Figuring out the inequalities of death

I HAVE only been successfully sued once in my journalistic career - over a story about hospital death rates.

I had obtained details of death rates across the country which showed a six-fold variation and produced a league table which appeared in The Times. Unwisely, as it turned out, I made some uncomplimentary remarks about the areas with the worst rates based on a separate report which suggested that extra deaths could indicate incompetent surgeons and poor after-care. The hospitals in the named areas took umbrage and, on the advice of The Times' lawyer, the dispute was settled quickly for pounds 10,000.

That was five years ago and it was therefore gratifying last week to witness the government publishing the first hospital death rates for England on the basis that they tell us something worth knowing about the variation in clinical standards. For that is what lies at the heart of this exercise.

Despite 50 years of posturing about the NHS's commitment to equity, the service it provides across the country is anything but equitable. The NHS is more a collection of fiefdoms, each run by its consultants and managers, than a truly national service with national standards of care. As a result, your chances of survival vary widely depending on where you are treated, and by whom.

With the help of the tables, we can now see this variation in standards laid out in graphical form - though strenuous efforts have been made to prevent hospitals being ranked in death-rate order. Of course, doctors and managers will complain, as they did last week, that like is not being compared with like. But the virtue of the tables is that they reveal, for the first time, the extent of the variation - and prompt some tough questions.

Why does Rotherham General Hospitals have a death rate following emergency surgery that is 12 times higher than Kettering General Hospital? There may be excellent reasons related to the social and economic features of the area, the severity of the cases treated, or the way in which surgical admissions are defined. But at least the publication of the figures will ensure that the questions get asked. That has not been the case in the past.

In his introduction to the tables published last week, Frank Dobson, the Health Secretary, wrongly describes them as a "breakthrough" because "for the first time they begin to allow hospitals and health authorities to compare their performance".

In fact, similar tables have been circulated to hospitals and health authorities for a decade, on computer disk. It was from these that I obtained the death-rate table first published in The Times in 1993, and again in 1994. After it appeared, I received dozens of calls from puzzled hospital managers asking where the information had come from. They had been sent the computer disks but they had never looked at them.

Mr Dobson has rightly judged that, difficult and complex as the information in the tables is to interpret, publication should concentrate minds. As Jim Johnson, chairman of the joint consultants committee of the medical royal colleges, observed, every hospital in the land will be scrutinising the figures over the coming weeks to see how they compare with their rivals.

In future years, as the information is refined, it may become less interesting. Hospitals with the worst ratings could be expected to move towards the average. But if the tables become dull, they will have achieved their purpose of evening out standards across the country - and the health service may at last begin to justify the "National" in its title.