Robert Dingwall looks at the implications for families and for international comparisons of mortality statistics.
Recent media coverage of health service issues has been so dominated by the junior doctors’ contract dispute that other important developments have been overlooked. One is a further inching forward of reforms to the process of certifying deaths in England and Wales. The introduction of a system of medical examiners was announced by the Secretary of State at a Global Safety Summit in London on 9 March 2016. While this announcement presents the change as a contribution to patient safety, it has the hallmarks of a civil service measure that has been opportunistically grafted onto successive crises of confidence in the present arrangements.
The reform process began with a Fundamental Review of Death Certification and Investigation in England, Wales and Northern Ireland (Cm 5831), which began work in July 2001 and reported in April 2003. This noted that there had been previous reports in 1936 and 1965, neither of which had resulted in much action. The system was showing the consequences. It was fragmented, chaotic, amateurish, and weakly managed, providing a poor service to bereaved relatives, creating opportunities for abuse, and lacking public confidence. Some of this was attributable to the division of responsibility between three central government departments– the Home Office, the Department of Health and what is now the Ministry of Justice – and their local agents. There was also discontent with the handling of deaths among people in the custody of the state – prisoners, immigration detainees and mental patients. This had been the subject of campaigns by the charity INQUEST since 1981. The Human Rights Act 1998 had strengthened the state’s positive duty to investigate such deaths. Patient safety concerns only emerged later, in the Third Report of the Shipman Inquiry.
The term ‘medical examiner’ seems to have been introduced by a Department of Health consultation document in 2007 and then added into a draft Bill from what is now the Ministry of Justice, to form the Coroners and Justice Act 2009. While the ‘Justice’ side has pushed ahead with reform, the medical side has stalled. This may be down to successive NHS reorganizations, which have made it difficult to find an administrative home for the new appointments. Originally, they were to be linked with Primary Care Trusts, but these bodies were slated for abolition from 2010. The provisions of the 2009 Act could not be implemented, which subsequently attracted critical comments from both the Mid-Staffs and Morecambe Bay Inquiries. However, it is not clear that either inquiry fully understood the proposals. In other countries, ‘medical examiner’ describes an official with powers much closer to those of the English and Welsh coroner than the kind of quality controller of death certification that is envisaged here.
In the meantime, a number of local pilots have been carried out and the Royal College of Pathologists designated as the lead body for accrediting medical examiners. The Secretary of State acknowledged the implementation delays in March 2015 but the present announcement further defers the start date until April 2018. When this happens, medical examiners will be based in local authorities. They must be fully licensed practitioners of at least five years’ standing and will mostly be recruited on a part-time basis alongside other clinical work as GPs or hospital doctors.
The process of death certification will then be the same whether the body is to be buried or cremated. The doctor attending the patient at the time of death will complete a certificate and send this together with the medical records to the examiner for review. The two doctors will discuss the certificate and the examiner will also discuss the cause of death with a close relative of the deceased, if one is available. The certificate may be confirmed or revised and either doctor may still refer the death to the coroner if it is considered to require further investigation. However, the experience of the pilots suggests that such referrals will decline by 15-20 per cent. The process should also be quicker, and more sensitive to those faith groups whose beliefs require rapid disposal of the body. The new system is expected to create better opportunities for medical examiners to identify patterns in causes of death, making it harder for maverick doctors (Shipman) or abusive institutions (Mid-Staffs) to go undetected.
There are still important areas of uncertainty. One is funding – the medical examiner service is expected to be self-financing. Cremations currently require an elaborate process of certification, with fees adding up to £184. Burials, however, generate minimal costs. In future, both options will be reviewed in the same way with a standard fee of about £100, payable directly by relatives to the local authority. In proportion to the overall cost of a funeral, this is a small sum but it will no longer automatically be rolled up into the undertaker’s disbursements. The pilots have already shown that local authorities in poorer areas may have difficulty in collecting this fee – and find it disproportionately costly to pursue the debt. A great deal is being left to local arrangements, which means that important details about office location and support are currently unknown.
Another uncertainty is the impact on UK mortality data. In the long run, this should improve as causes of death are recorded more accurately. In the short term, though, there will be several years where time series are disrupted and trend data become unreliable. The Office of National Statistics found that the pilots led to recoding in about 20 per cent of deaths. While the ONS can be trusted to take this into account, the compilers of comparative international mortality tables may miss the significance of these changes. This is even more likely to be true of some tabloid media headline writers.
The medical examiner system has had a lengthy gestation but it does seem likely to improve mortality data and offer a better user experience to bereaved families. It is less clear whether it really will contribute to the quality and safety agenda to which it has been harnessed. A patchwork of part-time doctors, each working across several areas to provide 365 day availability, does not seem a promising basis for avoiding the next scandal. But we can all hope.