RAMI: Ropey And Muddled Information?


How safe is your local hospital? Yesterday, there was no way of telling as the Risk Adjusted Mortality Index, or RAMI, figures for Wales had never been published together in one place.

Today, they have. And are you as a patient any the wiser? Well, that depends. And, on balance, probably not.

After the Mid-Staffordshire scandal and the subsequent Francis report, transparency is the new name of the game for the NHS right across the UK. Today's release is a big part of that response in Wales. The headlines are clear. 11 out of 17 of Wales' District General Hospitals have higher patient mortality rates than the average, and five out of the six health boards are above it. There's huge variation too, even for hospitals within the same health board.

In brief - all hospitals in the RAMI system are given a score. 100 is the average - very crudely, above this is bad, below this is good.

The whole point of the "risk adjusted" element of RAMI is that it's meant to allow at least some degree of comparison between death rates in different hospitals, even if say, one is a small hospital doing very little complex surgery, and another is a large hospital treating a high number of trauma and critical cases.

How then, do you explain the contrasting scores for the two main hospitals in Cardiff and Vale UHB?

The board itself has today raised concerns about Wales' largest hospital, the University Hospital of Wales, which shows a RAMI score of 128, way above where it should be - and the highest in Wales. Across the city, Llandough Hospital has a RAMI of 86, the joint lowest in Wales.

In the North too, there are real discrepancies. Wrexham Maelor has a RAMI of 117, while Glan Clwyd scores 103.

The fundamental problem here is clear - it's to do with the way that Welsh LHBs collect and process data on their patients, called coding. This is absolutely chaotic by the sound of it. For the RAMI system to work properly, every patient passing through a Welsh hospital has to be accurately coded - simply put - with their risk of dying. This is the only way the "risk adjusted" format of the index can work properly.

Most Welsh LHBs are, frankly, pretty bad at doing this. The University Hospital of Wales alone has a backlog of 40,000 patients still waiting to be coded. Officials say that the fewer patients who are coded, or inaccurately coded, the more likely it is that a hospital's RAMI score will be higher.

Even when patients are being coded in time, things are still all over the shop. In the North, it now turns out that Glan Clwyd count large number of patients attending hospitals for short period, for treatments such as dialysis, who are very unlikely to die in hospital. Wrexham Maelor don't, and therefore their RAMI is far higher, even though the health board says in reality the mortality rates are very similar.

RAMI would perhaps be better expressed as Ropey and Muddled Information. There are clearly major problems - but based on this data, we're not much the wiser about where they are. As it was put today - there's a fire alarm going off but we now need to find the fire.

Welsh Government officials don't hold back about these failings - and part of the reason for publishing the figures today based on such (self-confessedly) shoddy data, one suspects, is to give the LHBs an almighty shove to get their house in order.

However, they're very reticent to go too far down this road. Mid Staffordshire initially sought to explain away their higher mortality rates by blaming data deficiencies. When in depth investigations were finally carried out it showed exceptionally high rates of deaths which were little to do with data and everything to do with poor care.

As Grant Robinson from Aneurin Bevan LHB says bluntly: "Anyone who says this is only about coding would be missing an important opportunity to improve care".

Asked why Welsh hospitals are so poor at coding while their English counterparts are, apparently, very much on the ball, there was an equally honest answer from officials. In the market-driven, purchaser/provider NHS in England hospitals don't get paid for the treatment of a patient until they've been coded. What greater financial incentive could there be?

In the monolithic Welsh NHS, it doesn't bring a penny more or less in whether a patient is coded or not. And judging by the queues of ambulances backed up outside A+E departments and the scramble to break even at the end of the financial year, LHBs have got other things on their minds.

It's important to remember that, however good English hospitals are at coding, at this stage that the whole issue of hospital mortality indexes are a controversial issue within the medical profession across the UK and beyond.

The conspiracy theorist might suggest that the Welsh Government, struggling to win the public argument on reconfiguration, has put these figures out in order to make the case for centralising services in fewer, larger hospitals more compelling. The Welsh Conservatives have already spotted a flaw in which case - by and large the figures show lower RAMI rates in smaller hospitals, not larger ones.

There is certainly a strong argument that this is a step forward in transparency for the Welsh NHS. Never before have these figures been so accessible. And yet, from a patient point of view, what is the point? There's little if any choice in the health service here. Are people really going to say to their doctor, I'm not going to Wrexham Maelor, they've got a RAMI of 117, I want to go to Glan Clwyd please? In Cardiff, there's a world of difference in the services offered by UHW as compared with Llandough.

And what do the figures mean for the Welsh NHS itself? In the wake of the Mid-Staffs scandal, 14 English Trusts are under investigation after their mortality rates showed a major cause for concern. Welsh Government officials, who've had access to the statistics for years, remember, refused to put any sort of threshold as to when they might look to step in here.

Asked whether they had any concerns about health boards "gaming" their coding records to artificially lower their RAMI scores, officials responded - in terms - we wish they were organised enough to even think about doing that.

So are you the patient, or us the media any the wiser today? We can hear the fire alarm, but we can't yet see the fire, which is not a comfortable situation for anyone to be in.

Betsan Powys Article written by Betsan Powys Betsan Powys Former political editor, Wales

A big day for health in Wales

A day of big health stories in Wales is capped with a potentially very significant announcement.

Read full article


This entry is now closed for comments

Jump to comments pagination
  • rate this

    Comment number 34.

    #33 The market principle and choice never made sense in Wales when patients and relatives were totally unprepared to travel to another hospital if it was further from home, regardless of published clinical outcomes.
    Choice can't be made on who makes a better cup of tea, or which is a bus-ride from your kids.

  • rate this

    Comment number 33.

    NHS Wales started to go backwards with the removal of the internal market. B4 all the rabid socialists call foul: the internal market was not about privitisation; it was about freedom to act and responsiveness to patients. There is an astonishingly arrogant denial of the choice agenda in Wales borne from the One Wales agreement.
    Rip it up WG

    There is no such thing as failure only learning!

  • rate this

    Comment number 32.

    #31 I think that we would concur that WG had enoug NHS penpushers to seriously investigate the MI figures. At least, at present, no NHS hospital can claim that their figures are commercially sensitive. So, let's compare the Cardiff figures & Swansea figures with other British hospitals. And if we don't like the outcome dig down to see where the problems lie.

  • rate this

    Comment number 31.

    Boxer - I suspect that we are not a million miles apart in our views. In particular if you go back to your comment #1. I bow to your knowledge in #30

    My initial objection - which remains, is the use of cliches used by Betsan to denigrate anything that she disapproves of. I am also concerned that the WAG does not believe that it should order an investigation into the figures relating to Wales

  • rate this

    Comment number 30.

    John, there is a maxim'If it looks like a duck, and quacks like a duck, it probably is a duck'
    FYI the new public will not 'run' pathology services, it will oversee and look at financial reports. I doubt if it will even look at quality-control data.
    At present, if Cardiff had a problem with its thyroid assays, it could send the samples to Swansea. With one giant M4 centre for South Wales, not


Comments 5 of 34



Copyright © 2015 BBC. The BBC is not responsible for the content of external sites. Read more.

This page is best viewed in an up-to-date web browser with style sheets (CSS) enabled. While you will be able to view the content of this page in your current browser, you will not be able to get the full visual experience. Please consider upgrading your browser software or enabling style sheets (CSS) if you are able to do so.