Face the facts on closures
Clinical and operational performance information should be made public so changes are not just branded as ‘cuts’
Recently a number of my friends spent their Saturday afternoon marching to save our local accident and emergency. It was in response to a consultation which proposes a series of changes to consolidate specialist and acute services around logical geographies, including that four of the nine A&E departments that cover the two million people in our area should be downgraded to 24/7 urgent care centres.
I was not marching with my friends because I have access to information that the general public does not see. I know, as do most health managers, that however good your hospital, when it comes to specialist emergency care, a good big-un will beat a good little-un.
When I a pulled muscle playing football a few weeks ago and was worried I had a hernia, I went to my local A&E. I was seen swiftly and expertly in the new urgent care facility. They told me to take painkillers and go home. If I had a heart attack or a stroke, I would want to go to one of the local teaching hospitals because I know that their in-hospital mortality for emergency admissions is up to 30 points better than the risk-adjusted national average, whereas my local district general is about on par with the national average. The extra 10 minutes in an ambulance would be worth it.
I know that little nugget of information because when I was a hospital chief executive I used the Dr Foster and CHKS benchmarking systems as well as data produced directly from the NHS Information Centre. When I left the NHS and wanted to continue to license access to these systems, it was impossible due to data protection rules.
If a member of the public googles “in hospital mortality rates for emergency admissions by hospital” they will end up at a complex Information Centre spreadsheet and the phrase: “Data that may potentially identify an individual have been removed (in cells marked by X) from the internet version.” This means they can see that between 2007-08 and 2009-10 39 more patients died in England undergoing a coronary artery bypass graft procedure than was expected, an 8 per cent improvement on the previous period. However, the individual hospital data has been redacted, so you have no basis to understand that not all services are the same.
Similarly, only last year’s A&E waiting time data is on the internet, although it is collected weekly, so the fact one of my local hospitals is routinely in the top two or three highest performers for A&E waits nationally, while others languish in the bottom third of national performers, is not clear to the public.
We therefore find ourselves in the peculiar position of trying to consult the public over complex and controversial decisions, while using only half the arguments that NHS managers and clinicians used to convince themselves.
My friends were marching against “the cuts”. This is a reasonable response, as the consultation document focuses upon the financial pressures the local NHS faces, the further pressures that are to come in the future and the need to do something now to avoid the risk that “some major things will start going very badly wrong”.
It is right that a consultation such as this should confront the public with the cost to the NHS and the need for it to use its staff and resources efficiently, but if we don’t share with the public clinical and operational performance information it is hard to avoid these changes being branded simply as “cuts”.
Clinical outcome variation is one of the great challenges for the NHS, and the reality is that this variation is far more often driven by systemic and structural issues, such as the availability of specialists to provide 24/7 cover, than by failures of individual staff and institutions.
There is a government commitment to “transparency” that would allow the public to hold the public services to account and facilitate a more mature debate about how services should be structured. Dr Foster co-founder Tim Kelsey was appointed into the Cabinet Office to lead this charge. In health the progress has been glacial but the data that has been made available is hard to interpret, out of date or edited to the point to uselessness.
I am delighted Kelsey is now at the Commissioning Board. He has the opportunity to share the performance management data it is using and move the secondary uses service into the public domain in a usable way.
Local health systems also need to share clinical and operational performance data so the public can understand change is not necessarily about disrupting a uniformly safe and stable system to save money, but can be about eliminating variation and improving health.
Matthew Swindells is chair, BCS Health, the Chartered Institute for IT and senior vice president for population health and global strategy, Cerner.