speaking from a hospital doctor perspective, this should be quite easy to do with some minimal tweaking on how data is gathered. Operational performance data is either the best or as good as any other indicator of a doctors skill.

Increasing objectivity still would not resolve the underlying issue of a process change for all doctors based on outliers and not trends. The GMC also needs to resolve other issues. Is revalidation a quality assurance process or a quality improvement process? Because the theory and the tools for assurance are different from improvement

Revalidation is important. It is likely that as it stands the revalidation process is heavily subjective. Given the importance of healthcare of the nation it would be advisable to quickly move to mainly objective criteria. We are where we are, let us make it better and fit for purpose.

©M HEMADRI 

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