Mark Drakeford AM, Minister for Health and Social Services
In July 2014, Professor Stephen Palmer’s review of the use of risk-adjusted mortality data in NHS Wales was published. He concluded the risk-adjusted mortality index (RAMI) was not a meaningful measure of hospital quality in Wales and its use could divert attention away from more meaningful approaches to measuring and improving hospital care.
He made a series of recommendations for the Welsh Government and NHS Wales to ensure it has meaningful information to describe the quality of care provided in Welsh hospitals, including the timely review of all deaths in hospital – the case note mortality review process – an improvement in clinical coding and full participation in national clinical audits.
Professor Palmer also highlighted the importance of health boards ensuring they have a clear line of sight to the quality of clinical care and making timely, explicit, risk-based judgements about the quality and safety of services.
This statement provides Assembly Members with an update about progress to implement Professor Palmer’s recommendations across NHS Wales.
Mortality case note reviews
Dr Jason Shannon, the national clinical lead for mortality case note review in Wales, has led the work to develop a consistent approach to mortality reviews, with support from the 1,000 Lives Improvement Service.
All deaths in all acute hospitals in Wales are now reviewed and health boards are increasingly extending this to include deaths in community hospitals. Case note mortality reviews are a 2-stage process – the first is a universal mortality review, which is an initial screening of all deaths. If any concerns are identified, that individual’s case is subject to a more in depth stage 2 review. This involves a root cause analysis, which can, where necessary coordinate with the Putting Things Right process. Wales is the only UK country to implement such a single system for mortality case note reviews of all deaths in hospital.
The use of mortality case note reviews has identified sepsis as an area for improvement across Wales. The effective use of the National Early Warning Score, the sepsis 6 bundle and the sepsis response bag have helped to improve the identification and management of patients with sepsis. A recent analysis of Welsh patient episodes statistics has shown a significant reduction in the percentage of deaths from sepsis from 29% to 24%. This equates to as many as 500 fewer people a year dying from sepsis in Wales.
All health boards have plans in place to support better data quality and clinical coding. Abertawe Bro Morgannwg University Health Board, for instance, have plans for closer working between coders and clinical teams and now hold quarterly training sessions for their junior doctors.
Betsi Cadwaladr and Hywel Dda university heath boards have both undertaken in depth analysis of their coding services and have made significant investments in coding services.
Clinical audit is an integral component of the quality improvement process and is embedded within the Welsh Health and Care Standards. The requirement to participate and learn from audits is also central to the major condition delivery plans.
The National Clinical Audit and Outcome Reviews Advisory Committee, chaired by Professor Peter Barratt-Lee, has improved participation in clinical audit and there has been a significant increase in the profile of clinical audit at board level; every NHS organisation has robust procedures to escalate any concerns in respect of findings, data or themes to their executive teams.
Some specific examples of clinical audits leading to real improvements in the NHS include Aneurin Bevan University Health Board’s access to mental health services. Young people with diabetes have better access to child and adolescent mental health services; there is improved access to smoking cessation programmes for mental health patients and more open access to psychological therapies; all of which have resulted from implementing recommendations in audit reports.
Cardiff and Vale University Health Board has undertaken targeted work following the publication of the National Audit for Fractured Neck of Femur and the National Emergency Laparotomy Audit – key lessons include timely access to emergency theatre and appropriate critical care provision post-operatively.
Stroke care in Wales has been transformed by the Sentinel Stroke National Audit Programme (SSNAP). The third all-Wales annual report for stroke set out the progress the NHS in Wales has made in preventing and treating stroke against the Welsh Government’s Stroke Delivery Plan. In 2005, 3,158 people died from a stroke in Wales. In 2014 it was 2,317, a 26% fall and a reduction of 841 deaths.
Professor Palmer’s final recommendation was to ensure health boards were fully sighted on the quality of clinical care and to make timely, explicit, risk-based judgements about the quality and safety of services.
All health boards have identified their improvement work and have processes in place to routinely review clinical data. This is evidenced by the case note review audit, which showed all health boards are reporting mortality review data to their clinical teams, to divisional or directorate levels, to quality and safety committees and public board meetings, in addition to publishing updates and data on their websites.
We can be confident that Wales has a strong mortality review system in place, with a continuous improvement ethic driving innovative ways of measuring quality and care. Organisations continue to participate in and learn from national clinical audit and have demonstrated a real commitment to reporting high quality data and information in an open and meaningful way.
This has led to tangible improvements for the NHS in Wales with the additional benefit of providing important assurance for the public on the quality of clinical care. Theses are factors which have contributed to the conclusions of the recent OECD report that “quality is at the heart of the Welsh healthcare system” and continuously improving the quality of care is a “deeply established and widely-shared commitment in the Welsh healthcare system”.