Report from our annual debate

The Centre’s annual debate sought answers to the question of how key policy areas might contribute to the drive to improve both quality and efficiency of care.  Excellent contributions to start the debate were provided by experts in standards, regulation and competition. 

An online survey conducted before the debate had indicated a near perfect bell-shaped distribution in the degree of optimism people shared in the future sustainability of health and care services.  This was offset marginally in favour of the pessimists.  One in 8 registered “not at all confident” with only one in 40 declaring that they were highly confident. 

That same survey indicated that Mike Kelly of Nice might have the easiest task in making his case that standards would indeed drive both quality and efficiency, albeit that the survey did indicate only a minor contribution in the short term, with improvement taking several years to pay real dividend. 

From this advantageous starting point, Mike kicked off the debate with an excellent exposition reminding us that the whole work of standards began over 40 years ago when Archie Cochrane recognised that the apparently arbitrary degree of variation throughout the system was simply not good enough. 

Mike went on to express that the value of establishing standards based on a shared and common interpretation of the best available evidence is shared across all stakeholder groups because it establishes a common language of exchange, which:

  • defines the basis on which professionals make their decisions about treatment;
  • sets a clear expectation for patients and carers to make their choices;
  • defines the benchmark performance against which different providers will be compared;
  • enables commissioners to define the criteria they will use to reward quality and performance.

Mike reminded the audience that in driving for continuous improvement, it is important to understand the health gradient linking social and health status.  It is all too easy to deepen health inequity by improving the quality of outcomes disproportionately for those who tend to have the least complex care needs.  The ideal aim in driving new and better standards is to target improvement on those with complex care needs to overcome the current inequity in outcomes.

In contrast, Nick Bishop of CQC entered the debate for regulation with a small opening handicap, having been assessed as the policy area most likely to be neutral in its effect, although it too was perceived to contribute more positively in the longer term.  Nick began by praising the importance of standards as the essential basis against which regulations were defined and compliance assessed. 

Nick reminded us of the sheer scale involved in anything to do with healthcare – 1 million GP visits and 2 million prescriptions issued per day, 50 000 visits to A&E and 2000 births just to provide a sample.  To drive home this point, Nick illustrated the sheer scale, by pointing out that a £1 million stack of £50 notes would be roughly the height of the tallest human, whereas the NHS budget would stretch to 220km high – more than 26 Everests. 

With so many events in a risky business, there will always be some which don’t turn out as planned, and the quality regulator’s role is to expose where this is happening more than is reasonable.  With over 30 000 organisations to regulate through annual inspection (that is over 120 organisations per day, small and large), the challenge for CQC boils down to the same issue with which Mike began – understanding the unwarranted variations in health.  Somehow, amidst the millions of events and thousands of organisations, CQC must spot an anomalous pattern within the plethora of intelligence to enable them to weed out those providers who are simply not performing within agreed and safe limits – and to do this with a substantially reduced budget compared with historical inspection.

Andrew Taylor was our final speaker in the debate.  Until recently, Andrew was the Chief Executive of the Co-operation and Competition Panel – the body charged with ensuring that none of the provider organisations within the NHS is able to wield its power to the detriment of the service user/ patient or carer. The stance of the Health and Social Care Bill towards competition has probably been the cause of the greatest volume of dispute and objection.  This was no exception in our debate, as again demonstrated in the pre-debate poll, where results showed a strongly polarised opinion.  A strong showing both for and against its contribution to improving quality, and a much smaller neutral vote.  Competition was also felt to offer the strongest contribution to rapid improvement in quality, though with much reducing value over the longer term.

Andrew distinguished between the effect of competition within the NHS, and between the NHS and other providers.  The influence of patient choice to incentivise better performance should not be minimised – currently mainly between providers, but soon to be opened up to choice of individual consultant.  The new area of competition signalled by the Bill is that of increasing market testing by commissioners, with the opening up of the market to any qualified provider (AQP).  Andrew pointed out that in the current wave, the maximum value of community services covered by AQP is unlikely to exceed £50-100m.  Borrowing a leaf from Nick’s scale of measurement less than 0.1% of the NHS budget and a mere BT tower high stack of £50 notes.  In the current round of competitive tendering, commissioners have been instructed to market test 3 services from a list of 12 – every one a service in which the NHS generally fails to offer a service of credible quality – wheel chair services being the archetypal example.

In the debate which followed, there was considerable agreement that these policies are not an either/or choice – each has its place, and each can contribute positively to improving quality and efficiency.  The survey results reinforced the expected views that structural change is seen as the least helpful of any policy approach and integration offers the greatest hope for improvement.  Overwhelmingly though, the plea from the audience was to find voice to the patient, service user or carer, and for a greater sense of local ownership with reduced imposition of centralist control.

A more detailed report, including the survey results will follow.

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Trust them with the numbers

In 1972, Archie Cochrane launched the new phase of healthcare, when he observed an almost random level of variation in successful outcomes of supposedly similar treatments at different hospitals.  The seeds were sown for evidence-based medicine, and application of scholarship to discover what constituted best known practice for medical treatments and interventions.  His name is immortalised through the work of the Cochrane Collaborative which relies on the collective efforts of many scholars critically reviewing and synthesising published research to establish gold standards for all to see – doctors and public alike.

So, nearly 40 years down this road,  some of the best minds have been pressured into agreeing a new indicator which seeks to predict what levels of mortality are to be expected at each hospital in the country.  If you have been following the debate, you will be aware how much this has led to intense deliberation, argument, counter-argument and near rebellion on occasions.

No-one is claiming that this is an easy task.  We know, for instance that there are direct links between disease and socioeconomic status, geography, gender, ethnicity and lifestyle factors such as smoking.  We also know that different treatments and interventions carry different risks.  We aren’t surprised therefore, to realise that the predicted mortality rate for a hospital will be affected by the complexity of care it provides and the characteristics of the population it serves.

So you would expect it to be difficult to predict accurately how many people are likely to die within 30 days of being treated in hospital.  That is what standardisation is all about, and why the indicator is called standardised hospital mortality indicator (SHMI).  No-one has ever pretended that delivering healthcare is easy.  Doctors have to do difficult things  most days.  Nurses do different things, equally difficult.  Managers too have their share of difficult things, but, despite being politicians’ favourite targets for abuse, they contribute to the success or otherwise through their planning and management of resources to keep the healthcare system running.

So it is right to expect people who do difficult things to be accountable to the public whom they serve.  You would expect someone to be accountable for predicting the likely number of deaths a hospital can expect.  You would expect the publication of such information to be contentious because it takes away some of that air of mystery that professionals can generally get away with creating.  

Two surgeons with the same mortality rate can in reality be at the opposite end of performance – the very best and the very worst sharing the same raw number.  The one who takes on all the cases that are too risky for anyone else to consider, and in so doing saves many lives, offers a completely different level of care from that of the incompetent surgeon who fails on even the easy cases, and ends up taking lives that didn’t need to be lost. 

And raw numbers can indeed tell such a tale.  Unfortunately, within a society where most people run scared of numbers, our first reaction is more likely to be to worry about how people will misuse such raw figures, instead of concentrating on helping overcome their fear so that they do know what to do with them.  I always say that the data rarely provides answers, its power is in helping you to understand what questions to ask.  And asking the right questions in the above example very quickly leads to a clear understanding of what is happening.  Only the incompetent in our example has something to fear amongst an educated population, and rightly so!

So, when we look for the evidence on mortality, we expect clever people to work their magic in such a way that they can help Joe and Miranda Public to see whether their local care services are doing a good job or not.  The experts need to put twice as much energy into educating people how to interpret those numbers, than they do in producing the right values in the first place.  The sort of good job Archie Cochrane was worried about back in 1972.

So when the Information Centre published its new evidence exposing the considerable variation in performance between hospitals, we expected transparency on the numbers, supported by meaningful education to allow people to make sense of it for themselves.  Instead of this, energy seems to have been spent on building the smoke screen behind which the hospitals and clinicians can continue hiding from the ongoing and horrific reality of unwarranted  variation. 

Of course we want all hospitals to offer the same high quality outcomes, but we aren’t there yet, and until we reach such a utopia, we should each have the chance to make the personal choice of how much inconvenience we will accept so that we can get to the very best, if we so wish.  Alternatively, we might choose the extra risk so that we have minimum disruption.  And that trade-off is not as obvious as you might think.  People diagnosed with cancer in the Isle of Wight frequently choose a regime with an inferior prognosis so that they can stay at home on the island, rather than choosing a much more intensive treatment regime away from family and friends in Southampton. That is what choice is about, and why it is so important.

But sadly, those clever people in the Information Centre have determined that the data on mortality is far too complex to translate into an accessible form for the public to digest. Instead it is presented, buried in complex, highly caveated reports aimed at fellow statisticians.

Now I know a thing or two about statistics.  I know that most people do indeed have more legs than the average person!  So I’ve looked at the data with interest. 

I live in Ipswich, and I know that no relative of mine has had a good experience from my local hospital, and that its leaders only ever face the light of day defensively.  I was pleasantly surprised to discover that its performance is pretty close to the centre of the band you would expect it to be in.  I was even more surprised to discover that the hospital local to Cass is predicted to have a similar number of deaths each year, despite providing much more specialist care as well as facing the more complex health demand of its east- end population.  But instead of the same number of deaths as predicted, it positively glows at number two in the country for lowest mortality.  It only had around 68% of its predicted number of deaths.  Well done Barts and the London!  But if I got off the train in Colchester by mistake, then instead of a similar number again, this time I would have found data pointing to worse mortality: 5 deaths for every 3 at Barts and the London.

We may be delivering more sophisticated treatments, and calculating some pretty clever stuff to produce these figures compared with Archie’s day.  Like him, we know that we must avoid ascribing too great a precision to our findings because the statistical significance of each of the standardised mortality figures is never better than 5-10% or so.  But even though these subtle niceties may be lost in translation for many people, we have to trust the public with such serious trade-off as 5 versus 3.  After all, this isn’t 5 tins of beans from Morrismart for the price of 3 from Markrose.  This is about lives.  Shorter than necessary lives.  Well and truly short-changed!

What of the Bill?

As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them? 

I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.

Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you.  But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return.  Going back is not an option.  Too much has already changed for that to happen.  Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid. 

It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane.  Such a debate would pivot around what it takes to secure a sustainable future for health services:

  • that are better at adopting innovation,
  • in which all elements of the system drive together towards best possible outcomes for available resources,
  • that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.

Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains.  The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance.  Such ambiguities include:

  • detail of how Clinical Commissioning Groups (CCG) will be held to account;
  • how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
  • how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards. 

Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done.  If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.

Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact.  Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working.  These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged.  “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat.  What we need is an open-minded focus on how to achieve successful transition to a new shape.  The health system is too big and complex, to be susceptible to management by central diktat.  We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives. 

We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system.  GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care.  There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision.  That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour. 

Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account.  Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together.  Success of these boards is pivotal to the future.  It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions.  We see no attempts being made to nurture the new relationships on which success can be assured.

The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date.  There are important matters to be understood, which will make a real and important difference.

David & Rob