"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Thursday, 2 June 2011


I was looking for some evidence about healthcare commissioning in the US and as a consequence re-read the evidence given to the Health Select Committee last November. The following is interesting because it addresses the issue of whether competition or choice will raise quality:

Professor Gwyn Bevan: There are systematic reviews in the United States for putting information out on a hospital's performance. They consistently find that people do not switch from poor to high-performing hospitals. One of the paradoxes about the New York study where they issued data on risk-adjusted mortality rates for cardiac surgery is that patients continued to go to hospitals with high mortality rates. But by publishing the information, the hospitals got better. The most famous case is Bill Clinton, who had his quadruple bypass in a hospital that the information said at the time was one of the two worst outliers in the whole of New York State he could have gone to. 
What Prof Bevan is saying here is that publishing hospital performance, even poor results, will not affect the number patients using the hospital. Patients presumably see themselves as individuals rather than part of an aggregated statistic. Bill Clinton used the hospital he did because he thought that the performance data would not include him. Isn't that what we all think? The interesting part is that publishing the performance data improved the hospital because hospital management were effectively shamed into doing so. They do think in terms of aggregated figures: the hospital's reputation.

The government's faith is that competition and choice will raise standards, whereas it seems that choice will not do that.


  1. I am sorry if I have missed the point, but if the hospital 'got better', has that not raised the standard. I accept that choice did not play a part, publishing the data did.
    The other possibility of course is that the figures were, how shall I put this, managed?

  2. Hmm.

    I agree with the other poster that this post conflates information transparency and choice.

    The issue I have with complaints about choice is that it doesn't stop to consider the opposite: no choice. Ask one of the surviving relatives of a patient who was treated at MidStaffs if it is right that they should have no choice but to use MidStaffs for their own treatment, and I suspect the answer will not be polite. Similarly, ask the poor sodding patients in various parts of the country who are stuck with a GP practice that is so poor they have to queue up if they're ill on a Monday morning, whether they think it's OK that they have no choice but to use that service because other local practices have closed their lists, and you'll get the same short shrift.

    Choice is not a panacea, by any means. But lack of choice is not great either.

  3. You both misunderstand. People want to go to their local hospital, when given the choice, they still go to their local hospital.

    The Competitions and Co-operation [sic] Panel published a report that showed the same thing (except they spun it otherwise). The CCP showed a graph of patients using Thurrock hospital before, during and after the bad press a couple of years ago. The before and after figures were the same, but there was a dip during the couple of months when the media were effectively telling people not to go there. All other figures: MRSA, C-diff, HSMR etc were available during the entire period, so their influence was clearly minor in patients' choice.

    As to MidStaffs, well let's wait for the Francis Report to be published before making a conclusion about care there, but it has to be said that patients did have a choice of NHS hospital from 2006 (when the issues are reported to have happened) yet patients did not exercise that right and go somewhere else: they still used it even though (according to some) the place was supposed to be a charnel house. (Before you say, where else would they go? Well after the scandal arose, Stafford Hospital stopped treating stroke and heart attacks, so patients could not choose to go to Stafford for those conditions and had to go else where. Hence there were suitable alternatives nearby.)

    The point I was making was that the improvement came from professional pride. By shaming the hospital with their poor figures they made the changes to improve. (In the case of Thurrock, the Press shaming the hospital had the same effect.) The decision of patients did not do this.

    Anonymous#2 talking about GP choice is an entirely different situation.