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Heddiw, rwyf yn cyhoeddi’r adolygiad a gynhaliwyd gan yr Athro Stephen Palmer, Athro Talbot Epidemioleg ac Iechyd y Cyhoedd ym Mhrifysgol Caerdydd, o’r  defnydd o ddata marwolaethau wedi’i addasu yn ôl risg yn GIG Cymru.

Mae Llywodraeth Cymru a GIG Cymru wedi ymrwymo i dryloywder canlyniadau i gleifion ac maent wedi cyhoeddi nifer cynyddol o ddangosyddion ansawdd a pherfformiad i bawb eu gweld dros y 18 mis diwethaf.

Un mesur sydd wedi achosi cryn ddryswch ymhlith y cyhoedd yw’r mynegai marwolaethau wedi’i addasu yn ôl risg (RAMI), a gyfrifir yng Nghymru gan gwmni allanol ar gyfer ysbytai cyffredinol dosbarth unigol. A bod yn benodol, bu ansicrwydd eang ymhlith arbenigwyr a’r cyhoedd, ac mae’r ansicrwydd hwn yn parhau, ynghylch i ba raddau y gall ffigur unigol gyfleu ansawdd y gofal sy’n cael ei ddarparu gan yr ystod eang o wasanaethau mewn ysbyty.

I fynd i’r afael â’r cwestiwn pwysig hwn, gofynnais i’r Athro Palmer, epidemiolegydd o fri, gynnal adolygiad i’m cynghori ar y cwestiynau canlynol:

* I ba raddau y mae data marwolaethau wedi’i haddasu yn ôl risg  yn darparu  gwybodaeth ddilys?
* Sut y gall mesurau marwolaethau wedi’u haddasu yn ôl risg  gael eu dehongli i GIG Cymru?
* Yn achos ysbytai sydd â dangosyddion marwolaethau wedi’u haddasu yn ôl risg sy’n uwch na 100, a oes angen gwaith pellach o ran data neu ansawdd clinigol?
* Sut y mae byrddau GIG Cymru’n defnyddio data clinigol i wella ansawdd?
* Beth yw ansawdd data clinigol sy’n cael ei ddefnyddio gan GIG Cymru at ddibenion gwella?
* A yw cyrff GIG yn defnyddio data clinigol yn effeithiol i wella ansawdd?
* Beth y mae’r data clinigol yn ei ddweud wrthym am ansawdd gofal yn GIG Cymru?

Hoffwn ddiolch i’r Athro Palmer am ei adroddiad cytbwys. Mae wedi ymgysylltu’n helaeth â rhanddeiliaid a defnyddio cyfoeth ei wybodaeth a’i brofiad i lywio ei dasg.  Mae ei adroddiad yn cynnig trosolwg arbenigol gwerthfawr o sut y mae data am ansawdd a diogelwch yn cael ei gasglu, ei brosesu a’i ddehongli ar draws y GIG  NHS yng Nghymru a gobeithio y caiff yr adroddiad ei ddarllen yn eang.

Mae’r Athro Palmer yn casglu nad yw RAMI yn fesur ystyrlon o ansawdd; yn wir mae’n dweud ei fod yn gamarweiniol.  

Er hynny, mae’n gwneud argymhellion i Lywodraeth Cymru a GIG Cymru sicrhau bod ganddo wybodaeth ystyrlon a defnyddiol i fesur a disgrifio ansawdd gofal mewn ysbytai.

Mae’r Athro Palmer yn cefnogi’r broses o adolygu achosion marwolaethau, sydd wedi’i sefydlu ar gyfer pob marwolaeth yn ysbytai Cymru. Maes lle mae Cymru’n arwain y DU yw hwn. Mae’n cynghori ar sut y gellir cryfhau’r broses adolygu hon ymhellach trwy gysondeb gwell ac ymgysylltu clinigol. Mae’r Athro Palmer hefyd yn gwneud  argymhellion i wella codio clinigol, cyfranogiad mewn archwiliadau clinigol cenedlaethol a dehongli data ar gyfer Byrddau.  

Mae Prif Swyddog Meddygol Cymru’n ysgrifennu heddiw at holl glinigwyr GIG Cymru i atgyfnerthu eu cyfrifoldebau ynghylch cofnodion meddygol, sydd wedi’r cyfan yn fater o ddiogelwch cleifion, ond sydd hefyd yn bwysig er mwyn sicrhau y manteisir ar godio clinigol.

Pan gomisiynais yr adolygiad hwn gofynnais hefyd i’r Athro Palmer edrych ar chwe ysbyty, a oedd â sgôr RAMI Cymreig o fwy na 100 ym mis Mawrth 2014\. Gofynnais iddo roi gwybod imi a oedd ffigur RAMI yn yr achosion hyn yn golygu bod "larwm mwg" yn canu fel petai. Ym mhump o’r chwe ysbyty, mae’n glir bod yr Athro Palmer casglu nad yw hyn yn wir.

O ran Ysbyty’r Tywysog Siarl, Merthyr Tudful ac Ysbyty Brenhinol Morgannwg, yn  Llantrisant, mae’r Athro Palmer yn casglu y disgwylir sgoriau o fwy na 100 o’r ffordd y caiff y mesur ei gyfrifo. Mae’n dweud hefyd fod gan Fwrdd Iechyd Prifysgol Cwm Taf broses adolygu ragorol ac amlwg ar gyfer nodiadau achos marwolaethau, sy’n cynnig sicrwydd i’r bwrdd nad yw sgoriau RAMI uchel yn ddangosyddion gofal gwael.

Yn Ysbyty Castell\-nedd Port Talbot ac Ysbyty Singleton, yn Abertawe, mae’r Athro Palmer yn casglu bod y sgoriau RAMI i’w priodoli yn ôl pob tebyg i newidiadau mewn codio a chategoreiddio ac nad ydynt yn adlewyrchu diffygion yn ansawdd gofal. Mae’n argymell, er hynny, fod Bwrdd Iechyd Prifysgol Abertawe Bro Morgannwg yn cymryd camau i ganiatáu i’r broses adolygu marwolaethau ennill ei phlwyf yn llwyr.

O ran ysbyty Wrecsam Maelor, nid yw’r Athro Palmer o’r farn bod adroddiad y RAMI’n gofyn am gamau gweithredu pellach. Ymhellach, mae’n dweud bod proses adolygu drylwyr a systematig ar gyfer marwolaethau, sy’n cwmpasu pob marwolaeth mewn ysbytai wedi’i sefydlu a bod pedwar ym mhob deg o farwolaethau’n cael eu hatgyfeirio am adolygiad trylwyr.

Cyn belled â bod Ysbyty Glangwili, yng Nghaerfyrddin, yn y cwestiwn, mae’r  adolygiad yn casglu mai newidiadau i’r ffordd y cyfrifir RAMI 2013 sy’n gyfrifol i bob golwg am y sgôr RAMI uchel.

Er hynny, mae’r Athro Palmer o’r farn bod angen gwaith pellach i ddeall ym mha ffyrdd y gallai newidiadau yn y ffordd o gategoreiddio achosion gofal lliniarol a  materion eraill fod wedi cael effaith ar sgôr RAMI. Mae’n cefnogi’r gwaith ychwanegol y mae cyfarwyddwr meddygol Bwrdd Iechyd Prifysgol Hywel Dda yn ei wneud ar hyn o bryd.

Ceir sawl tebygrwydd rhwng casgliadau’r Athro Palmer ynghylch RAMI a pha werth y gall ei ddarparu i’r GIG a dealltwriaeth y cyhoedd yng Nghymru o ansawdd y gofal a ddarperir mewn ysbytai ledled Cymru ac adroddiad a gyhoeddwyd gan dasglu tryloywder a marwolaethau’r Dirprwy Brif Swyddog Meddygol ym mis Mawrth 2014\.

Bydd y tasglu felly yn ailymgynnull i ystyried adroddiad yr Athro Palmer a’i argymhellion yn fanwl. Bydd yn darparu cyngor pellach yn yr hydref ynghylch sut y dylai Llywodraeth Cymru a GIG Cymru ymateb.

Rwyf yn cymeradwyo adroddiad yr Athro Palmer i’r holl Aelodau. Mae’n cadarnhau fy marn fy hun \- a barn llawer o arbenigwyr ac academyddion eraill \- mai set o rifau nad ydynt o gymorth mawr yw RAMI i raddau helaeth. Er hynny, rwyf yn rhannu barn yr Athro Palmer bod mesurau llawer mwy defnyddiol y mae rhaid inni eu cofnodi a’u hadolygu yn gyson ac yn drylwyr.

Mae’n darparu sylfaen awdurdodol ar gyfer trafod ystyr a defnyddioldeb data RAMI. Rwyf yn rhannu casgliad yr Athro Palmer sef bod adolygiadau nodiadau achosion marwolaethau’n cynnig mesur mwy defnyddiol, \- mesur y gellir ei wella ymhellach trwy gofnodi ac adolygu cyson a thrylwyr. Fel y dywedais gynt wrth yr Aelodau, rwyf yn bwriadu adrodd yn helaethach ar y defnydd o adolygiadau nodiadau achosion marwolaethau ym mis Medi.     








Translation:


 
 


 


Today I publish the review undertaken by Professor Stephen Palmer, the Mansel Talbot Professor of Epidemiology and Public Health at Cardiff University, into the use of risk\-adjusted mortality data in NHS Wales.


The Welsh Government and NHS Wales are committed to transparency of patient outcome and have been publishing an increasing number of quality and performance indicators for all to see over the last 18 months.


One measure which has caused particular public confusion is the risk adjusted mortality index (RAMI), which in Wales is calculated by an external company for individual district general hospitals. To be specific, there has been – and continues to be \- widespread uncertainty among experts and the public, about the extent to which a single figure can indicate the quality of care delivered by the wide and complex range of services within a hospital.


To address this important question, I asked Professor  Palmer, a distinguished epidemiologist, to undertake a review to advise me about the following questions:


 


* To what extent does risk adjusted mortality data provide valid information?
* How can risk adjusted mortality measures be interpreted for NHS Wales?
* Do hospitals with risk adjusted mortality indicators above 100 require further work on data or clinical quality?
* How are NHS Wales boards using clinical data for quality improvement?
* What is the quality of clinical data used by NHS Wales for improvement purposes
* Are NHS organisations using clinical data effectively for quality improvement?
* What do the clinical data tell us about the quality of care in NHS Wales?


 


I would like to thank Professor Palmer for his considered report. He has undertaken significant stakeholder engagement and applied the wealth of his personal knowledge and experience to this task.  His report provides a valuable expert overview of the ways in which quality and safety data are collected, processed and interpreted across the NHS in Wales and I hope it will be widely read.


Professor Palmer concludes RAMI is not a meaningful measure of quality, indeed he says it is misleading.  


He does, however, make recommendations for Welsh Government and NHS Wales to ensure it has meaningful and useful information to measure and describe quality care in hospitals.


Professor Palmer supports the mortality case review process, which is in place for all deaths in Welsh hospitals – this is an area in which Wales leads the UK. He advises ways in which this review process can be further strengthened by improved consistency and clinical engagement. Professor Palmer also makes recommendations to improve clinical coding, participation in national clinical audits and data interpretation for Boards.  


The Chief Medical Officer for Wales is today writing to all clinicians in NHS Wales to reinforce their responsibilities about medical records, which is, after all a patient safety matter, but which is also important to ensure clinical coding is optimised.


When I commissioned this review I also asked Professor Palmer to look at six hospitals, which had a Welsh RAMI score of more than 100 in March 2014\. I asked him to let me know if, in these cases, the RAMI figure represented the sounding of a "smoke alarm". In five of the six hospitals,  Professor Palmer concludes, clearly,  that it is not.


  

As far as Prince Charles Hospital, in Merthyr Tydfil and Royal Glamorgan Hospital, in Llantrisant, are concerned Professor Palmer concludes the RAMI scores of more than 100 are expected from the way in which the measure is calculated. He also says Cwm Taf University Health Board has an impressive and highly visible clinical case note mortality review process in place, which provides considerable reassurance to the board that high RAMI scores are not indicators of poor care.


At Neath Port Talbot Hospital and Singleton Hospital, in Swansea, Professor Palmer concludes that the RAMI scores are probably the result of coding and classification changes and not a reflection of deficiencies in quality of care. He does however recommend that Abertawe Bro Morgannwg University Health Board takes steps to fully embed the mortality review process.


In relation to Wrexham Maelor Hospital, Professor Palmer does not consider that the report of the RAMI to require any additional action. Furthermore, he says a rigorous and systematic mortality review process, which covers all hospital deaths, is in place with four out of 10 deaths referred for an in depth review.


As far as Glangwili Hospital, in Carmarthen, is concerned, the review concludes that the high RAMI score appears to be a consequence of changes to the way the 2013 RAMI is calculated.


However, Professor Palmer believes further work is needed to understand the ways in which changes to the classification of palliative care cases and other matters may have had an impact on the RAMI score. He supports the additional work the medical director at Hywel Dda University Health Board is currently carrying out.


There are many similarities between Professor Palmer’s conclusions about RAMI and what value it can provide to the NHS and the Welsh public’s understanding of the quality of hospital care provided across Wales and a report published by the Deputy Chief Medical Officer’s transparency and mortality taskforce in March 2014\.


The taskforce will therefore reconvene to consider Professor Palmer’s report and his recommendations in detail. It will provide further advice in the autumn, as to how the Welsh Government and NHS Wales should respond.


I commend Professor Palmer’s report to all Members. It confirms my own view – and that of many other experts and academics – that RAMI is largely an unhelpful set of numbers. However, I share Professor Palmer’s belief that there are more helpful measures which we must record and review with consistency and rigour.


It provides an authoritative basis on which debate about the meaning and usefulness of RAMI data can be moved forward. I share Professor Palmer’s conclusion that mortality case note reviews provide a more helpful measure, and one which can be further improved through consistent and rigorous recordings and review. As previously indicated to Members, I intend to report more extensively on the use of mortality case note reviews in September.