A glimmer of light from Sir Bruce

James Gubb, 29 May 2008

Perhaps one of the biggest misnomers in the NHS at present is payment by results, quite simply because it isn’t payment by results at all. It’s payment by caseload.
For an operation from the same health resource group, whether you bungle it and leave the patient ridden with MRSA and disabled for life or whether you’ve done a world-class job that Lord Darzi himself would be proud of, you’ll get paid the same.

Not a great incentive to do well – in fact, professional pride aside, one might say there’s an incentive to bang them out without consequence to get maximum income. Not unless of course the public really know about it and use it to exercise a choice.
Patient-centred care is the trendy byword at the moment, but it’s so far from reality it’s untrue. Rather, the reality is patients don’t have a clue what goes on in the operating theatre or the hospital until they have the misfortunate to end up there.
So here’s where hats must now bow to Sir Bruce Keogh, medical director at the NHS, Bernard Ribeiro, at the RCSEng, and, yes, the DH. For now, this might change.
According to the Guardian, the government is preparing to publish for the first time the death rates of patients undergoing major surgery at NHS hospitals in England. This will be on NHS Choices and for patients to make a choice. What’s clear is that it’s going to make uncomfortable reading for some and will show, once and for all, that a national service does not equal national quality.
“The move”, writes John Carvel, “will expose alarming variations in the mortality rates of NHS trusts carrying out commonplace procedures”. And hospitals will have to act.
Crucially, this seems to have at least some buy-in from the professionals. Mr Ribeiro went on record speaking to the Independent earlier this year saying Britain’s 6,000 surgeons must be more open about what they do and accept assessment of the outcomes of their operations to guarantee patient safety: “Trust”, he said, “is a big issue in medicine. Trust comes with information. The patient who has information will trust the doctor.”
Of course, as with everything there are limitations to what’s being proposed:
– Data will, to begin with, refer only to hospital trusts, not individual surgeons or teams. You could still get a bad egg within what appears a high performing institution overall.
– Data quality must be assured. The DH’s record on such matters, if the National Office of Statistics is to be believed, is patchy at best. But with proper support from the RCSEng, who have experience in such matters – heart surgery death rates have been published since 2004 in the wake of the Bristol Inquiry – there’s a better chance of success than with waiting times data, for example.
– Death is very much a worst case scenario; and not necessarily the most appropriate measure of quality for ‘minor’ operations. In the long-term we must be looking at morbidity measures; such as the patient reported outcomes being piloted by Professor Nick Black and his team at the LSHTM and used in this recent report on ISTCs and the NHS.
– More than anything, there must be proper risk-adjustment; so that surgeons and trusts don’t get penalised with excessive death rate statistics when it’s just a function of the fact they are performing massively more complicated operations on much frailer patients. There’s little evidence this has happened with heart surgery in the NHS – suggesting they’ve got the risk adjustment right – but there is evidence it has caused surgeons to cream-skim healthier patients when a similar system was introduced in the New York.
So, some words of warning, but Sir Bruce has it right: “The writing has been on the wall since the inquiry into the deaths of children at Bristol Royal Infirmary 10 years ago. There has been a lot of talk about more openness, but we as a profession have not made much progress. So I am now inviting the institutions of medicine to step up to the plate and help us accelerate the process. We want their help.”
And he added this: “We want people to submit to us what they think are useful measures of the quality of treatment and, if we agree, we will apply those measures across the board in the NHS. They will not be targets, but they will be benchmarks showing how people perform.”
A glimmer of light emerges.