Until 1991 the Department of Health collected and published reasonably accurate statistics on the use of electroconvulsive therapy (ECT) in England. A booklet was produced annually, listing the numbers of treatments given to in-patients and out-patients in each region and each district. There were bar charts and tables comparing the use of ECT with that of previous years and each region’s use of ECT per 100,000 population, and a brief summary of the main points emerging from the statistics (‘As in previous years, during 1990/1 there was wide variation across the regions in the numbers of ECT treatments administered….’, etc).
That all stopped in 1991. Since then the only published statistics (for most years) are those in the Hospital Episode Statistics (HES). The old and new systems overlapped for a couple of years, and this overlap revealed that only a fraction of the ECT used was finding its way into the HES. For example, in 1990/91 there were about 16,000 courses of ECT according to the old statistics; only 2,680 found their way into the new system. One-off surveys of ECT use in England in 1999 and 2002 again found that less than a quarter (1999) and one half (2002) of ECT used in English hospitals appeared in the HES. As the survey commented: ‘…the HES data for ECT can be considered to be randomly under-recorded’.
The Department of Health has long been aware of the problems with ECT in the HES. A ‘Coding Clinic’ in 1995 had this to say about ECT:
“To capture accurate, consistent data, therefore, is very important. While psychiatric care covers a wide range of disorders and procedures one item in particular that is poorly recorded nationally, in relation to psychiatric coding, is Electroconvulsive Therapy (ECT).
The procedure consists of introducing convulsions by electrical stimulation of the brain for the treatment of certain mental illnesses… It is a procedure that is of great interest to many groups and all staff responsible for the recording of clinical data on psychiatric patients should know that it is necessary to code this procedure on relevant psychiatric episodes.
The code in OPCS-4 for Electroconvulsive therapy is A83.9, unspecified. This code should be used on every occasion a patient has this treatment”.
In 1998 the National Health Service issued new guidance on the clinical coding of ECT. According to this guidance, which described the HES ECT data as ‘unusable’, the first treatment in a course should appear on the HES as ECT, other specified – A83.8 and subsequent treatments in a course as ECT, unspecified – A83.9. So, in the HES 3 character tables the figure under A83 should represent the total number of individual treatments, while in the 4 character table the figure under A83.8 should represent the number of courses, and A83.8 plus A83.9 (the total number of treatments) divided by A83.8 (the total number of first treatments, or courses) should approximate to the number of treatments in a course. But a quick glance at the 2009/10 figures shows 1,221 first treatments and 783 subsequent treatments which would mean lots of people having just one treatment. This is obviously not the case (the mean number of treatments in a course is somewhere in the 5-7 region). So there appear to be a lot people not understanding the coding instructions. Unless the instructions have changed – but judging from this recent Welsh clinical coding communication they have not.
The 3 and 4 character tables referred to above cover the ‘main operations and procedures’, the most resource intensive procedure performed during the episode (an ‘episode’ being nearly, but not quite, the same as a hospital stay). Perhaps ECT isn’t considered to be a ‘main’ procedure in some hospitals, but in that case the treatments should find their way into the total procedures and interventions tables where there is room for up to 12 different operations and procedures, not just the main one. In 2009/10 for example there were 7,954 treatments reported in total, of which nearly three-quarters were not the main procedure. This makes me wonder if some hospitals are mistakenly counting the first treatment in a course as the main treatment, and subsequent treatments as second, third, etc, procedures. But in any case the figure still amounts to only a fraction of the ECT used in England; the 2002 survey found approximately 50,000 administrations of ECT while the number in the HES total procedures table was 10,000.
It would appear that, over 15 years after it was identified, the problem with ECT data in the HES has still not been put right.