Death Certification Test Site Evaluation

3 Findings

Introduction

3.1 This chapter sets out the findings of the evaluation under the following headings:

• benefits and drawbacks of the test site process
• communication
• duration
• person specification for Medical Reviewers and Medical Reviewer Assistants
• consistency
• training and education
• data/IT issues
• rural/urban issues
• sustainability/proportion
• faith issues.

Benefits and drawbacks of the process

3.2 The benefits identified through the test site process are that it provides a good opportunity to support and educate doctors about the importance of completing death certificates accurately. In the case studies some of the doctors themselves identified that this had been useful.

3.3 The other benefit identified is the obvious opportunity to improve the accuracy and quality of data held about the causes of death that the new process provides.

3.4 In terms of drawbacks stakeholders identified that when the process is implemented nationally in 'real time' there will be some pressure on registrars, medical reviewers and doctors to ensure the reviews are completed in a timely fashion as there is otherwise the danger that funerals may be delayed potentially causing upset to families already bereaved.

Communication

3.5 The importance of good communication has been evident during the test site process. This includes the communication between the registrars and MRs, between the MRs and doctors and between MRs and NHS ISD. Aspects of the communication require good negotiation skills e.g. working with a doctor to re-do the MCCD.

3.6 Another aspect of communication that has been highlighted as being important is for doctors and funeral directors to communicate with the relatives of the deceased person when handing over the MCCD so that they understand that a review might take place. This has not always happened during the test site but will be important in the national implementation.

3.7 Some national stakeholders have emphasised how essential the communication about the new process will be in terms of raising public awareness and ensuring that the right messages are conveyed: in particular the issue about payment to registrars (which has not been part of the test site process) has been raised in this respect.

Duration

3.8 The evidence contained in the previous chapter has shown that most reviews have been completed within the intended time but that there are some factors that can cause delays, most notably access to medical records and to the certifying doctors. It is to be hoped that these may be less of an issue when the process is being done in 'real time' as the reviewing of certificates will be more immediate than it has been in the test sites and so it is likely that doctors will not have moved jobs, be away or on holiday. However there will still be potential times when this is more problematic for example over holiday periods such as the Christmas season when it may be more difficult to get in contact with the certifying doctor.

Person specification for Medical Reviewers and Medical Reviewer Assistants

3.9 Several interviewees commented on the attributes that they think will be important for the posts of Medical Reviewer and Medical Reviewer Assistant. These include the following:

• ability to communicate well and to have good 'people skills' so that they can establish good relationships quickly and maintain them;
• for the MRs, at least five years' experience in a variety of areas and with a specialism in one area;
• ability to negotiate and compromise;
• willingness to be flexible: for example about when they speak to doctors due to doctors' shift patterns (during the test site process the MRs related that they have often had to undertake out-of-hours work in order to speak to doctors);
• ability to act decisively when required;
• ability to take on an educative role with doctors to help them complete MCCDs more accurately.

3.10 In terms of the Senior Medical Reviewer (SMR) post interviewees highlighted the importance of that person being able to ensure consistency across the work of the MRs.

Consistency

3.11 The last paragraph highlighted the importance of consistency for the SMR role. This is an issue that has been raised by a number of interviewees. There is a concern that without a reasonable degree of consistency in the way the reviews are handled across Scotland that it may damage the perception of the whole process in the eyes of the public.

3.12 One of the areas linked to consistency where interviewees expressed fears was around the potential for delays to funerals and the impact of this on bereaved families. There was discussion about the planned expedited process where a funeral is required quickly e.g. on religious grounds, with one interviewee pointing out that this process should be accessible wherever necessary.

Training and education

3.13 The paragraphs above highlight the clear need there will be for careful training with the MRs and MRAs so that they have clear guidance as to how to undertake the process and when there can be exceptions to the rule. The test site has shown that different people will approach the process in different ways and it will be important to be clear with the appointed MRs about what is acceptable and unacceptable in terms of the MCCDs and when to rule an MCCD as out of order.

3.14 It is also clear that training and education about the new process and how it is to work will be required for registrars. Included in this will be the handling of the £30 fee which they will be responsible for collecting.

3.15 There will also be a need to raise awareness and provide training and education for doctors about the new system and the levels of quality and accuracy in the MCCDs that the MRs will be looking for. Some interviewees expressed the wish that this new process will help doctors see the whole issue differently and support them to be more empathic in their communication with bereaved families. The importance of including education about the death certification process and support for the bereaved at undergraduate level was raised by some interviewees.

Data/IT issues

3.16 There have been a number of access issues relating to IT during the test site process including the access to NHS systems from a non-NHS site in Dundee and generally accessing medical records in both areas. One of the MRs commented that it would be very helpful if it was possible for MRs to have access to GP records electronically.

3.17 There were some problems in completing the data form for ISD and ISD intend to revise the form before the national implementation. It is likely the revised form will need to be trialled before use and the MRs and MRAs will require careful training in its completion to avoid any inconsistencies.

Rural/urban issues

3.18 The rurality of Dumfries & Galloway had an impact on the travel time involved when the MR had to view records held outwith Dumfries in person. The geographic size of Dumfries & Galloway meant that the MR had to drive long distances on occasion, although she overcame this barrier on many occasions by asking GPs to fax a four page summary of the records and by using the NHS internal mail system to receive deliveries of records from hospitals outwith Dumfries.

3.19 The MR in Dundee also had to leave her base to view medical records but, given the geographic size of Dundee, this did not entail such a burden on her time.

Sustainability and proportion

3.20 The level of MCCDs not in order in the test site at 3% is low. It is likely that with further education and awareness of the importance of completing the MCCD accurately that this figure might drop further in the first few years of national implementation. At present it is intended to check 25% of the MCCDs but there is scope within the legislation to review this level of checking if it is considered appropriate to do so. Some of those we interviewed thought that in a few years' time it might be possible to reduce the level of checking.

3.21 The MRs in the test site have had to work more hours at times than the allocated 0.5 FTE and have also had to be willing to be flexible in terms of when they contacted doctors to fit in with when they could get hold of the certifying doctor.

Faith issues

3.22 While it was recognised by several stakeholders that issues relating to faith and practices after death could potentially arise in the new system, in fact during the test sites this did not arise as a specific issue.