Research ‘just do it’ to save the NHS?

At the recent HSRN Symposium 2014 Nick Black (LSHTM) attempted to annihilate the standardised measures of hospital mortality (HSMR and SHMI).  The measures have been criticised for years, and yet are glued into the fabric of our world and, are extensively reported.  They have prompted large scale investigations (e.g. Keogh 2013) and continue to feed tabloid scandal on ‘killer hospitals’.  In Nick’s vociferously stated opinion they should go.  Now.

HSMRs are not saving people.

Nick’s statements were based in large part on Helen Hogan’s PRISM1 study on the relationship between avoidable hospital deaths and other measures of safety (not much).  She reported the full study in the patient safety session on day 2 and received (and acknowledged) some robust criticism from Alex Bottle from the Dr Foster Unit, creators of the HSMR.  Helen is now extending the same to up the statistical power.

What interests me is not (simply) whether standardised measures of anything are right or wrong, but how and why these particular measures have flown into use and stuck so tight.  Much of the rest of the time, those of us interested in implemented evidence or innovations into practice seem to have to drag it proverbially kicking and screaming to practice settings and trap practitioners in corners and work them like dogs to identify how to interpret evidence, transform it into something that will work in their setting and implement it reliably and consistently for all relevant patients.

It’s not easy to find time to do this.  After all, as Peter Homa (NottsUHT) wearily pointed out, organisations have to deliver against over 250 indicators.

I asked the end of day 1 panel my ‘killer question’ (not directly related to HSMRs) –

‘Should there be a moratorium on all research until we’ve identified how to put into practice everything we already know.’

Is it contentious to ask researchers if their research should be stopped, or at least redirected: How would they react?

The answers from Gary Ford (Oxford AHSN), Naomi Fulop (UCL) and Nigel Edwards (NuffT) (who spotted my tongue in my cheek) were interesting and included ‘it’s not about research, they just need to do it’, ‘you sometimes do need researchers to demonstrate that you don’t need research to get things done’ and ‘I don’t want to stop researching, there are many questions that still interest me.’

Interim findings from my studies (reported in the knowledge session on day1) suggest that NHS staff do not have the skill-set to put change into practice in a reliable sustainable way.  And they know this.

So the answers from the researcher panel weren’t ideal for me.  One of my colleagues, Julie Reed, (CLAHRC Northwest London) went so far as to suggest that one of the panelists had ‘insulted those people who are trying to a million things at the same time’ in response to his example that they ‘just need to find the phone number for district nurses’.

My vote goes to Judith Smith’s (NuffT) proposal in conversation with Jessica Corner (UoSoton) and Kieran Walshe (MBS) on care after Francis.  ‘Perhaps’, she said, ‘we need to research what it takes to be a good manager in these times.’

When I was asked 10 years ago what it is that keeps me up at night I used to answer ‘medications’.  They’re prescribed badly, dispensed erratically, administered haphazardly.  It’s a wonder we don’t kill everyone.  We’re working on that, and slowly but surely things are improving.

What keeps me up at night now is that we don’t know how to run routine services according to good practice – because we don’t know how to introduce new ideas and innovations in a sustainable, safe and reliable way.  This is the generalised version of the mediations problem.

What concerns me more is that researchers don’t seem to care too much.  Apparently we ‘should all just be doing it.’

This is perhaps the fundamental problem of the NHS in our time – and an awesome area for research.  If we understand how to deliver reliable but constantly improving services, where each change is delivered and implemented in a sustained reliable way, we’ll save the NHS.

And who wouldn’t want to be a part of doing that?