No, up YOUR coding! Why the ‘45% more NHS deaths’ is nonsense

Please share this widely. The NHS is under propaganda attack yet again – the lie has a head start and the truth needs to catch up.

Apologies to everyone that I’ve been quiet for the last week or so. The arrival of my new granddaughter , but especially the everyday exigencies of trying to put bread on the table since I started my own company with a colleague with the aim (among others) of gaining more flexibility to write, have taken just about every waking hour for a while.

But I’ve been dying to write, about a number of topics – especially the NHS. I’ve wanted to write this post since last week – and I’ve been grinding my teeth in frustration at the patent and utterly irresponsible rubbish once again being pushed about the NHS based on that most vaporous foundation: HSMR mortality statistics.

It was claimed – predictably enough by the right-wing media, but shamefully also by Channel 4, who usually do a better job on the NHS – that a patient’s chances of dying in the NHS are an astonishing 45% higher in the NHS than in the US healthcare system.

Professor Sir Brian Jarman – the man behind the HSMR system – has been doing a nifty two-step: distancing himself from the headlines and saying his findings are

no more than a trigger to further see whether the large differences in adjusted death rates … indicate possible differences in the quality of hospital care in the two countries

while also fuelling the headlines by declaring himself

quite frankly shocked

by the findings. Neat footwork.

My teeth-grinding was because – as usual – the media headlines are absolute bollocks, and the detail of the articles is no better. Here’s why:

Apples and oranges

The saying that you have to ‘compare apples with apples’ was never more pertinent in this case. As well as highlighting the supposed ‘death deficit’ in the NHS compared to the UK, Prof Jarman’s latest ‘findings’ supposedly show that:

over more than 10 years found NHS mortality rates were among the worst of those in seven developed countries.

But there are simply no grounds or justification for this conclusion. For a start – as Prof Jarman has himself commented to me on Twitter – HSMRs in the UK are ‘rebased’, whereas in other countries they are not. Search this article for ‘rebased’ for details of what it means.

The professor infamously commented that this rebasing was necessary because people in the UK are ‘too simple-minded’ to understand the statistics without it. But whether that’s correct or he’s just incredibly condescending, the fact is that different methodologies in different countries make comparisons meaningless.

Not only this, but as the SKWAWKBOX revealed months ago, the head of DFI, the company behind HSMRs and hospital league tables, admitted to the Francis Inquiry that there is no auditing of HSMR results in the UK, nor any training given in how to ‘code’ patients’ diseases consistently.

‘Coding’ – the allocation of codes for patients’ ‘co-morbidities’, the co-existing conditions from which a patient suffers alongside the main one for which s/he is being treated on that particular occasion – is not a standardised methodology, so there are so many potential variations in the data input among countries that no statistician worthy of the name would assume that any two countries are both ‘apples’.

More on coding in a moment. But if the lack of control and training for data input make comparisons among hospitals in the UK meaningless, how much more so to draw comparisons among different countries.

The only way is up..

As my analysis (and that of many others) of Stafford hospital’s HSMRs showed, the completeness – or ‘depth’ in the jargon – of coding of patients has an absolutely massive effect on the apparent mortality statistics, because HSMRs (attempt to) measure actual death rates against ‘expected‘ death rates.

Let’s say a patient is in hospital for a thyroid operation. If s/he is in otherwise good health, the expected mortality rate for that operation might be, say, 1 in 100 (this is just for the sake of clarity).

But if the same patient has, for example, co-morbidities of chronic heart or lung disease, the expected death rate might be 3/100.

If the co-morbidities are not coded, as far as the stats are concerned the complicating conditions didn’t exist. A death rate of 3 in 100 – which should look normal – will then look enormously high. Compared to a false expectation.

By contrast, if that patient is ‘overcoded’ – if more conditions are included as co-morbidities than should be – the same 3/100 mortality rate will look low, because the ‘expected’ figure will be inflated.

Now here’s the crunch: upcoding.

The US situation regarding coding is not merely uncontrolled and of unknown variability – it is rampantly corrupt, and in only one direction.

Google ‘upcoding USA health profits’ and you will very quickly learn that the profit-motive in US healthcare has led to a situation in which huge numbers of ‘patient episodes’ are routinely and deliberately ‘upcoded’ in order to claim more money for treatments provided.

For example, Philips & Cohen, a US law firm specialising in representing whistleblowers, reports a case in which a healthcare firm paid an out-of-court settlement of $2 million to the government after whistleblowers exposed massive upcoding fraud. highlights the fact that the Obama administration is having to conduct targeted audits of health providers because of ‘surging’ payments to hospitals caused by suspected upcoding.

The reason for this phenomenon in the US is plainly financial – greed is causing companies to try to milk the system to increase profits.

But a known and documented side-effect of upcoding will be to lower HSMRs, because a patient dying from something with a high death rate won’t raise the HSMR – even when they don’t actually have the condition.

‘Not your average’ idiot

The nonsense of Prof Jarman’s conclusions – and of the media claims exploiting them to damn the NHS – is shown with absolute clarity by an article by ‘NHS Choices’, “the online ‘front door’ to the NHS”.

Ironically, this article makes a worthy attempt to address the imbalance of the latest HSMR claims – but in doing so it repeats, and therefore highlights, a stunning misunderstanding of how HSMRs work. NHSC’s article states:

Comparing the number of hospitals in England and the US that had HSMRs in the different ranges, the majority of US hospitals tended to fall into the less than 100 bracket, meaning their hospital death rates were lower than expected.

The majority of English hospitals tended to fall into the 100 to 150 bracket, meaning their death rates were slightly higher than expected – that is, if they had the average mortality rate for all the hospitals in the countries examined.

The average HSMR for England was 122.4, making it the highest of the seven countries examined. The average HSMR for the US was 77.4.

Why is this idiotic? Because HSMRs are all about averages. The expected death rate is not based on a clinically-calculated mortality probability for a particular set of conditions. It’s based on the average death rate for that condition across all the hospitals in the measured territory. Similarly, a hospital’s overall HSMR is based on its position relative to the average.

It is therefore impossible for the average HSMR in England to be 122.4 – because ‘rebasing’ would turn 122.4 into 100, because 100 is the average.

According to Prof Jarman, HSMRs in the USA are not rebased – so saying the average US HSMR is 77.4 is meaningless unless you know the answer to the question, ‘Compared to what?

Comparing a rebased HSMR to an unrebased HSMR is utterly, utterly meaningless. And pointless – unless of course your point is to damn the NHS, and you’re ready to say ‘damn the evidence’ in the process.

Apples and oranges; corruption and fraud; a complete lack of consistency and checks on the quality and methodology of the coding which has a massive effect on HSMRs; a complete and demonstrable ignorance of what HSMRs are and how averages work.

All of these add up to an inescapable conclusion.

It is utterly, utterly – teeth-grindingly – obvious that a comparison of mortality rates in such fundamentally and uncontrolledly different countries and systems is absolutely meaningless. And that any emphatic claims of ‘45% this or that’ are even more so.

All of which is perfectly clear to anyone who bothers to perform even a basic fact-check, or even a bit of commonsense reasoning.

Which means that the latest ‘45%’ claims, if seen properly, do not damn the NHS, but rather those making the claims, and the motives that drive them to make them.

39 responses to “No, up YOUR coding! Why the ‘45% more NHS deaths’ is nonsense

  1. Reblogged this on Vox Political and commented:
    It looks as though the lie has gone around the world and the truth needs to get its skates on (again). This blog is no friend of the numerous attempts to smear the British National Health Service so let’s share this around and make sure people can read arguments both for AND against the current system – so they can make up their own minds.

  2. I read another good article about the Channel 4 programme, saying the same thing. I hope the message gets spread into the right quarters!

  3. Yes, great article. Many thanks – and much love to Immy..!

    This might not be specifically relevant to this post (so please delete/move as req’d) but why is the NHS providing funds to DFI when Prof Jarman clearly breaches at least one of the Royal Statistical Society’s Rules of Professional Conduct every few weeks, by brazenly acquiescing to data distortions which deceive the public?

    Rule 6 begins:
    “Fellows should not allow any misleading summary of data to be issued in their name.”

    Francis, Laker, Keogh, Rawlins, Spiegelhalter, Lilford, Black et al have been quite damning of the recent misleading headline figures extracted from DFI stats. Their effect is to smear the NHS and its staff as failures, undermining morale and so making poor care much more likely to occur.

    Yet Lynton Crosby and No.10 have encouraged papers to print them as headlines which, as Steve has shown, patently deceive the public (as indeed the stats themselves do).

    Prof Jarman also clearly welcomes these corrosive headline distortions, as long as they provide the publicity he’s after to expose other NHS issues – issues that many believe are symptoms rather than causes of a regime for which 95% of NHS staff bear no responsibility.

    Why is the NHS providing funds to DFI when Prof Jarman, by acquiescing to the use of such figures, is surely not abiding by RSS rules?

    Perhaps he feels free to do so because he isn’t even a member of the Royal Statistical Society:

    If so, was he blackballed by the RSS for misleading the public or for bypassing peer reviews or withholding data or for doing so for commercial reasons?

    The most vital area of public life – health – is being poisoned by an organisation funded by us.

    Problems obviously exist in the NHS, as in all large institutions, which must be exposed and addressed rather than covered up – even if most are likely to stem from funding, staffing & management shortcomings.

    The poisoning affects and seriously demoralises an enormous proportion of the wonderful staff still working extremely hard, for long hours, trying their best to provide excellent care to the most vulnerable sick, old and frail.

    It should be remembered that the NHS – still one of the most efficient general health systems worldwide – by helping us recover at little cost, adds immeasurably to our lives and also to the economy, because we’re then quickly able to resume our activities in better health.


    Reminder of interesting links by Steve & others

    NHS privatisation going to plan:

    Defending NHS:

    Legal minefield for subcontracted services:

    Threat to NHS pensions:

  4. Pingback: No, up YOUR coding! Why the ’45% more NHS deaths’ is nonsense | SMILING CARCASS'S TWO-PENNETH·

  5. Reblogged at SMILING CARCASS’S TWO-PENNETH with the comment-

    “Another excellent and revealing article from the Skwawkbox; however, I’d like to add statistics are, as evidenced here, akin to a drunk leaning on a lampost; more for support than illumination.

    One must also remember that the HSMRs are based on hospital deaths; how many people died in the US because they couldn’t afford treatment in the first place? Think on that before you condemn the NHS based on, as Skwawkbox says, apples and oranges comparisons.”

    • I’ll mention suicidal deaths in the USA here because I know personally of one tragedy caused by health insurance running out after a Cancer op and the subsequent diagnosis of Diabetes. The tragedy was caused by a much higher premium, with no chance of working again that insurance couldn’t be met, the person could see only one way out. Sadly three yrs later history repeats it’s self for the brother. I dread to think how many sucides happen there and how soon this could begin to happen here.

  6. No institution is perfect, but the Tories want to destroy our NHS and we won’t get it back from New Labour if the Tories and their little yellow friends the Lib Dems break it.

  7. Hi Steve and good to have you back. Tweeted/Facebooked article. I’m looking forward to the day when the Secretary of State for Health and his department actually offers a positive piece about the NHS (that doesn’t include how well THEY are doing! Keep up the good work (and balancing work and life!).

  8. Pingback: No, up YOUR coding! Why the '45% more NHS death...·

  9. This all makes perfect sense, I had to read it carefully but I got there. However, while I don’t think like Prof. Jarman that people are simple minded, I do believe that you need to appeal to people’s emotions first in order to get them to engage their brains and that people will not generally read an article like this with the care required. I’m not being disparaging about other people here, I recognise these things in myself too. So, can you make something like this into a few lines, no more than a single page on the screen?

    • That’s a tough ask, since the issues are very complex. Fully appreciate what you’re saying, though. The headlines are there to be written, based on the facts and reasoning outlined, that could appeal to the emotions as well – the question is, who in the mainstream is bold enough to publish them?

    • This is going to be difficult because, without the detail, which some may find hard going, you’ve just got another load of soundbites; then everything descends to he said this, she said that so who do you believe. It is always easier to get people to believe something that makes them frightened than to get people to read the facts. I don’t think people are so much simple minded as wary of having to read detailed articles and there are many reasons for that (time, lack of confidence in their own ability to understand, bone idle etc) and that is why the tabloid press are so popular because they are easy to consume.

      Steve presents verifiable facts in a clear way which even I can understand! It’s down to us all to share these blogs and talking to others to spread the word. The mainstream press is another problem because they have a vested interest in, frankly, suppressing the facts about this issue.

  10. Another excellent article Steve, thank you. Where would this shower be without their ‘statistics’ eh? This lot seem to see the HSMRs like one of those kid’s stretch toys – ‘what contortion will I stretch it into today?’ !!

  11. Another excellent blog, Steve – it is amazing that so many in the media still peddle this nonsense. Channel 4 news are as guilty as anyone but they did have a Dr.Jacky Davis who was interviewed last Tuesday I think and she could have been quoting from your blog – she was talking so much sense. Keep up the good work in between all your other responsibilities!!

    • Thank you! Jacky’s a founder of the NHA party if I remember rightly. If she was quoting me, that’s an honour! Wonder whether the broadcast is still available online anywhere..

  12. Thanks for once again refuting Professor Jarman and his smear campaign against the NHS.

  13. Reblogged this on Beastrabban’s Weblog and commented:
    The Skwawkbox once again does an excellent job of demolishing the specious propaganda against the NHS, specifically the mendacious claims of Prof. Jarman that there are 45 per cent more deaths in the NHS than in the American system. Not only does post show the claim to be untrue, it also details the way the corrupt nature of the American system means that their mortality statistics are regularly falsified. This needs to be read by everyone. Make no mistake, Jarman’s statistics are propaganda. They are being used over here to push the piecemeal privatisation of the NHS by the Tories and their Libdems accomplices. In America it’s being used to attack Obamacare. This needs to be read, before anyone automatically believes what’s repeated about the death rates in the media.

  14. i once said to mike sivier why not get this out into mainstream media and he said they[including the bbc]would not repeat it. well what about the daily mirror,surely in the interests of justice and truth they would publish it.

  15. Very well done as usual – this article shows that the issues can be understood if illumination is what you are seeking. The really sad thing is the damage that has been done by all this drivel despite the occasional corrective by token sensible public health doctors/epidemiologists etc. Damage to individual hospitals (and the patients who rely on them) and damage to the NHS as a whole.
    I read somewhere that 15% of the NHS budget in England is spent on monitoring processes. This is sickening, if correct, on 2 fronts.
    1) It’s far more than the amount needed to keep local district hospitals going in the UK (I should probably say England because they’ve stopped closing hospitals in Scotland as a matter of policy) and
    2) It’s a lot of money to spend on data that is often misleading (to be generous to it).
    PS Look out for the Children’s March for Stafford Hospital on 28th!

  16. Could it be that in the US people are likely to not seek treatment because of the prohibitive cost and end up dying somewhere that’s not a hospital.

    • I am an American citizen, and assure you that this happens quite frequently. One main concern is dentistry, which is weakly insured in many countries.

  17. So we all know the agenda. Rubbish the NHS, “solution” privatisation/competition etc then all will be well and not HMGs responsibility. Then listen to this interesting and hilarious blog from the USA where it’s run like that:

    then this one (which demonstrates that the US way of running healthcare isn’t even good for the economy!)

  18. Looks like the system can’t take two blogs so I’ll try again for the second one:

  19. Back with a bang, Steve!

    As the Tories continue to dig the hole to bury the NHS, what will they put on the headstone? “God rest the NHS, where you were 45% more likely to die”? You watch them try. An utterly pointless and almost desperate comparison. How far is this government willing to go? I seriously wonder.

  20. Well another interesting development in the Rubbish Stafford Hospital section of the Rubbish the NHS. All 4 of the cases the GMC had going for the last several years against doctors with management responsibilities have been dropped. It turns out they were hard working individuals doing their best under the circumstances. Well hoo bloody ray. If nearly half the consultants at Stafford were investigated by the GMC (and that’s very traumatic and usually lasts 1-2 years) with flop all result in the end – does this provide prima facie evidence of a witch hunt? See

  21. Breaking News: Children’s March at Stafford just finished. March from Town Square to Hospital. Elderly excused this time. Took about half the time of the previous March which fits in with early estimates of 20,000 (pretty good for a niche march eh?) Ended with speeches and community event – stalls, bouncy castle, face painting, nosh etc. MP, Council leader with all party support etc on platform together.
    Cost so far of the TSA process now £9.25m (well they don’t undervalue themselves do they?) – slightly irritating because I could have come up with a better, more sustainable and cheaper plan and I’d have only charged £9.25 – oh what the heck, I’d have probably done it for nothing!

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