The Use of Palliative Care Coding in the Summary Hospital-level Mortality Indicator

The Use of Palliative Care Coding in the Summary Hospital-level Mortality Indicator

Table of Contents 1. Introduction... 3 2. Limitations in Coding... 3 3. Use of Palliative Care Coding... 4 4. Use of Palliative Care Diagnosis versus Palliative Medicine Treatment Specialty Coding... 7 5. Correlation with Other Data Sources... 10 6. Variations in the Use of Palliative Medicine Treatment Specialty Coding (315)... 14 7. Regional Approaches to Coding Practice... 15 8. Investigation of the Impact on SHMI Scores of Adjusting for Palliative Medicine Treatment Specialty Coding... 15 8.1. Scope of Investigation... 15 8.2. Investigation Methodology... 15 8.3. Model Impact... 17 8.4. Summary of Findings... 21 8.5. Issues Raised... 22 2013, The Health and Social Care Information Centre Page 2 of 29

1. Introduction The Summary Hospital Level Mortality Indicator makes no adjustments for palliative care. Following concerns raised by some hospital trusts that they are unfairly penalised under the current methodology for offering specialist inpatient palliative care or hospice services, an investigation was conducted to review whether making an adjustment to the SHMI calculation for such service provision was practical and to what extent it would produce differing results from the current methodology. The Health and Social Care Information Centre (HSCIC) currently publishes two contextual indicators on palliative care to support the interpretation of the SHMI. The first indicator, Percentage of admissions with palliative care coding, gives a measure of the palliative care provided by each trust reported in the SHMI. Using the same spell level data as the SHMI, this indicator presents crude percentage rates of finished provider spells that are coded with palliative care either in diagnosis or treatment specialty fields. The second indicator Percentage of deaths with palliative care coding presents crude percentage rates of deaths that are coded with palliative care either in diagnosis or treatment specialty fields. For both of these contextual indicators, palliative care is identified from the dataset as follows: If any Hospital Episode Statistics (HES) diagnosis field (DIAG_1-DIAG_20) in any episode in the spell has an ICD-10 code of Z51.5 then the patient is identified as having a diagnosis of palliative care If the HES treatment specialty field (TRETSPEF) has a value of 315 for any episode in the spell then then patient is identified as being treated under the palliative medicine treatment specialty 2. Limitations in Coding Hospital trusts with specialist inpatient palliative care units argue that these services are used by patients from a wider geographical area than normal trust boundaries, and this type of service provision is not captured in the modelling of the expected number of deaths within the indicator. 1 Out of area patients accessing the service would, however, be captured in the observed deaths resulting in a higher SHMI value and a higher likelihood of the observed deaths being much greater than expected number of deaths. The main issue with the coding rule on the HES diagnosis field(s) is that: 1 http://www.enherts-tr.nhs.uk/blog/6140/news/new-national-mortality-data-is-misleading-ourtrust%e2%80%99s-response/ 2013, The Health and Social Care Information Centre Page 3 of 29

a) Some organisations interpret the guidance to mean that any patient who has any contact with a member of the palliative care team, regardless of the type of activity, is receiving palliative care and therefore should be coded to Z51.5. b) Other organisations only use the code if the patient is seen specifically by a palliative care consultant. c) A few organisations only use the code if the patient were under the care of a palliative care consultant or in a hospice facility. The latest advice (not a new standard or coding clinic but responses to queries sent in to Connecting for Health (CfH) on this subject) suggests approach a) above should be used. If this is to be enforced then there is likely to be a large increase in the use of the Z51.5 code, which will effectively negate its usefulness as a means of adjustment for mortality ratios. The issues above indicate that there is difficulty in establishing a consistent definition of what constitutes a specialist inpatient palliative care unit, with some trusts having specific on-site units, others with joint-funded hospices based within hospital grounds and others with specialist palliative care teams covering wards. It is even more difficult to quantify the extent to which units are used by people outside of the usual catchment area of the hospital. Research was conducted as to whether a list of specialist palliative care units was available, including seeking advice from the National End of Life Care Intelligence Network (NEoLCIN). They have responded to our enquiry indicating that they do not hold such a list and that they themselves struggle to identify such units. 3. Use of Palliative Care Coding The degree to which palliative care coding is used in the HES diagnosis field(s) and/or the HES treatment specialty field varies between trusts. The two tables below illustrate the distribution of the extent to which palliative care coding is used. Table 1 illustrates the distribution of the extent to which palliative care is coded in the HES diagnosis fields across hospital trusts, whilst Table 2 illustrates the distribution of the extent to which palliative care is coded in the HES treatment specialty field. 2013, The Health and Social Care Information Centre Page 4 of 29

Table 1: Distribution of finished provider spells with palliative care diagnosis coding Percentage of finished provider spells with palliative care diagnosis coding (Z51.5) Number of trusts by SHMI publication October 2011 January 2012 April 2012 Up to 0.5% 32 (22%) 31 (21%) 25 (17%) > 0.5% - 1.0% 60 (41%) 60 (41%) 65 (44%) > 1.0% - 2.0% 53 (36%) 53 (36%) 53 (36%) > 2.0% 2 (1%) 3 (2%) 4 (3%) Total 147 147 147 Number of finished provider spells with palliative care diagnosis coding (Z51.5) Minimum 3 4 2 Maximum 1,673 1,775 1,917 Range 1,670 1,771 1,915 Mean 514.0 505.3 522.4 1st quartile 277.0 257.0 284.5 Median 437.0 455.0 463.0 3rd quartile 719.5 677.0 695.5 Inter-quartile range 442.5 420.0 411.0 Palliative care diagnosis coding is used by all trusts, with the distribution of the extent to which it is used remaining relatively stable across the first three SHMI publications. There was a small decrease in the number of trusts having less than or equal to 0.5% of finished provider spells with palliative care diagnosis coding in the April 2012 publication. The mean number of finished provider spells with palliative care diagnosis coding across all trusts has fluctuated between the October 2011 and April 2012 publications, rising by 1.6% over the period. However, the range of the number of finished provider spells with palliative care diagnosis coding has increased at a greater rate over the same period. Although the minimum reported by a trust has remained relatively constant at fewer than five finished provider spells with palliative care diagnosis coding, the maximum has risen from 1,673 in October 2011 to 1,917 in April 2012, an increase of 14.6%. This suggests that there are a small number of trusts who have increased their usage of palliative care diagnosis coding at a much faster rate than the majority within the period. 2013, The Health and Social Care Information Centre Page 5 of 29

Table 2: Distribution of finished provider spells with palliative medicine treatment specialty coding Percentage of finished provider spells with palliative medicine treatment specialty coding (315) Number of trusts by SHMI publication October 2011 January 2012 April 2012 0.00% 98 (67%) 100 (68%) 94 (64%) > 0.00% - 0.25% 33 (22%) 31 (21%) 35 (24%) > 0.25% - 0.50% 10 (7%) 9 (6%) 10 (7%) > 0.50% - 1.00% 5 (3%) 6 (4%) 7 (5%) > 1.00% 1 (1%) 1 (1%) 1 (1%) Total 147 147 147 Number of finished provider spells with palliative medicine treatment specialty coding (315) Minimum 0 0 0 Maximum 674 659 615 Range 674 659 615 Mean 39.1 39.7 41.1 1st quartile 0.0 0.0 0.0 Median 0.0 0.0 0.0 3rd quartile 1.0 1.0 1.5 Inter-quartile range 1.0 1.0 1.5 The use of palliative medicine treatment specialty coding is more variable than the use of palliative care diagnosis coding. Within each of the first three SHMI publications, approximately two thirds of trusts do not use the palliative medicine treatment specialty code, suggesting they do not offer palliative medicine specialist treatment. Of those trusts who do use the code, they can be divided into those that infrequently use the code (i.e. between 0 and 0.25% of finished provider spells have palliative medicine treatment specialty coding) and those who use it more frequently (on over 0.25% of finished provider spells). Out of the 35 trusts in the April 2012 SHMI publication where between 0% and 0.25% of all finished provider spells had palliative medicine treatment specialty coding, 27 reported a total number of finished provider spells with the code of 10 or less. In 17 out of 18 trusts where the percentage of finished provider spells with palliative medicine treatment specialty coding was greater than 0.25%, the total number of finished provider spells with the code was over 100. Unlike palliative care diagnosis coding (Z51.5), the maximum number of finished provider spells with palliative medicine treatment specialty coding has decreased between the October 2011 and April 2012 SHMI publications. The mean has remained stable, suggesting the highest user has been reducing the number of finished provider spells with the code, but that this is offset by other trusts already using the code increasing reported numbers. 2013, The Health and Social Care Information Centre Page 6 of 29

4. Use of Palliative Care Diagnosis versus Palliative Medicine Treatment Specialty Coding Inconsistency in the use of palliative care coding, including in the use of the palliative care diagnosis and palliative medicine treatment specialty coding, makes it difficult to clearly identify trusts with specialist inpatient palliative care units through the existing data. It does not necessarily follow that the trusts with specialist inpatient provision will have the highest rate of finished provider spells with palliative care diagnosis coding (see Table 3 below). Table 3: Top 15 ranked trusts using palliative care diagnosis coding (Z51.5) as a percentage of finished provider spells (based on the April 2012 SHMI publication) REM Provider code and name AINTREE UNIVERSITY HOSPITALS NHS Palliative care diagnosis coding (Z51.5) Palliative medicine treatment specialty (315) Rank Rate Rate Rank 1 3.17% 0.00% 39 RWH EAST AND NORTH HERTFORDSHIRE NHS 2 2.88% 0.50% 8 RQQ HINCHINGBROOKE HEALTH CARE NHS 3 2.05% 0.03% 24 RA3 WESTON AREA HEALTH NHS 4 2.04% - - RDE COLCHESTER HOSPITAL UNIVERSITY NHS 5 1.88% - - RM3 SALFORD ROYAL NHS 6 1.77% - - RFS CHESTERFIELD ROYAL HOSPITAL NHS 7 1.72% - - RC1 BEDFORD HOSPITAL NHS 8 1.71% - - RN5 BASINGSTOKE AND NORTH HAMPSHIRE NHS 9 1.68% 0.00% 37 RL4 THE ROYAL WOLVERHAMPTON NHS 10 1.67% - - RNZ SALISBURY NHS 11 1.67% 0.67% 4 RTG DERBY HOSPITALS NHS 12 1.64% 0.54% 7 RDD RRV RGN BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS UNIVERSITY COLLEGE LONDON HOSPITALS NHS PETERBOROUGH AND STAMFORD HOSPITALS NHS 13 1.64% 1.28% 1 14 1.56% - - 15 1.53% - - 2013, The Health and Social Care Information Centre Page 7 of 29

Aintree University Hospitals NHS Foundation Trust, which provides inpatient specialist palliative care through an independent charitable trust based on the trust campus 2, reports the highest rate of finished provider spells with palliative care diagnosis coding (Z51.5) across the three SHMI publications October 2011, January 2012 and April 2012. However, the trust did not record provider spells with the palliative medicine treatment specialty coding (315). Out of the top 15 trusts in terms of the percentage of finished provider spells with palliative care diagnosis coding, 8 did not use palliative medicine treatment specialty coding. East and North Hertfordshire NHS Trust reports the second highest rate of finished provider spells with palliative care diagnosis coding but is also ranked in the top 10 trusts in terms of the percentage of finished provider spells with palliative medicine treatment specialty coding. Similarly, Derby Hospitals NHS Foundation Trust ranks highly in terms of the percentage of finished provider spells with palliative care diagnosis coding and palliative medicine treatment specialty coding. Both trusts provide inpatient specialist palliative care through NHS funded hospice facilities within their hospitals. 3 However, of the other trusts ranked in the top 15 (of 147) in terms of percentage of finished provider spells with palliative care diagnosis coding (Z51.5), the majority do not have specialist palliative care inpatient units such as those described by East and North Hertfordshire NHS Trust and Derby Hospitals NHS Foundation Trust, or Aintree University Hospitals NHS Foundation Trust. This suggests that changing the SHMI methodology to make adjustments based on palliative care diagnosis coding would be too indiscriminate to address the concern raised. 2 http://www.woodlandshospice.org/aboutus/about+woodlands+hospice 3 East and North Hertfordshire NHS Trust: Michael Sobell House, situated at Mount Vernon hospital in Northwood, Middlesex provides specialist palliative care to patients who have cancer and other life threatening diseases through a 16 bed NHS funded hospice. http://www.enherts-tr.nhs.uk/our-hospitals/mount-vernon-cancer-centre/ Derby Hospitals NHS Foundation Trust: The Nightingale Macmillan Unit (NMU) is a specialist palliative care inpatient unit or hospice, located on the ground floor of the Royal Derby Hospital. NMU is part of the wider specialist palliative care service. http://www.derbyhospitals.nhs.uk/about-us/departments-services/specialist-palliative-care-medicine/ 2013, The Health and Social Care Information Centre Page 8 of 29

Table 4: Top 15 ranked trusts using palliative medicine treatment specialty coding (315) as a percentage of finished provider spells (based on the April 2012 SHMI publication) RDD RDZ RGC Provider code and name BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION WHIPPS CROSS UNIVERSITY HOSPITAL NHS Palliative medicine treatment specialty (315) Palliative care diagnosis coding (Z51.5) Rank Rate Rate Rank 1 1.28% 1.64% 13 2 0.99% 1.14% 42 3 0.87% 0.90% 67 RNZ SALISBURY NHS 4 0.67% 1.67% 11 RN1 WINCHESTER AND EASTLEIGH HEALTHCARE 5 0.62% 1.06% 54 NHS RHM UNIVERSITY HOSPITAL SOUTHAMPTON NHS 6 0.57% 0.94% 63 RTG DERBY HOSPITALS NHS 7 0.54% 1.64% 12 RWH EAST AND NORTH HERTFORDSHIRE NHS 8 0.50% 2.88% 2 RD3 POOLE HOSPITAL NHS 9 0.42% 0.97% 59 RTF NORTHUMBRIA HEALTHCARE NHS 10 0.41% 1.47% 19 RTH OXFORD UNIVERSITY HOSPITALS NHS 11 0.40% 0.90% 69 RR7 GATESHEAD HEALTH NHS 12 0.37% 0.69% 99 RX1 NOTTINGHAM UNIVERSITY HOSPITALS NHS 13 0.33% 0.74% 92 RXQ BUCKINGHAMSHIRE HEALTHCARE NHS 14 0.33% 1.39% 24 RHQ SHEFFIELD TEACHING HOSPITALS NHS 15 0.31% 1.34% 27 The list of the top 15 (out of 147) trusts ranked by the percentage of finished provider spells with palliative medicine treatment specialty coding (315) is made up of trusts who have NHS funded inpatient palliative care units (including The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 4, Derby Hospitals NHS Foundation Trust, and Northumbria Healthcare NHS 4 The Macmillan Unit, situated in Christchurch Hospital is an NHS Unit, supported by Macmillan Caring Locally. The Macmillan Unit has an inpatient ward caring for 18 patients, a team of palliative care sisters who visit patients in the community, a day centre and a hospital support team who see patients in the Royal Bournemouth Hospital, and on other wards in Christchurch Hospital. 2013, The Health and Social Care Information Centre Page 9 of 29

Foundation Trust 5 ), or have inpatient provision through independent or jointly funded hospices situated within the grounds of the trust (for example, Nottingham University Hospitals NHS Trust and Oxford University Hospitals NHS Trust 6 ). Basildon and Thurrock University Hospitals NHS Foundation Trust, which is the trust with the highest rates of finished provider spells with palliative medicine treatment specialty coding (315) has a wardbased palliative care team including a consultant and specialist registrar in palliative medicine, with specialist inpatient palliative care provided at two charity funded hospices 7. However, it is possible to find other trusts who describe similar models, such as Calderdale and Huddersfield NHS Foundation Trust 8, where the palliative medicine treatment specialty code was not used. In addition, the rate of finished provider spells with palliative care diagnosis coding (Z51.5) at Calderdale and Huddersfield NHS Foundation Trust in the April 2012 SHMI publication (0.8%) was half that reported at Basildon and Thurrock University Hospitals NHS Foundation Trust (1.6%). Ranking trusts based on the percentage of finished provider spells with palliative medicine treatment specialty coding (315) also illustrates that it does not necessarily follow that the trust will also have a relatively high percentage of finished provider spells with palliative care diagnosis coding (Z51.5). Of those trusts ranked in the top 15 for percentage of finished provider spells with palliative medicine treatment specialty coding, only four are also in the top 15 for percentage of finished provider spells with palliative care diagnosis coding (Z51.5). These four trusts are East and North Hertfordshire NHS Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust, Salisbury NHS Foundation Trust and Derby Hospitals NHS Foundation Trust. 5. Correlation with Other Data Sources Further information was sought to establish the consistency in usage of the palliative medicine treatment specialty coding (315) and whether it is an appropriate proxy for identifying trusts with specialist inpatient palliative care units. The average daily number of occupied beds open overnight 5 Northumbria palliative care unit is a unit based at North Tyneside General Hospital providing specialist care to patients who need to stay in hospital to receive palliative care. It has 19 beds and is staffed by consultants, junior doctors, nurses, occupational therapists, social workers and physiotherapists. http://www.northumbria.nhs.uk/our-services/hospital/palliative-care 6 Sobell House is a comprehensive specialist palliative care service based at the Churchill Hospital, jointly funded by Oxford University Hospitals and charitable contributions http://www.sobell-house.org.uk/in%20patient%20unit.aspx 7 http://www.basildonandthurrock.nhs.uk/index.php?option=com_content&view=article&id=107&itemid=784 8 http://www.cht.nhs.uk/services/clinical-services-a-z/medicine-elderly/oncology/specialist-palliative-careservices/ 2013, The Health and Social Care Information Centre Page 10 of 29

by consultant specialty 9 collected through Unify2 for the Department of Health provides data to monitor available and occupied beds that are consultant led. Table 5: Unify2 data showing average daily number of occupied beds open overnight by palliative medicine consultant specialty (January - March 2012 data), compared to finished provider spells using the same code (April 2012 SHMI publication) Provider code and name RXP County Durham and Darlington NHS Foundation Trust RTG Derby Hospitals NHS Foundation Trust RXQ Buckinghamshire Healthcare NHS Trust RX1 Nottingham University Hospitals NHS Trust RHQ Sheffield Teaching Hospitals NHS Foundation Trust RHM University Hospital Southampton NHS Foundation Trust RC3 Ealing Hospital NHS Trust Average occupied overnight beds (Unify2, January - March 2012) No. and % of finished provider spells with palliative medicine treatment specialty coding (315) (SHMI April 2012 publication) Description of palliative care inpatient beds provision (Trust websites) 69.7 0 0.00% n/a 18.8 443 0.54% Nightingale Macmillan Unit - specialist palliative care 20 bed inpatient unit / hospice, located in Royal Derby Hospital. 18.5 169 0.33% Florence Nightingale Hospice, Stoke Mandeville - 11 palliative care inpatient beds. 17.9 440 0.33% Hayward House specialist palliative care Cancer Unit providing inpatient beds in the grounds of Nottingham University Hospital. 16.4 313 0.31% Sheffield Macmillan Unit for Palliative Care on the Northern General Hospital site - 18 specialist palliative care beds. 16.3 500 0.57% Countess Mountbatten House - NHS palliative care service for the region. 25 bed hospice in the East of Southampton. 16.3 0 0.00% n/a 9 Average daily number of occupied beds open overnight by consultant specialty http://transparency.dh.gov.uk/2012/07/05/bed-availability-and-occupancy/ 2013, The Health and Social Care Information Centre Page 11 of 29

Provider code and name RTH Oxford University Hospitals NHS Trust RDZ The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust RWH East and North Hertfordshire NHS Trust RTF Northumbria Healthcare NHS Foundation Trust RE9 South Tyneside NHS Foundation Trust RDD Basildon and Thurrock University Hospitals NHS Foundation Trust RNZ Salisbury NHS Foundation Trust RD3 Poole Hospital NHS Foundation Trust RVJ North Bristol NHS Trust Average occupied overnight beds (Unify2, January - March 2012) No. and % of finished provider spells with palliative medicine treatment specialty coding (315) (SHMI April 2012 publication) Description of palliative care inpatient beds provision (Trust websites) 16.1 417 0.40% Sobell House - specialist palliative care service based at the Churchill Hospital, jointly funded by Oxford University Hospitals and charitable contributions. 13.6 441 0.99% Macmillan Unit, situated in Christchurch Hospital is an NHS Unit. Inpatient ward for 18 patients. 11.5 335 0.50% Michael Sobell House, situated at Mount Vernon hospital - 16 bed NHS funded hospice. 10.8 295 0.41% Unit based at North Tyneside General Hospital - 19 beds. 10.3 60 0.25% St. Clare's Hospice local independent charity. Services include 6 inpatient beds. 9.1 615 1.28% Inpatient units at (off site) charitable hospices - St Luke's & Fairhaven. 8.6 239 0.67% Palliative care service based at Salisbury Hospice, situated on the southern boundary of Salisbury District Hospital. 10 bed inpatient unit, 36% funded by Wiltshire PCT. 7.1 219 0.42% Forest Holme - specialist palliative care unit forms part of the Medical Clinical Care Group at Poole Hospital NHS Foundation Trust. 10 beds for inpatients on the first floor. 7.0 132 0.18% Macmillan Palliative Care Unit 8 bed purpose built inpatient unit at Frenchay Hospital site. Patients are admitted from home, transferred from other wards within North Bristol NHS Trust or occasionally from other hospitals. 2013, The Health and Social Care Information Centre Page 12 of 29

Provider code and name RNS Northampton General Hospital NHS Trust RR7 Gateshead Health NHS Foundation Trust RGC Whipps Cross University Hospital NHS Trust RN5 Hampshire Hospitals NHS Foundation Trust * Average occupied overnight beds (Unify2, January - March 2012) No. and % of finished provider spells with palliative medicine treatment specialty coding (315) (SHMI April 2012 publication) Description of palliative care inpatient beds provision (Trust websites) 6.6 9 0.02% n/a 6.5 125 0.37% St Bede s Palliative Care Unit - 10 bed unit that offers a short term ward for patients who aren t ready to go home from hospital, or for those patients who are at home but need respite or symptom control. 6.5 461 0.87% The Margaret Centre, part of Whipps Cross, is the base for local specialist palliative care services. 12 bed inpatient unit. 5.6 1 0.00% The North Hampshire Palliative Care Service includes professionals based in the hospital and St Michael s Hospice which offers inpatient services. *RN1 WINCHESTER AND EASTLEIGH HEALTHCARE NHS merged with RN5 HAMPSHIRE HOSPITALS NHS Performing a simple cross reference from the rates of finished provider spells with palliative medicine treatment specialty coding from the April 2012 SHMI publication and the January - March 2012 data from the Unify2 based collection on the same treatment specialty code shows a correlation between those trusts ranked highest in terms of the percentage of finished provider spells coded with this specialty and those ranked highest in terms of the average number of beds occupied for this specialty (see also Table 4). This principally serves to confirm the list of trusts that are using palliative medicine treatment specialty coding, but is also provides an indication of where specialist inpatient palliative care service provision is delivered. Only County Durham and Darlington NHS Foundation Trust, Ealing Hospital NHS Trust and Northampton General Hospital NHS Trust which appear on the Unify2 list as having occupied beds coded with the palliative medicine treatment specialty do not have specialist inpatient palliative care units. Further investigation is needed to understand why some trusts that describe specialist inpatient palliative care provision are omitted from the list (for example Aintree University Hospitals NHS 2013, The Health and Social Care Information Centre Page 13 of 29

Foundation Trust), whereas other trusts with similarly described provision are included (for example Nottingham University Hospitals NHS Trust). 6. Variations in the Use of Palliative Medicine Treatment Specialty Coding (315) Use of the palliative medicine treatment specialty code (315) has increased between the October 2011 SHMI publication and the April 2012 SHMI publication. In the October 2011 SHMI publication, there were a total of 5,747 finished provider spells with palliative medicine treatment specialty coding, compared to 5,837 in the January 2012 publication and 6,047 in the April 2012 publication, representing a 5% increase over the period of the three publications. Those trusts reporting large increases in the use of this code across the period include a 10% rise at Hull and East Yorkshire Hospitals NHS Trust (215 for October 2011 compared to 237 for April 2012), a 9% rise at Derby Hospitals NHS Foundation Trust (405 to 443), and 33% Northumbria Healthcare NHS Foundation Trust (221 to 295). However, the rise in reporting was not consistent across all trusts using the code. For example, Basildon and Thurrock University Hospitals NHS Foundation Trust reported 9% fewer finished provider spells with the code for the April 2012 SHMI publication compared to the October 2011 publication (674 compared to 615) and University Hospital Southampton NHS Foundation Trust showed a decrease of 7% over the same period (536 compared to 500). The majority of trusts that used the palliative medicine treatment specialty code for the April 2012 SHMI publication also did so for the October 2011 publication, suggesting a degree of consistency in the trusts using the code. However, there are a small number of trusts who have started using the code subsequent to the October 2011 SHMI publication, and one trust who used the coding in the October 2011 publication but not since. Table 6: Trusts who have either started or ended using the palliative medicine treatment specialty code by SHMI publication Provider code and name Number of finished provider spells with palliative medicine treatment specialty coding by SHMI publication Oct 2011 Jan 2012 Apr 2012 RXQ BUCKINGHAMSHIRE HEALTHCARE NHS 1 76 169 RVJ NORTH BRISTOL NHS 0 63 132 RE9 SOUTH TYNESIDE NHS 0 0 60 RCB YORK TEACHING HOSPITAL NHS 10 154 0 0 10 The October 2011 SHMI publication contained a submission error by York Hospital Foundation Trust (YHFT - provider code RCB) meaning that the SHMI figure published for YHFT in October 2011 was incorrect. Figures 2013, The Health and Social Care Information Centre Page 14 of 29

7. Regional Approaches to Coding Practice The geographical distribution of the trusts that are the main users of the palliative medicine treatment specialty code may suggest evidence of an inconsistency of use nationally. In the list of trusts ranked by the percentage of finished provider spells with palliative medicine treatment specialty coding (Table 4), five of the top fifteen ranked trusts are geographically adjoining trusts based in the South of England (although the trusts do not belong in the same Strategic Health Authority). None of trusts in the same list are from the North West region. This suggests either a concentration of provision in this geographical area coupled with areas without provision; that similar services elsewhere in England are not being coded in the same way; or that there is an over use of this code in certain areas. 8. Investigation of the Impact on SHMI Scores of Adjusting for Palliative Medicine Treatment Specialty Coding 8.1. Scope of Investigation In order to distinguish between those trusts delivering specialist inpatient palliative care from wider more generalised provision using the available data, the scope of the investigation uses those provider spells with palliative medicine treatment specialty coding as a proxy. Palliative medicine as a treatment specialty is identified in the HES data dictionary as follows 11 : HES field name: HES field: Value: Treatment specialty tretspef 315 (Palliative medicine) 8.2. Investigation Methodology Investigation into the impact of adjusting for palliative medicine treatment specialty coding was conducted through the re-creation of the full SHMI model in SAS (using the April 2012 publication dataset) as a control against which to assess changes. Using the same dataset, further models were built by adding palliative medicine treatment specialty to the model as a case-mix adjustment variable. for the SHMI publication in October 2011 were not revised as the national impact of the changes is very limited. 11 The HES Admitted Patient data dictionary can be accessed at http://www.hscic.gov.uk/hesdatadictionary 2013, The Health and Social Care Information Centre Page 15 of 29

The models were evaluated based on the results of convergence and their c statistics, and further models were created to look for improvements in the reliability of results. Table 7: Details of models tested Model 1 SHMI published methodology (as for April 2012 publication) Model 2 Model 3 Model 4 SHMI case-mix adjusted for palliative medicine treatment specialty with the options RIDGING=NONE and NOCHECK SHMI case-mix adjusted for palliative medicine treatment specialty with the options RIDGING and NOCHECK removed SHMI case-mix adjusted for palliative medicine treatment specialty with the options RIDGING=ABSOLUTE and NOCHECK No other changes from the published methodology were made to the models. The outputs of the models are illustrated in the tables below: Table 8: Sum difference (total expected deaths total observed deaths) Model 1 Model 2 Model 3 Model 4 Total observed deaths 272,931 272,931 272,931 272,931 Total expected deaths 273,495.3047 276,443.0738 312,424.2727 272,931.0021 Difference 564.3047 3,512.0738 39,493.2727 0.0021 In terms of the difference between the total expected and total observed deaths across all trusts, both Model 2 and Model 3 produced a larger difference than the published SHMI (see Table 8). Model 4 produced the smallest difference, with the expected results providing an almost exact match to the number of observed deaths. There is a separate risk model for each of the 140 diagnosis groups used in the SHMI calculation 12. Table 9 shows the number of diagnosis group risk models converging for each model described above, along with the warning messages generated by SAS. Model 4 produced the fewest convergence issues with all 140 risk models converging. Table 9: Number of risk models converging and SAS warning messages Model 1 Model 2 Model 3 Model 4 Convergence criterion (GCONV=1E-8) satisfied. 137 119 50 140 Ridging has failed to improve the likelihood function. 3 21 65 0 Quasi-complete separation of data points detected. 0 0 25 0 12 Details of the 140 diagnosis groups used in the calculation of the SHMI can be referenced in the SHMI methodology specification document, which is available to download at http://www.hscic.gov.uk/shmi 2013, The Health and Social Care Information Centre Page 16 of 29

In terms of c statistics, only Model 3 produced results which were different to the published results, as shown in Table 10. Table 10: C statistics Model 1 Model 2 Model 3 Model 4 Minimum 0.515 0.515 0.508 0.515 Maximum 0.966 0.966 0.966 0.966 Range 0.451 0.451 0.458 0.451 Mean 0.821 0.823 0.819 0.823 1st quartile 0.767 0.771 0.771 0.771 Median 0.845 0.849 0.845 0.848 3rd quartile 0.888 0.887 0.876 0.890 Interquartile range 0.122 0.116 0.106 0.119 8.3. Model Impact The models adjusted for palliative medicine treatment specialty coding were compared against the April 2012 SHMI publication to assess the differences in results. Based on the results of the convergence analysis, Model 4 was used as the principal model to compare against the published SHMI results. A full list of the differences in results between the April 2012 SHMI publication and the results obtained using Model 4 are listed in Appendix 1. Of the 147 trusts, 22 had a reduced SHMI score after the adjustment and 125 had a higher SHMI score. Table 11: Distribution of SHMI scores for April 2012 SHMI publication compared to the results obtained using Model 4 April 2012 SHMI publication Model 4 Minimum 0.675 0.681 Maximum 1.230 1.241 Median 1.008 1.014 The trust with the largest decrease in SHMI score using Model 4 compared to the April 2012 SHMI publication was: 2013, The Health and Social Care Information Centre Page 17 of 29

Diff in Expected Values The Use of Palliative Care Coding in the Summary Hospital-level Mortality Indicator Basildon and Thurrock University Hospitals NHS Foundation Trust with a decrease of 0.171 The trust with the largest increase in SHMI score using Model 4 compared to the April 2012 SHMI publication was: University Hospitals Birmingham NHS Foundation Trust with an increase of 0.016 Figure 1 shows the diffsum plot comparing Model 4 with the published SHMI results. It can be seen that seven trusts would see their SHMI score decrease by more than 5% by adjusting for the palliative medicine treatment code, these trusts being the principal users of the code. The majority of trusts (who do not use the code) would see their SHMI score increase by between 1% and 2%. Figure 1: Diffsum plot of the difference in expected values versus the mean for the April 2012 SHMI results compared to Model 4 with +/- 5% guidelines 300 +5% 250 200 150 100 50 Trusts not using palliative medicine treatment specialty coding 0-50 -100-150 -200 RN1 RNZ RGC RDZ RTG RHM -5% Trusts using palliative medicine treatment specialty coding -250 RDD -300 0 1000 2000 3000 4000 5000 Mean of Expected Values Trusts are assigned a banding based on their SHMI score as follows 13 : Band 1 - if the SHMI score is greater than the upper control limit ( higher than expected ) 13 Details of the methodology used to calculate the upper and lower control limits can be found in the SHMI methodology specification document, which is available to download at http://www.hscic.gov.uk/shmi 2013, The Health and Social Care Information Centre Page 18 of 29

SHMI Value SHMI Value The Use of Palliative Care Coding in the Summary Hospital-level Mortality Indicator Band 2 - if the SHMI score is between the lower and upper control limits ( as expected ) Band 3 - if the SHMI score is less than the lower control limit ( lower than expected ) The funnel plots below illustrate the distribution of trust scores alongside the control limits for the April 2012 SHMI publication (Figure 2) and Model 4 (Figure 3). Figure 2: Funnel plot with 95% control limits for the April 2012 SHMI publication 1.30 1.20 1.10 1.00 0.90 0.80 0.70 0.60 0 1000 2000 3000 4000 5000 Expected No of Deaths Figure 3: Funnel plot with 95% control limits for Model 4 1.30 1.20 1.10 1.00 0.90 0.80 0.70 0.60 0 1000 2000 3000 4000 5000 Expected No of Deaths 2013, The Health and Social Care Information Centre Page 19 of 29

Table 12 below illustrates the number of trusts falling into the 3 bandings for the April 2012 SHMI publication and each of the additional models created. There was little difference in numbers between the published results and Model 2 and Model 4. Model 3, where the RIDGING and NOCHECK options were removed from the SAS logistic regression model, produced greatly different results with more trusts falling between the upper and lower control limits. Table 12: Number of trusts falling into each SHMI band Model 1 Model 2 Model 3 Model 4 Band 1 higher than expected 9 6 0 9 Band 2 as expected 124 123 135 123 Band 3 lower than expected 14 18 12 15 Although the Model 2 and Model 4 produced similar results in terms of numbers of trusts in each banding, they did produce a small change in trusts moving between bands. The table below summarises the movement between bandings for the models adjusted for palliative medicine treatment specialty coding (Models 2, 3 and 4) compared to the April 2012 SHMI publication (Model 1): Table 13: Number of trusts changing banding for models adjusted for palliative medicine treatment specialty coding compared to April 2012 SHMI publication Model 2 Model 3 Model 4 Band 1 to Band 2 3 9 3 Band 3 to Band 2 0 4 1 Total number of trusts moving inside control limits 3 13 4 Band 2 to Band 1 0 0 3 Band 2 to Band 3 4 2 2 Total number of trusts moving outside control limits 4 2 5 The trusts that change SHMI banding when adjusting for palliative medicine treatment specialty coding using Model 4 compared to the April 2012 SHMI publication are listed in Table 14 below. Although some trusts move from the higher than expected band to the as expected band (including East and North Hertfordshire NHS Trust who have argued that they are unfairly penalised by the current SHMI methodology), this is offset by other trusts that move from the as expected to the higher than expected band. 2013, The Health and Social Care Information Centre Page 20 of 29

Table 14: Changes in Banding in when adjusting for palliative medicine treatment specialty coding using Model 4 compared to the April 2012 SHMI publication Trusts moving to higher than expected band Banding April 2012 Model 4 SHMI score Banding SHMI score RLQ WYE VALLEY NHS 2 1.146 1 1.156 RXR EAST LANCASHIRE HOSPITALS NHS 2 1.134 1 1.146 Trusts moving to lower than expected band RD3 POOLE HOSPITAL NHS 2 0.887 3 0.849 RGC WHIPPS CROSS UNIVERSITY HOSPITAL NHS Trusts moving to as expected band RDD RWA RWH RH8 BASILDON and THURROCK UNIVERSITY HOSPITALS NHS HULL AND EAST YORKSHIRE HOSPITALS NHS EAST and NORTH HERTFORDSHIRE NHS ROYAL DEVON AND EXETER NHS 2 0.893 3 0.794 1 1.154 2 0.984 1 1.163 2 1.137 1 1.174 2 1.132 3 0.869 2 0.879 8.4. Summary of Findings Including palliative medicine treatment specialty coding as a case-mix adjustment variable in the SHMI risk-adjustment methodology has the effect of reducing the SHMI score for those trusts currently using this code, including several of those trusts who argue that they are unfairly penalised by the published methodology because of their specialist inpatient palliative services. The small number of trusts who represent the main users of this code will experience the largest drop in their SHMI score, with Basildon and Thurrock University Hospitals NHS Foundation Trust, Whipps Cross University Hospital NHS Trust, Salisbury NHS Foundation Trust, Derby Hospitals NHS Foundation Trust, Winchester and Eastleigh Healthcare NHS Trust, The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and University Hospital Southampton NHS Foundation Trust seeing a decrease in their SHMI score of 0.05 or more. The revised methodology shows that adjusting based on palliative medicine treatment specialty coding does not have a significant impact on the score of the majority of trusts, who will see their scores increase by between 1% and 2%, resulting in a net overall effect of a small increase in the mean SHMI score. 2013, The Health and Social Care Information Centre Page 21 of 29

The models created to test the inclusion of an adjustment for palliative medicine treatment specialty show that only nine trusts change banding compared to the April 2012 publication, but the net effect is less as the five trusts moving outside of the upper or lower control limits is offset by four trusts moving within the control limits. 8.5. Issues Raised In considering the benefit of adjusting the SHMI based on palliative care coding to address the concerns that the current model unfairly penalises some trusts with specialist inpatient palliative care units, the main issue raised is the consistency of coding practice. It is difficult with the available data to clearly identify those organisations with specialist inpatient palliative care provision. Trusts which provide specialist palliative care services may take differing approaches to coding, for example Aintree University Hospitals NHS Foundation Trust do not appear to code for palliative care in the same way as Nottingham University Hospitals NHS Trust, although they appear to have similar service provision. Additionally, Basildon and Thurrock University Hospitals NHS Foundation Trust which has a ward-based palliative care team with inpatient palliative care provided at two charity funded hospices, has a higher rate of finished provider spells with palliative medicine treatment specialty coding than East and North Hertfordshire NHS Trust which provides inpatient specialist palliative care to patients through an on-site NHS funded hospice. Although there appears to be a correlation between the trusts with the highest rates of palliative medicine treatment specialty coding and trusts who provide inpatient specialist palliative care beds (either through specialist units or on-site hospices), anomalies in use have been highlighted. This includes regional groupings which suggest there are variations in local or regional approaches to coding practice and there is an absence of a consistent understanding at a national level. Additionally, it is difficult to identify whether there are hospitals that have similar service provision but do not use the code, and any consistent reasoning behind the circumstances in which the code is used. In terms of the usage, the list of trusts using the coding and the levels to which those trusts use the code has remained, to the most part, consistent over the publication period of the SHMI since October 2011. However a small number of trusts have large variations in reported numbers over the course of the three publications. This includes those who have stopped using the code and those who have started using the code having previously reported null readings. This further illustrates the potential risk of inconsistency of coding, or localised changes in coding practice, skewing SHMI scores. Without evidence of a consistent coding of specialist palliative provision, the overall benefit in adjusting for palliative medicine treatment specialty coding is diminished. Adjusting based on palliative medicine treatment specialty coding also increases the risk of gaming. The model illustrates that those coding heavily on this specialty will benefit the most in terms of 2013, The Health and Social Care Information Centre Page 22 of 29

reducing the SHMI value. Therefore, some trusts may be tempted to inappropriately increase the use of this coding to reduce their SHMI score. The final point to make is that the findings of the investigation show that a small number of trusts would likely feel that a methodology which adjusted for palliative medicine treatment specialty coding results in a more representative SHMI score. However, as some trusts will also move from the as expected to the higher than expected band as a results, there is likely be a similar number of complaints from other trusts feeling that the change unfairly disadvantages them. Therefore the net benefit of making an adjustment for palliative medicine treatment specialty remains questionable. 2013, The Health and Social Care Information Centre Page 23 of 29

Appendix 1 SHMI scores by trust obtained using Model 4 (where an adjustment for palliative medicine treatment specialty increase is included) compared to the April 2012 SHMI publication, ranked by size of decrease in SHMI score Provider code and name Published score Model 4 score Difference RDD BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS 1.154 0.984-0.171 RGC WHIPPS CROSS UNIVERSITY HOSPITAL NHS 0.893 0.794-0.099 RNZ SALISBURY NHS 0.982 0.908-0.074 RTG DERBY HOSPITALS NHS 1.096 1.036-0.060 RN1 WINCHESTER AND EASTLEIGH HEALTHCARE NHS 1.005 0.946-0.059 RDZ THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS 1.035 0.979-0.056 RHM UNIVERSITY HOSPITAL SOUTHAMPTON NHS 0.932 0.882-0.050 RTH OXFORD UNIVERSITY HOSPITALS NHS 1.010 0.967-0.043 RWH EAST AND NORTH HERTFORDSHIRE NHS 1.174 1.132-0.043 RD3 POOLE HOSPITAL NHS 0.887 0.849-0.039 RTF NORTHUMBRIA HEALTHCARE NHS FOUNDATION 1.018 0.987-0.030 RXQ BUCKINGHAMSHIRE HEALTHCARE NHS 1.108 1.079-0.030 RWA HULL AND EAST YORKSHIRE HOSPITALS NHS 1.163 1.137-0.027 RX1 NOTTINGHAM UNIVERSITY HOSPITALS NHS 0.947 0.921-0.026 RCX THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS 0.993 0.973-0.020 RR7 GATESHEAD HEALTH NHS 0.998 0.979-0.019 RHQ SHEFFIELD TEACHING HOSPITALS NHS 0.904 0.885-0.018 RVJ NORTH BRISTOL NHS 0.965 0.949-0.016 RQM CHELSEA AND WESTMINSTER HOSPITAL NHS 0.765 0.749-0.015 RN3 GREAT WESTERN HOSPITALS NHS FOUNDATION 1.043 1.032-0.011 RAJ SOUTHEND UNIVERSITY HOSPITAL NHS 1.019 1.010-0.009 RE9 SOUTH TYNESIDE NHS 1.079 1.077-0.001 RAX KINGSTON HOSPITAL NHS 0.844 0.846 0.002 RQQ HINCHINGBROOKE HEALTH CARE NHS 0.898 0.904 0.006 RKE THE WHITTINGTON HOSPITAL NHS 0.675 0.681 0.007 2013, The Health and Social Care Information Centre Page 24 of 29

Provider code and name Published score Model 4 score Difference RD7 HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS 1.016 1.023 0.007 RV8 NORTH WEST LONDON HOSPITALS NHS 0.819 0.827 0.007 RFW WEST MIDDLESEX UNIVERSITY HOSPITAL NHS 0.925 0.933 0.008 RTK ASHFORD AND ST PETER'S HOSPITALS NHS 0.956 0.964 0.008 RVL BARNET AND CHASE FARM HOSPITALS NHS 0.895 0.903 0.008 RVR EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS 0.923 0.931 0.008 RC3 EALING HOSPITAL NHS 0.893 0.901 0.008 RNH NEWHAM UNIVERSITY HOSPITAL NHS 0.797 0.806 0.009 RVV EAST KENT HOSPITALS UNIVERSITY NHS 0.969 0.977 0.009 RGR WEST SUFFOLK NHS 0.908 0.917 0.009 RDU FRIMLEY PARK HOSPITAL NHS FOUNDATION 0.897 0.906 0.009 RJN EAST CHESHIRE NHS 1.011 1.020 0.009 RXP COUNTY DURHAM AND DARLINGTON NHS 0.946 0.954 0.009 RBN ST HELENS AND KNOWSLEY HOSPITALS NHS 1.024 1.033 0.009 RK9 PLYMOUTH HOSPITALS NHS 0.941 0.950 0.009 RM3 SALFORD ROYAL NHS 0.889 0.898 0.009 RAL ROYAL FREE LONDON NHS 0.758 0.767 0.009 RA9 SOUTH DEVON HEALTHCARE NHS FOUNDATION 0.947 0.956 0.009 RTP SURREY AND SUSSEX HEALTHCARE NHS 0.933 0.942 0.009 RJ7 ST GEORGE'S HEALTHCARE NHS 0.773 0.782 0.009 RJ2 LEWISHAM HEALTHCARE NHS 0.993 1.003 0.009 RC1 BEDFORD HOSPITAL NHS 1.002 1.011 0.009 RA3 WESTON AREA HEALTH NHS 1.074 1.083 0.009 RQW THE PRINCESS ALEXANDRA HOSPITAL NHS 0.998 1.008 0.009 RWG WEST HERTFORDSHIRE HOSPITALS NHS 1.035 1.044 0.009 RWW WARRINGTON AND HALTON HOSPITALS NHS 1.026 1.035 0.009 RCF AIREDALE NHS 0.923 0.933 0.009 RAS RF4 THE HILLINGDON HOSPITALS NHS FOUNDATION BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS 0.905 0.915 0.010 0.938 0.947 0.010 2013, The Health and Social Care Information Centre Page 25 of 29

Provider code and name Published score Model 4 score Difference RNS NORTHAMPTON GENERAL HOSPITAL NHS 1.092 1.102 0.010 RJ6 CROYDON HEALTH SERVICES NHS 1.022 1.032 0.010 RNQ KETTERING GENERAL HOSPITAL NHS 1.080 1.090 0.010 RQ6 ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS 1.027 1.036 0.010 RWJ STOCKPORT NHS 0.919 0.929 0.010 RH8 ROYAL DEVON AND EXETER NHS FOUNDATION 0.869 0.879 0.010 RXH BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS 0.979 0.989 0.010 RBL WIRRAL UNIVERSITY TEACHING HOSPITAL NHS 1.033 1.043 0.010 RBZ NORTHERN DEVON HEALTHCARE NHS 0.976 0.986 0.010 RD1 ROYAL UNITED HOSPITAL BATH NHS 0.946 0.956 0.010 RMC BOLTON NHS 1.044 1.054 0.010 RNJ BARTS AND THE LONDON NHS 0.684 0.694 0.010 RJZ KING'S COLLEGE HOSPITAL NHS FOUNDATION 0.897 0.907 0.010 RP5 DONCASTER AND BASSETLAW HOSPITALS NHS 1.006 1.016 0.010 RJC SOUTH WARWICKSHIRE NHS FOUNDATION 1.102 1.112 0.010 RYJ IMPERIAL COLLEGE HEALTHCARE NHS 0.760 0.770 0.010 RAE BRADFORD TEACHING HOSPITALS NHS 0.929 0.939 0.010 RFS CHESTERFIELD ROYAL HOSPITAL NHS 1.070 1.081 0.010 REF ROYAL CORNWALL HOSPITALS NHS 1.005 1.015 0.010 RXF MID YORKSHIRE HOSPITALS NHS 1.032 1.042 0.010 RVY SOUTHPORT AND ORMSKIRK HOSPITAL NHS 1.047 1.057 0.010 RK5 SHERWOOD FOREST HOSPITALS NHS 1.008 1.018 0.010 RBK WALSALL HEALTHCARE NHS 1.089 1.099 0.010 RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION 1.054 1.065 0.010 RJR COUNTESS OF CHESTER HOSPITAL NHS 1.074 1.084 0.010 RHU PORTSMOUTH HOSPITALS NHS 0.981 0.991 0.010 RLQ WYE VALLEY NHS 1.146 1.156 0.010 2013, The Health and Social Care Information Centre Page 26 of 29

Provider code and name Published score Model 4 score Difference RRF WRIGHTINGTON, WIGAN AND LEIGH NHS 1.054 1.065 0.010 RFF BARNSLEY HOSPITAL NHS 1.077 1.087 0.010 RTR SOUTH TEES HOSPITALS NHS FOUNDATION 0.933 0.944 0.010 RJD MID STAFFORDSHIRE NHS 0.968 0.979 0.011 RCD HARROGATE AND DISTRICT NHS FOUNDATION 0.938 0.949 0.011 RR1 HEART OF ENGLAND NHS 1.017 1.028 0.011 RJE UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS 1.050 1.061 0.011 RXL BLACKPOOL TEACHING HOSPITALS NHS 1.215 1.226 0.011 RM4 TRAFFORD HEALTHCARE NHS 1.124 1.134 0.011 RWP WORCESTERSHIRE ACUTE HOSPITALS NHS 1.061 1.072 0.011 RW6 PENNINE ACUTE HOSPITALS NHS 1.046 1.057 0.011 RLN CITY HOSPITALS SUNDERLAND NHS FOUNDATION 0.987 0.998 0.011 RYR WESTERN SUSSEX HOSPITALS NHS 1.099 1.110 0.011 RXC EAST SUSSEX HEALTHCARE NHS 1.070 1.081 0.011 RBT MID CHESHIRE HOSPITALS NHS FOUNDATION 1.108 1.119 0.011 RQX HOMERTON UNIVERSITY HOSPITAL NHS 0.978 0.989 0.011 RWY CALDERDALE AND HUDDERSFIELD NHS 1.003 1.014 0.011 RD8 MILTON KEYNES HOSPITAL NHS FOUNDATION 0.986 0.997 0.011 RYQ SOUTH LONDON HEALTHCARE NHS 0.920 0.931 0.011 RGT CAMBRIDGE UNIVERSITY HOSPITALS NHS 0.799 0.810 0.011 RM1 NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS 1.002 1.013 0.011 RFR THE ROTHERHAM NHS 1.049 1.060 0.011 RBD DORSET COUNTY HOSPITAL NHS FOUNDATION 1.054 1.065 0.011 RGQ IPSWICH HOSPITAL NHS 1.027 1.038 0.011 RXK SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS 0.999 1.010 0.011 RBA TAUNTON AND SOMERSET NHS FOUNDATION 0.946 0.958 0.011 RLT GEORGE ELIOT HOSPITAL NHS 1.230 1.241 0.012 2013, The Health and Social Care Information Centre Page 27 of 29