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2 Become 1: How will Aggregate Ratings turn Two Great Pillars of Truth into A Single Version of the Truth?

April 20, 2013

‘Experience and solid reason’ observed the seventeenth century scientist and medical man Sir Thomas Browne, ‘[are] the two great pillars of truth’. It’s a maxim that the good doctor could never have anticipated would be tested almost to destruction by a very twenty-first century rumpus at the Children’s Heart Surgery Unit of Leeds General Infirmary (LGI). The saga began on March 28th, when paediatric heart surgery at the hospital was abruptly suspended by Sir Bruce Keogh, Medical Director of NHS England. The next day, Sir Bruce told BBC Radio 4’s Today programme that he decided to act after a phone call from ‘an extremely agitated senior cardiologist’ who had seen ‘a preliminary cut of some mortality data from Central Cardiac Audit Database, which showed that mortality for 2011-12 and 2010-11 was considerably higher than any other unit in the country’. “I couldn’t” Sir Bruce quite reasonably concluded “do nothing”.

Children’s heart surgery at Leeds was due to recommence this week. On 9th April, Sir Bruce reappeared on the Today programme to admit that “the immediate safety issues [at Leeds] have gone” and that he had “acted on inaccurate data”. So that was that, then. Well…not quite. On 12th April, Professor Sir Roger Boyle, director of the National Institute for Clinical Outcomes Research, belatedly entered the fray. He told the BBC that in the  hypothetical case of his own child requiring cardiac surgery, he would not choose Leeds. “I would go somewhere else” he said. “I would go to Newcastle”. Asked to respond to his eminent colleague’s intervention, Sir Bruce said that “people are puzzled by these remarks. I don’t know what’s going on in his mind”. He doesn’t know? How does he think the public feels?

The background to the shenanigans at Leeds are, if anything, even more intriguing than the events themselves. Statistics suggest better outcomes for many high-risk medical procedures when they are carried out in fewer, larger centres where doctors can get lots of experience of managing a wide variety of cases. In line with this thinking, the government has proposed to concentrate children’s heart surgery in England into seven specialist centres. Three existing units are earmarked for closure. Leeds is one of them. On March 27th  – the day before the suspension was announced – local campaigners opposed to this course of action had secured a High Court ruling that the consultation process which resulted in the decision to close their unit was both ‘flawed’ and ‘ill-judged’. Commentators of a certain cast of mind scented a conspiracy.

Grumbling Appendix has no opinion on the sense, or otherwise, of keeping children’s heart surgery at LGI – but it’s a fair bet that Professor Sir Roger Boyle does. From 2000 to 2012, he was Clinical National Director for Heart Disease and Stroke. In his highly-recommended recent book God Bless the NHS: The Truth Behind the Current Crisis (2013), Roger Taylor describes him as ‘[a candidate for] the one individual who has saved most lives in Britain over the past ten years’.

Professor Sir Roger owes this accolade to his strategy, begun under the Blair government, of removing services for stroke and heart-attack cases from small Accident and Emergency departments and locating them exclusively in the hands of large hospitals equipped with state-of-the art technology. The result, according to Taylor, is that ‘London is now quite probably the best place in Europe in which to have a stroke’. So although his comments may have been ill-timed, Professor Sir Roger Boyle is definitely someone we should listen to. On the other hand, he is not, so far as I am aware, the single parent of a sick West Yorkshire child who is also having to juggle the competing demands of other children, paid employment and extended family.

In Patients First and Foremost:The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013), the government announced that from now on, truth and transparency were to be its watchwords as far as the NHS was concerned. In line with this, an aggregate ratings system under which all health care providers – care homes as well as hospitals – would be awarded a rating of ‘outstanding’, ‘good’, ‘requiring improvement’ and ‘poor’ ‘will be compiled using both judgement and data to ensure there is a system wide ‘single version of the truth’’ (Patients First and Foremost, para 2.14). The recent history of children’s heart surgery at LGI highlights a number of awkward questions about this aspiration.

Firstly – and most obviously – how can service users be confident the ‘single version of the truth’ awarded to their local hospital will have any meaning when even those who are supposed to be experts can’t agree on how to interpret the data which will form the basis of the rating? And secondly, given the strength of local opposition to closure of the Leeds unit and the fact that during the recent controversy many parents took to the airwaves to express their complete satisfaction with the service it offers, how can the government be sure that when the aggregate ratings are compared to the results of the already up-and-running Friends and Family Test, the picture will show not truth, but confusion? What if  health care providers are basing their judgements on a completely different set of criteria from health care consumers?

Nurses are all-too-familiar with being stuck in the middle of this type of situation. Take, for example, the 2am observation  round. Understandable fears that patient deterioration may go unnoticed under the cover of darkness have prompted some hospitals to insist that all patients – irrespective of previous condition – must have their observations checked at 2am. Patients themselves, meanwhile, woken from much-needed slumber in the middle of the night simply so that the nurses can ascertain that – in the overwhelming majority of cases – there is nothing much wrong with them, react on a scale that ranges from the bemused to the unprintable.

The aggregate ratings policy is largely informed by a document called Rating Providers for quality: a policy worth pursuing? (2013), commissioned by the government from the Nuffield Trust. Chapter 6 lists numerous sources of data which could potentially feed into an aggregate rating. Information on many of them (for example serious untoward incidents, delays in transfers of care, complaints, staffing levels) would have to be provided wholly or partly by nurses. Jeremy Hunt has – famously – vowed to cut paperwork in the NHS by one third. While most nurses would welcome this, achieving it against a background of increased surveillance, inspection, ratings and performance indicators seems like a big ask.

Insofar as it is possible to generalise about what hospitalised patients want from nurses, we are probably on fairly safe ground in assuming that they want them to be visible and responsive to patient need. Anything which distracts nurses from these core activities is likely to elicit a negative reaction from service users. Rating Providers for quality explicitly states that the aim of the ratings system is ‘to aid choice by users (their relatives and carers), and by commissioners of publicly-funded care (mainly NHS primary care trusts and the new NHS clinical commissioning groups, and local authorities)’ (p 65). On the other hand, ‘For users, ratings may be more useful for choosing providers that offer relatively simple and more homogeneous services…as compared to more complex care in hospitals’ (p 6). In other words, clinical commissioning groups rather than individuals, are the primary audience.

Additionally, according to Rating Providers for quality ‘a rating per se may not necessarily be able to spot serious failures in the quality of care, particularly in hospitals’ (p 85) and ‘Where choice [of health care provider] did not exist…ratings could actually undermine confidence and increase concern about care’ (p 68). What this points to, potentially, is a situation where nurses are pulled away from the bedside (the place patients want them to remain) in order to input data which will be, at best, of unproven benefit to those same patients and could even have the effect of masking poor care. Dissatisfaction with this state of affairs may then be reflected in the results of the Friends and Family Test.

In a polity that values choice almost to the point of fetishism, the fact that people sometimes choose the wrong (ie not politically expedient) thing is always discomfiting. Unfortunately for nurses and other front-line staff, this is precisely the space – between abstract politics and actual patients – where they carry out their daily duties. While it may be the case that ‘(patient) experience and solid reason’ are still ‘the two great pillars of truth’, upholding both of them together is exhausting and stressful. If the edifice they support ever comes crashing down, nurses might like to reflect, as they run for cover, on the title of the book from which this quotation is drawn: ‘Enquiries into Vulgar and Common Errors’.

Department of Health (2013): Patients First and Foremost:The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry. London. The Stationary Office. Available to download at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170701/Patients_First_and_Foremost.pdf

Nuffield Trust (2013): Rating Providers for quality: a policy worth pursuing? London. The Nuffiled Trust. Available to download at:
http://www.nuffieldtrust.org.uk/sites/files/nuffield/130322_rating_providers_for_quality_full_report-final.pdf

Taylor, Roger (2013): God Bless the NHS: The Truth Behind the Current Crisis. London. Faber and Faber.

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