NHS report author says claim of "13,000 needless deaths" is a misrepresentation

Bruce Keogh, the author of the report into 14 NHS trusts, writes: "Don’t believe everything you read, particularly in some newspapers."

The claim that there have been "13,000 needless deaths" at 14 NHS trusts since 2005 led several of the weekend's papers and has prompted 10 Conservative MPs to call for the resignation of shadow health secretary Andy Burnham, who was responsible for the NHS between 2009 and 2010. In an open letter they write:

It is clear now that the last Labour government oversaw thousands of unnecessary deaths in our NHS Hospitals and failed to expose or confront these care scandals. The patients we represent were betrayed. It would be an outrage if Andy Burnham were ever to return to the role of secretary of state for health.

But while the Tories have seized on the claim for political purposes, the man responsible for the report in question, NHS medical director Bruce Keogh, has entirely rejected the basis for this allegation. 

The figure of 13,000 is based on Hospital Standard Mortality Ratios (HSMRs), which are used to measure whether the death rate at a hospital is higher or lower than expected. But while HSMRS are able to tell us this much, they are, on their own, unable to tell us whether the deaths were due to poor quality care (and therefore avoidable) or other factors. The only way to judge whether or not the deaths were "needless" would be to study each individual's case notes. 

It was for this reason that Robert Francis QC, the author of the report into the Mid Staffordshire NHS Trust, warned that it was "misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care" and that "it would be unsafe to infer from the figures that there was any particular number or range of numbers of avoidable or unnecessary deaths at the Trust."

In addition, as academics at the University of Birmingham have noted, "The HSMR has a poor performance profile (10 of 11 elevated HSMRs would be false alarms and 10 of 11 poorly performing hospitals would escape attention). Crucially, the aim of a post-test investigation into an elevated HSMR is unclear. The use of the HSMR as a screening test for clinically avoidable mortality and thereby substandard care, although well intentioned, is seriously flawed."

When these points were put to Bruce Keogh, the author of today's report, by a reader of the Skwawkbox blog, he replied: 

Mr XXXX,

Thank you. I agree with your sentiments entirely. Not my calculations, not my views. Don’t believe everything you read, particularly in some newspapers.

I am very well versed in this topic, including the abstract you attach.

When you read my report you will regret sending this email!

With best wishes, Bruce Keogh

Having chosen to go on the offensive even before the report has been published, claiming not just that there were "thousands of unnecessary deaths" but that Burnham was to blame, the Tories may well be forced to backtrack when Keogh's conclusions are published in full at 2pm today.

Ambulances are seen at the Accident and Emergency department of St. Thomas' Hospital in London. Photograph: Getty Images.

George Eaton is political editor of the New Statesman.

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A swimming pool and a bleeding toe put my medical competency in doubt

Doctors are used to contending with Google. Sometimes the search engine wins. 

The brutal heatwave affecting southern Europe this summer has become known among locals as “Lucifer”. Having just returned from Italy, I fully understand the nickname. An early excursion caused the beginnings of sunstroke, so we abandoned plans to explore the cultural heritage of the Amalfi region and strayed no further than five metres from the hotel pool for the rest of the week.

The children were delighted, particularly my 12-year-old stepdaughter, Gracie, who proceeded to spend hours at a time playing in the water. Towelling herself after one long session, she noticed something odd.

“What’s happened there?” she asked, holding her foot aloft in front of my face.

I inspected the proffered appendage: on the underside of her big toe was an oblong area of glistening red flesh that looked like a chunk of raw steak.

“Did you injure it?”

She shook her head. “It doesn’t hurt at all.”

I shrugged and said she must have grazed it. She wasn’t convinced, pointing out that she would remember if she had done that. She has great faith in plasters, though, and once it was dressed she forgot all about it. I dismissed it, too, assuming it was one of those things.

By the end of the next day, the pulp on the underside of all of her toes looked the same. As the doctor in the family, I felt under some pressure to come up with an explanation. I made up something about burns from the hot paving slabs around the pool. Gracie didn’t say as much, but her look suggested a dawning scepticism over my claims to hold a medical degree.

The next day, Gracie and her new-found holiday playmate, Eve, abruptly terminated a marathon piggy-in-the-middle session in the pool with Eve’s dad. “Our feet are bleeding,” they announced, somewhat incredulously. Sure enough, bright-red blood was flowing, apparently painlessly, from the bottoms of their big toes.

Doctors are used to contending with Google. Often, what patients discover on the internet causes them undue alarm, and our role is to provide context and reassurance. But not infrequently, people come across information that outstrips our knowledge. On my return from our room with fresh supplies of plasters, my wife looked up from her sun lounger with an air of quiet amusement.

“It’s called ‘pool toe’,” she said, handing me her iPhone. The page she had tracked down described the girls’ situation exactly: friction burns, most commonly seen in children, caused by repetitive hopping about on the abrasive floors of swimming pools. Doctors practising in hot countries must see it all the time. I doubt it presents often to British GPs.

I remained puzzled about the lack of pain. The injuries looked bad, but neither Gracie nor Eve was particularly bothered. Here the internet drew a blank, but I suspect it has to do with the “pruning” of our skin that we’re all familiar with after a soak in the bath. This only occurs over the pulps of our fingers and toes. It was once thought to be caused by water diffusing into skin cells, making them swell, but the truth is far more fascinating.

The wrinkling is an active process, triggered by immersion, in which the blood supply to the pulp regions is switched off, causing the skin there to shrink and pucker. This creates the biological equivalent of tyre treads on our fingers and toes and markedly improves our grip – of great evolutionary advantage when grasping slippery fish in a river, or if trying to maintain balance on slick wet rocks.

The flip side of this is much greater friction, leading to abrasion of the skin through repeated micro-trauma. And the lack of blood flow causes nerves to shut down, depriving us of the pain that would otherwise alert us to the ongoing tissue damage. An adaptation that helped our ancestors hunt in rivers proves considerably less use on a modern summer holiday.

I may not have seen much of the local heritage, but the trip to Italy taught me something new all the same. 

This article first appeared in the 17 August 2017 issue of the New Statesman, Trump goes nuclear