I can find much to reflect upon in this article:
Every few years we unearth another hospital scandal in which we discover, all too late, that many patients have needlessly died. On the face of it there is no common theme to these failures: the bug clostridium dificille at Stoke Mandeville, possibly similar infections at Maidstone & Tunbridge Wells; emergency admissions at Mid-Staffordshire, and possibly poor hygiene at Basildon & Thurrock. But, as The Sun points out today, it seems that the Department of Health was warned in the strongest terms about flaws in the healthcare oversight mechanism.
Indeed, it is curious how these hospitals, which patently have major problems then wave around glowing reports from their regulator.
It is astounding that there is no system of performance improvement in the NHS. But suppose there was. If we could, say, spot increased mortality at any hospital on a monthly basis we could prevent temporary problems turning into scandals. But, there is already a way to do that. The Hospital Standardised Mortality Ratio (HSMR) was developed here in the UK. It accounts for different risk factors so that hospitals undertaking complex operations, or dealing with critical patients, are not painted in a poor light. It measures the hospital’s actual performance against what is expected and so can give an early warning to inspectors, regulators, clinicians, journalists and patients. HSMRs have been around for many years and consequently they have large evidence base which shows that they are reliable and robust.
I’m not entirely sure why it should be “astounding” that there is no system of performance improvement in the NHS. The NHS is an organisation which has no incentive to improve “performance” as we, the patients, would understand it. The NHS is an organisation that spends “government” (i.e., taxpayer) money on other people. The customer of the NHS is the government, which gives the NHS its funding. Patients are the “stock in trade” of the NHS, and the NHS has no more incentive to improve things for patients than Tesco has to improve the experience of a tin of beans on its shelves. Yes, it is certainly true that individual doctors and nurses care very much about the patients and the quality of their care, but the NHS as an organisation is not aligned to patient care. This may seem counterintuitive, but a little bit of thought about human nature, funding sources and government targets will make it clear.
This is exactly how a hospital, which is killing hundreds of people needlessly, can also get a glowing report from the regulator – the regulator is monitoring the things that government (the customer) deems important. The patient is largely irrelevant to this process and genuine medical or clinical matters are also largely irrelevant.
But HSMRs aren’t the preferred hospital performance measure of the Department of Health. Although the Care Quality Commission (CQC) – the health regulator – does monitor mortality rates it does not publish them amongst its list of core indicators. This almost makes the UK a statistical outlier, as more and more countries around the world are adopting and publishing HSMRs as part of their hospital performance improvement plan. Indeed, the persistently high HSMRs at Mid-Staffordshire, which led the regulator to pursue its investigation, was brought to attention by the health informatics company, Dr Foster.
Of course a clinical metric is not a core indicator. The regulator is monitoring the hospital against the targets set by government, and the government is not a clinical organisation.
Dr Foster, and the Research Unit at Imperial College, have pioneered the use of HSMRs; they calculate them on a monthly basis and publish results for all hospitals each year in their Good Hospital Guide. This tends to cause a storm when it is published and at the end of last year the tempest was about Basildon & Thurrock which had high mortality rates, yet a glowing report from the CQC. Following this year’s media storm, the Chair of the CQC, who it seems was in favour of greater enforcement powers for the health regulator, resigned from her new post.
It doesn’t really matter whether or not the regulator has greater powers of enforcement, if the regulator is enforcing the wrong thing, does it?
But as long as the current model of government-funded, government-mandated and government-targeted health care continues, we will continue to find people dying needlessly in dirty hospitals while hospital management proudly brandish their glowing reports from the regulators.
Personally, I would prefer them to meet fewer government targets and more clinical ones.