bmj.com -- Press Releases

Press Releases Saturday 5 June 1999
No 7197 Volume 318

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(1) RATIO OF DOCTORS TO PATIENTS IS GOOD PREDICTOR
OF HOSPITAL DEATH RATES IN ENGLAND

(2) CORONER SERVICE NEEDS OVERHAUL

(1) RATIO OF DOCTORS TO PATIENTS IS GOOD PREDICTOR
OF HOSPITAL DEATH RATES IN ENGLAND

(Explaining differences in English hospital death rates using
routinely collected data)
http://www.bmj.com/cgi/content/full/318/7197/1515

In this weekï¿½s BMJ Professor Brian Jarman and colleagues from
Imperial College School of Medicine and Harvard Medical School
report that one of the key determinants of hospital death rates is the
number of hospital doctors per bed and the number of general
practitioners per head of population in the localities from which
hospital admissions were drawn.

Based on a study of over 7.5 million discharges from 183 English
NHS hospitals, over the four years 1991-2 to 1994-5, Professor
Jarman and his team found that death rates varied across hospitals
from 3.4 per cent of admissions to 13.6 per cent. They say that the
most powerful predictor of this variation is the percentage of
emergency admissions (in this study 60 per cent of admissions were
considered emergencies). However, after adjustments for the
percentage of emergency cases and for age, sex and primary
diagnoses they found that the best predictors of hospital death rates
was the ratio of hospital doctors per bed and the number of GPs per
head of population served.

The authors report that England has one of the lowest number of
physicians per head of population of all the member countries of the
Organisation for Economic Cooperation and Development (OECD)
- the ratio of doctors to patients in England in 1994 was only 59 per
cent of the OECD average (1.6/1000 as opposed to 2.7/1000).
Jarman et al warn that considerable care should be exercised when
interpreting hospital mortality data, but based on their findings they
calculate that if the number of hospital doctors and general
practitioners were to be increased in England, this is likely to be
associated with a reduction in hospital mortality rates. They
therefore conclude that the higher the doctor to patient ratio the
lower the number of deaths but caution that their study is the first of
its kind and their findings need to be validated by further
investigations.

Contact:

Professor Brian Jarman, Emeritus Professor of Primary Health
Care, Department of Primary Health Care and General Practice,
Imperial College School of Medicine, London
Email: b.jarman@ic.ac.uk

(2) CORONER SERVICE NEEDS OVERHAUL

(The coroner service. A relic in need of reform)
http://www.bmj.com/cgi/content/full/318/7197/1502

England and Wales are in need of a national coroner service which
should be brought under the auspices of the Home Office, claims
Professor Derrick Pounder from the University of Dundee in an
editorial in this weekï¿½s BMJ. He writes that "... a national coroner
service could improve the quality of investigations and data
collection, reflect a greater sensitivity to the rights of next of kin and
give better value for money."

Professor Pounder says that striking the correct balance between
the reasonable needs of the state to investigate a death and the
rights of the next of kin to privacy and religious ritual is currently not
done well in England and Wales. He suggests that the Human
Rights Act, which will come into effect in England and Wales
sometime after 2000, could have wide reaching implications for
coroner service practices.

The number of deaths reported to the coroner increased between
1970 and 1996, says Pounder. According to a Home Office survey,
190,000 deaths (representing a third of all deaths in England and
Wales) were reported to the coroner in 1996. In 1970 this figure
was 130,000 (which accounted for one fifth of all deaths).

Reporting so many deaths to the medico-legal investigative system
is both intrusive for the families concerned and costly, he argues.
The author proposes that mandatory inquests should be abolished,
except for deaths in custody or an accident at work and greater
discretion should be given to coroners (as is the case in Scotland).
The budget for the coroner service is £46.8m, with mortuary
services costing £11.6m and pathologists fees accounting for
£11.9m. Significant savings could be made if the necropsy rate was
reduced says Pounder.

Currently 80 per cent of coroners are part time and less than half of
the coroner districts are computerised says the author. A national
database of investigated deaths would significantly improve access
to the wealth of useful information generated by coroners argues
Pounder. Among the 148 coroner districts included in the Home
Office survey, the number of necropsies varied greatly and
therefore not all districts can be striking an appropriate balance
between the needs of the state and the rights of the next of kin,
says the author. Pounder concludes that the coroner service should
focus more narrowly on deaths of legitimate medicolegal interest.