First night of the PROMs
Civitas, 14 May 2009
The HSJ today carries the revelation that the NHS is spending £144m annually carrying out operations on people who either have no significant complaints about their health before surgery or report that their condition is unchanged or worse afterwards. Should we be surprised? Probably not.
For one, the statistic derives from an analysis of DH data on the trial use of patient reported outcome measures (PROMs) of basic surgical procedures, such as hip/knee replacements, hernia and varicose vein operations. PROMs are a new arrow in the evidence base of health care, so NHS organisations will not yet have been able to benchmark against it. Why? First, there are teething problems with the data. It is hard to believe those undergoing surgery had ‘no’ complaints beforehand – it’s a question of degree and whether the risks of surgery are worthwhile. Also, the true outcome of hip/knee replacements may not be known until long after the 3 months used for PROMs collection. Second, discounting PROMs, the existing evidence out there on medical activity is surprisingly slim. In fact, according to the BMJ, over 45 per cent of the medical activity commonly carried out in health systems lacks an evidence-base, and only 13 per cent is proven to be beneficial. This is not to say it isn’t clinically effective, but that it needs to be explored. Even less prevalent is evidence of cost-effectiveness.
More widely the variations reflected in the PROMs data – why the £144m unnecessary ops exist – would be wholly in line with well documented problems of variable practice (of the unacceptable ilk). A recently acclaimed national study in the US, for example, looked across 439 quality indicators for 30 acute and chronic conditions and found that only 54.9 per cent of patients receive what is considered the recommended level of care. A further study actually concluded that quality of care and health outcomes are better in lower-spending regions, with no greater gains in survival in regions with greater spending growth. Much of this is down to the way physicians use resources.
Domestically, the picture is little different. Quality indicators such as hospital-standardised mortality ratios and the like vary significantly across hospitals and the NHS Institute for Innovation and Improvement estimates that ironing out differences in performance between hospitals in the NHS could release more than £3bn.
But there is a wider point about the statistics on PROMs, which gives equal cause for concern. This relates to the payment system and wider structure of the NHS. John Appleby, commenting on the HSJ’s story said the data would enable PCTs to “point the finger” at the quality of clinicians’ decisions about when to operate on a patient, to start to look at the data and ask hard questions of their providers – comparing not just between hospitals but between clinicians.
Of course, this is true, and all data on outcomes should be welcomed. But the extent to which PCTs will be able to do a whole lot with their ‘finger pointing’ is questionable. True, they have opportunities under the new CQUIN scheme, where additional payments can be offered for ‘quality’. Aside from this, however, the levers PCTs can use are otherwise limited, given that patients now have free choice of provider for the elective care that PROMs being collected for. PCTs can make the information available to patients, but can they really prevent the patient choosing a provider, even if the provider is operating when the clinical case is unclear? To do so would seem to go against the principles of choice enshrined in the NHS Constitution.
What’s worse for PCTs (and patients as well?) is that providers, under the payment-by-results system, actually have the incentive to operate on the marginal case, because they will get paid more. Great if you want to increase activity, but is it – in the absence of a genuinely competitive system that consumer power can work through – conducive to quality? As Jennifer Dixon and Sir Cyril Chantler put it in an insightful piece for JAMA:
‘The incentives in the system are not appropriate, being mainly designed to reduce waiting lists (i.e. to increase volumes of surgical cases moving through hospitals), not to reduce avoidable admissions—for example, through better management of medical conditions in primary care. Hospitals are paid a fixed national price for an admission based on diagnosis and are encouraged to admit more patients and to expand services that create a surplus rather than necessarily meet need or deliver the most cost-effective outcomes… The levers for PCTs to manage demand for hospital care are weak, and support of, and engagement by, [GPs involved in] practice-based commissioning is low… hospital specialists do not receive financial encouragement to work with general practitioners and others, and consequently care is often not integrated.’
As far as the history of the NHS goes – where hospitals have traditionally been paid a block contact – such incentives to over-treat are new. And it’s not just to over-treat. It’s to get patients out as quickly as possible. If the patient is subsequently re-admitted, no bother, the hospital will get paid again. PROMs are one matter, but the fact emergency re-admissions to hospital and emergency hospital admissions for chronic conditions (such as asthma) and acute conditions (such as ear, nose and throat infections) that are usually – and typically optimally – managed in primary care have been on the up over the past five years is further cause for concern. There are very few incentives in the system to reverse this.
Hospitals in the US – long paid in a similar way to the payment-by-results system in the NHS – are familiar with such perverse incentives. The New York Times carries a story just this week about how Nicollet Health Services, a hospital and clinic system based in St. Louis Park, Minn. Park Nicollet started tackling readmission problems four years ago, by spending as much as $750,000 annually on more nurses and on sophisticated software to track heart failure patients after they left the hospital. It reduced readmissions for such patients to only 1 in 25, down from nearly 1 in 6, and saved Medicare roughly $5 million a year in the process. But Park Nicollet is not paid to provide the follow-up care and fewer returning hospital patients meant lower revenue. The crude incentive was for the hospital to reverse its achievement.
PROM measurements should, of course, pick up on poor follow-up – information which can be conveyed to the consumer it making their choice of hospital. But this consumer power is, thus far, weak. Are the wider, systemic, incentives right?