In 1859, Florence Nightingale created the world’s first performance tables of hospitals. The school histories tend to miss this part out, but the Victorian reformer’s best work was conducted far away from the battlefields of the Crimea. Florence Nightingale was the architect of the modern British (arguably European) hospital – and, most importantly, the means of measuring its performance.
“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm,” she wrote in Notes on Hospitals. Nightingale demonstrated that high death rates, which were invariable then in large hospitals, were preventable.
Until very recently, the pioneering idea that a hospital (or for that matter the medical profession more generally) should be accountable to its end-user was largely ignored. Odd pockets of academic research kept alive the idea that health services were capable of – and should be subject to – comparison. Without scrutiny, there is little prospect of invariable quality.
In many respects it seems that the current British government is extremely determined in its health service reforms, built as they are around a very clear commitment to public accountability. But the British health service consumer has become more sceptical of the integrity of official publication and more demanding of independent, authoritative information on performance.
Earlier this year, an independent inquiry into the high level of deaths of children following complex heart surgery at the Bristol Royal Infirmary marked a turning point. It called resoundingly for better information to be published by independent authorities.
Dr Foster (named after one of the UK’s best-known nursery rhymes), was set up to meet this growing public demand. It is an independent organisation and a private company, supported by the Department of Health, and professional and patient organisations. It provides authoritative information about the services and standards of hospitals and other healthcare providers in the UK and Ireland.
It works with leading academics in the United Kingdom (including Sir Brian Jarman, one of Britain’s most famous general practitioners and medical professors) to develop indicators that are useful to the public in making the most of their health service.
It publishes health service guides – the Hospital Guide, the Birth Guide, the Consultant Guide, the Family Doctor Guide and so on – to the widest possible audience in partnership with media owners.
National and local newspapers publish extracts from these guides as special supplements. The guides are published as books and on the Internet and soon they will be available as pamphlets at supermarkets. It is a high-profile initiative that has proved that comparative performance information can be published and in a way that is meaningful to the ordinary user.
The first guide on hospitals is a good example of how Dr Foster works. It allows patients to evaluate the quality of care in hospitals, right down to specific care services. For now it covers acute services in general hospitals, but comparative guides of mental health, maternity care, nursing homes and primary care are under preparation. Patients can locate the hospital of their choice and read about it. The aim is to give a fair evaluation. For instance, it points out that one hospital has staffing shortages, but is nonetheless efficient for its treatment of stroke patients.
Not everybody has regarded the existence of independent benchmarks as a good thing for the National Health Service. On one occasion, confronted in a room by eight or nine civil servants, I was told that the NHS did not want to “wash its dirty linen in public” and “there are some things that should be dealt with internally”.
But the real opinion formers take a very different view. A number have joined the Ethics Committee which oversees the publication of the Dr Foster guides. They include Sir Donald Irvine, president of the General Medical Council. Another former member, Sir George Alberti, president of the Royal College of Physicians, has compared the current information revolution confronting the British health service to that faced by the medieval clergy when the Bible was first translated into English.
People should welcome, rather than run away from, accountability, which has the power to improve services and foster trust between doctor and patient. Measuring hospitals is in everybody’s best interests.
When Dr Foster started, our attention was drawn to the decade-old publication of surgeon-specific data in heart surgery in New York State – and the fact that this had driven mortality rates down by over 40% in some hospitals. “Doctors and hospitals did not like to look bad compared to their peer colleagues of [other] institutions,” says Arthur Levin, director of the Center for Medical Consumers in the US. That seems an unarguable benefit – that publishing performance information can so effectively improve standards.
Creating independent indicators is one part of a process which also needs to recognise the importance of educating consumers to understand them. Dr Foster spends much of its time experimenting with different media to make these indicators accessible to people – and relevant.
We have discovered that very few people are aware of their rights in selecting their healthcare provider. We have also discovered that when people are made aware of them, they use them. A good example followed the publication of our Birth Guide in the summer of 2001. In a very discernable way, women in late-stage pregnancy moved from one acute hospital (which was identified as under-staffed) to local midwife-led birth units. The acute unit is now very focused on improving its staffing situation.
The Dr Foster data clearly supports the view that there is unacceptable variation in hospital and other health service standards in the UK. Helping consumers to make more informed choices is one good way (possibly the best) of eradicating these deficiencies. People are not stupid and neither doctors nor governments have the right to treat them as such.
What the data also shows is that the British health service is increasingly effective at its job – adjusted mortality rates have been falling year on year by 2.5%. But, for now, the public perception is wholly on the varying standards between healthcare providers. Finding a way of making sure they understand the good news as well as the bad is a political imperative. British health ministers have always supported the Dr Foster project because they see it as complementary to their own initiatives on involving the public more in the health service. They publish management-focused indicators; ours are patient-focused.
There are good ways in which the private and public sectors can work together to improve healthcare delivery. This is one. Dr Foster has already been approached by a number of OECD governments to investigate the possibility of exporting the model overseas.
People often ask me about the impact of empowering patients with comparative information. Give people better information and they will use it. Does this mean they will all start moving house to be near the best performing hospitals, or doctors? That didn’t happen in America. It hasn’t happened so far in the UK. In fact, the onus is not on the patient, but the service, to improve. All that does happen is that weaker-performing hospitals get better. Individual consumers learn to be more demanding of their local hospitals – and everybody benefits. Florence Nightingale would probably have approved too.
©OECD Observer No 229, November 2001