Published: 24/07/2003, Volume II3, No. 5865 Page 20 21
The BMA's new president talks about how the NHS is becoming more responsive to patient needs
Professor Sir Brian Jarman, the new president of the British Medical Association, is a living embodiment of the contradictions within UK healthcare.
Consider, for example, the following statements from his interview with HSJ. First: 'The NHS is a pretty magnificent institution.
Doctors are really lucky to be in a set-up that lets them do their job.
In many countries, including the US, that is very difficult.'
Second: 'The great thing [about the US] is you're speaking directly to the clinicians and the managers who are going to make difference.
In the UK, you get stuck in the NHS treacle.'
It is not that Sir Brian's thinking is confused - a ridiculous proposition to apply to a man whose work has created clarity about a wide range of highly complex healthcare issues. It is simply an illustration of how that work sits at the centre of the NHS's greatest tension - how a monolithic, national system can be made responsive to patients.
In the late 1980s, as part of a group calculating the resource allocation for primary care, Sir Brian was given access to data that showed some hospitals had death rates significantly above that expected.
By 1991, he had compiled enough information to consider publication. 'Luckily I didn't', he says, claiming that not rushing into print allowed him to talk to enough fellow clinicians to understand the true value of the data.
Then in January 1999, Sir Brian was appointed as the only medical doctor on the 70-strong Bristol Royal Infirmary inquiry team.
'I felt particularly uncomfortable working on the inquiry, because I had a lot of information about the quality [of hospital] services - which showed that [in some trusts] there were hundreds more deaths than you would have expected, ' he says.
Bristol was far from the worst.
Sir Brian felt impelled to publish. There was only one problem, all those given access to the data had been required to sign the Official Secrets Act.
A white knight arrived in the unlikely shape of a former news editor from The Sunday Times, busy establishing his new health information business (HSJ interview, pages 20-21, 28 November 2002).
Dr Foster chief executive Tim Kelsey engineered a meeting with senior government adviser Simon Stevens - now the prime minister's adviser on health policy.
'I told him, ' Sir Brian says, 'that the Department of Health publishes large amounts of hospital data and quite often they put a little note saying 'these figures are unadjusted' - meaning, ignore everything above.Could I publish something that said 'this is adjusted, please take notice'?'
Some string-pulling later and Sir Brian's seminal paper, Explaining differences in English hospital death rates using routinely collected data, was published in the British Medical Journal in 1999.
The BMA president now says it is essential that patients are given the information they need to make informed choices.
'[Members of] public should have a right to know that if they drive another hour along the motorway with their child who has a congenital heart problem, they could get a death rate for open heart surgery which is a quarter of what it was at the place they were [originally] going to.'
He says he is committed to 'depoliticising' the debate around healthcare data and believes that 'worthwhile, accurate data' is the key to transforming the NHS.
'On the way here, I was in a taxi with a GP, who is professional executive committee chair.
'He was worried about the amount of day-case surgery being done in his hospital trust, but he said they could not get the trust to give them the data and did not have the resources to find it themselves.'
Although Sir Brian's work on death rates has often been criticised as not properly reflecting the complexity of healthcare, he is unrepentant. 'You mustn't flood people with data, ' he says.
'I prefer a small number of accurate, worthwhile bits of information which people trust and can compare one year to another.'
Sir Brian hopes that in the future data can be analysed, and the relevant findings identified, much more quickly. This, he says, will make it much easier to identify where problems are developing and therefore to tackle them quickly - saving money and lives.
Confident that outcome and process measures are becoming more robust, he would also like to see a further set of indicators gauging the impact of NHS structure.
Working with the Institute of Healthcare Improvement in the US, Sir Brian has calculated hospital standardised mortality ratios for a large number of institutions.
These revealed the huge variations he had already found in the UK.
However, he says the response has been 'dramatically different', with hospital doctors and managers moving quickly from denial and hostility to creating plans and setting targets to improve performance.
As suggested above, Sir Brian believes this is mainly because it is much easier to engage with those on the front line.
He says the NHS has a set-up that is 'fundamentally correct and fair.'
He also praises the increase in resources being delivered by the government. But he feels progress is being hampered because 'clinicians do not have the independence to get on with making a difference.
'There is always the temptation to fund an interesting bit of management consultancy on some sideline issue. We have already got enough knowledge to know the direction we want to go.'
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