Death Certification Test Site Evaluation

4 Conclusions and Implications for National Implementation

Conclusions from the test site evaluation

4.1 The two test sites have been useful in highlighting areas where there are differences of approach and where the process has faced challenges or worked well.

4.2 The evidence from the test sites has shown that the great majority of MCCDs are completed accurately under test site conditions. Only 3% of the MCCDs have been declared as not in order. Where the MCCDs were not in order the main reasons for this were to do with inaccurate information about the causes of death.

4.3 In addition to this there are clearly other minor inaccuracies, not sufficient to warrant asking for the MCCD to be re-done, but where there is room for improvement. The educative role of the MRs, going back to doctors to point out these smaller inaccuracies/quality issues, is seen as an important part of what they do. In time this educative role should mean that the overall quality and accuracy of MCCDs improves even further.

4.4 The difference in location for the MRs in the two areas, with one in a hospital and one in a non-NHS building has highlighted how much easier communication is within and between NHS settings and would suggest that future MRs should all be based within NHS settings.

4.5 The importance of the MRs being able to develop good relationships with registrars and doctors has been demonstrated: without good relationships between these key stakeholders the process may work less well.

4.6 The amount of time taken to complete reviews is critical when it is implemented nationally as there is concern that there will be delays to funerals. The evidence has shown that around three-quarters of level 1 reviews across both areas took under three hours to complete. In Dundee, 8% of the Level 1 reviews took seven or more days to complete (the equivalent data for this was not supplied from Dumfries & Galloway through the ISD reporting form but analysis of data provided by the MR indicates that 1% of level 1 reviews took seven or more days). This amount of time appears to be caused mainly by the difficulty of accessing the certifying doctors and we anticipate that this may be reduced when the process is being undertaken in 'real time' as it will be more immediate and doctors will be less likely to have moved on.

4.7 The test sites have highlighted a number of practical communication and information exchange issues that it will be useful to address before the national implementation takes place. These include:

• how referrals from registrars are transferred to the MRs. Faxes have been shown to have drawbacks in this test site process but not all registrars have scanners in their offices to enable them to use email communication;
• accessing an individual's medical records: there are several issues here (see paragraph 2.47) that will need to be addressed;
• faxing information back to registrars has the same drawbacks as in the initial referral and may also cause delay as the MR has to be in the office where the fax is situated to be able to fax it. Emailing information would make this part of the process simpler; and
• the sending of data/information to ISD has had to be reviewed during the course of the test site process. Based on the learning from this process, ISD will collaborate with HIS in order to agree the data requirements, then revise and improve the data collection process before national implementation.

4.8 The issue of consistency has been raised through the evaluation of the test sites and the differences identified have been useful in highlighting where inconsistencies might arise. One of the learning points from this is how important intensive and careful training with the MRs will be plus the need to keep checking/reviewing for consistency once the national implementation takes place.

Implications for National Implementation

4.9 The national implementation is planned to take place from April 2014 onwards. The main implications for the national implementation that this test site evaluation has highlighted are as follows:

• the location for where the MRs are situated is important: an NHS site (in particular a hospital as 60% of people die in hospital) facilitates the transfer of information and also allows easier access to medical staff at that establishment;
• the referral from registrars clearly has to be streamlined so that there is no delay in the administrative aspects of the process. Ideally this would be done by email but this may entail ensuring that all registrars have scanners;
• the evaluation has demonstrated that the communication and 'people skills' of the MRs and MRAs are essential elements of the person specification for these two jobs; other key elements include flexibility and willingness to negotiate;
• training and clear guidance (for MRs/MRAs/registrars/doctors) will be crucial to help the new process bed in and also to support a high level of consistency which is seen to be important for public confidence in the new system;
• there are IT and data issues that need to be resolved including:
  • access to medical records which might be simplified if GPs can fax/email a summary of the medical records (as happened in Dumfries & Galloway);
  • returning completed reviews to registrars (similar to the earlier point about referral); emailing will greatly help this process; and
  • the need for a revised data collection form for ISD (in hand).

4.10 When the process is implemented nationally it will clearly be important to check a number of things on a regular basis:

• the consistency across all MR areas in terms of outcomes for the reviews;
• the length of elapsed time that the reviews are taking so that any delays can be addressed where possible; and
• reviewing that the number of MCCDs declared not in order as at some point it may be considered more proportionate to reduce the overall level of checking.

4.11 The test site evaluation has provided some useful learning for the national implementation and should help to ensure that the full process is as smooth as possible when it starts in April 2014.