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Mortality in hospital

19 July 2013

PEOPLE go into hospital to die. This might not have been their intention, but, as they approach the end of their lives, their medical needs often dictate that a hospital is the only place where they can receive the care that their failing bodies require. As a consequence, hospital staff are dealing with death every day. Many deaths are natural, gentle, and predictable; others are unexpected and traumatic. This is the context in which Sir Bruce Keogh's review of 14 hospital trusts with higher than expected mortality rates should be viewed. Hospital staff work in an environment where death is often still seen as a failure, and in a wider culture that today lacks a unifying religious or philosophical understanding of mortality. They must cope with it in their own ways, and, inevitably, a proportion of them cope badly. This is one of the fundamental reasons why the other review reporting this week, Baroness Neuberger's investigation of the Liverpool Care Pathway (see article), called for fundamental changes of approach in end-of-life care. A sound programme to ensure that people in their last days are given the correct level of treatment has, in some cases, been applied in a disorganised and uncompassionate way.

Much of the blame for the poor treatment in the 14 trusts named on Tuesday must rest with the individuals who, when a professional and caring response was called for, failed to provide one. The Department of Health is right, however, to target the management of these trusts. The culture of a hospital - what standards are accepted, how the staff are treated, how funding is used - is up to them. This is, of course, another set of individuals, and the Health Secretary has promised that the guilty ones will be replaced, as is right.

There is a danger, though, that a fundamental weakness in the NHS is being ignored. Its present organisation into a series of competing trusts resulted from applying a market model to the Health Service. Under market thinking, a monopoly is a bad thing, leading to inefficiency and complacency, and evidence of these was easy to find in the old NHS monolith. But a working market model relies on a balanced relationship between supplier and customer, and here there is confusion over who the customer is. To a degree, it is the patient, who experiences the hospital's care, or lack of it, first hand. But patients' knowledge is limited. They know how long they have to wait for treatment, and this became, for a while, the chief measure of a hospital's performance. But they do not know about outcomes: comparing surgical success-rates between trusts, for example. For this, the Department of Health remains the customer, and the Government is thus to blame for failing in its scrutiny of its chosen suppliers. In the end, the market is just a business model: a successful supplier will provide the required level of service for the lowest price. The Health Service deserves more than this. Another reorganisation is out of the question, but a recognition that there are principles and practices that override commercial concerns would be a good place to start.

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