IWantGreatCare - a dangerous currency for quality? Health Policy Today, 14 July 2008

Tom Smith on IWantGreatCare.

The most interesting story on health today – just beating reports that Gordon Brown and Harriet Harman have fallen out over abortion – is the introduction of a new website, www.IWantGreatCare.org.  The idea of the site is for patients to rate doctors and read others’ ratings. It asks patients to answer three questions, by giving ratings from one to 100, about a doctor who has treated them or a relative: 'Do you trust them?', 'Did they listen to you?' and 'Would you recommend them?' They can then post a 'review' of the doctor. The doctor is then given an overall percentage rating.

Looking at the gastroenterologists, not all are listed, and only one has been rated, to the tune of 98%.  It will take time to develop the site, by which time, I guess, there will be more gastroenterologists listed and the one chap who has been rated will likely see his percentage rating fall.

But is this a good or a bad idea?

The website is the brainchild of Neil Bacon, which makes me take it more seriously. Neil created doctors.net, which I would say has transformed the way doctors interact.  It has been a phenomenon.  He not only knows doctors, but trained as a doctor himself - he was a renal specialist.

The Patient’s Association have welcomed the site.  While they may not be representative of all, I tend to be open-minded to patient-orientated initiatives. Spokesperson, Katherine Murphy says, “this information is long overdue”.  “Why shouldn’t patients – taxpayers who fund the NHS – have this information, just as they do research before buying a washing machine?”

One response might be, because this is akin to researching the manner of the washing machine salesman rather than the utility itself.  Of course I understand that in healthcare. the manner and utility are more closely combined.

The questions I’m asking myself are, does this site aim to expose poor doctors? Does it aim to reflect their good practice? Or is it about focusing doctors on core concepts that are important to patients? Is it useful to patients, to the NHS? Is it a useful indicator of quality?

When I met with Neil Bacon last month to discuss the idea, I got the strong sense he meant the site to concentrate doctors on patients.  I warned they would feel threatened and tear up the methodology.

Today’s reaction suggests I was right to warn that doctors’ reactions would not be uniformly positive.  But according to the Daily Mail, Neil Bacon has ‘hit back’ (what else to people do in DailyMailLand?).  He argues that the website will ‘force doctors to listen more to patients, explain themselves better and improve the treatment they provide

Patients have already started to post criticism.  According to the Mail, one wrote: 'I went to see the doctor on behalf of my mother who is schizophrenic. He refused to listen to the issues I needed to discuss and was very, very patronising and arrogant. He actually left me in tears as I left the surgery.'

The most entertaining piece of writing I read today was from regular Pulse contributor, Dr Copperfield (a pseudonym for an Essex GP).  Today he contributes to The Times. He is writing about reasons that GPs sometimes don’t take on patients who ask to be taken on.  He suggests it is nothing to do with “gentleman’s agreements” – Ben Bradshaw – and more to do with the motivations of the applicant.

"Long and bitter experience has taught me to tread carefully when anybody shows up asking to change doctor without moving house. Most of the GPs who work near me are capable and caring, and if one of their patients wants to jump ship my first instinct is to ask them why. More often than not it's because their current GP won't play ball. They won't order a test the patient wants or prescribe a drug the patient needs. They won't fill in an insurance claim form or issue a doctor's note. Almost every time I've fallen for a sob story like that, a few minutes spent reading the medical record has convinced me that the test wasn't needed, the drug wouldn't work, the insurance form was a scam or the patient was fit for work. So it's no surprise that many GPs interview patients before agreeing to accept them, a process that starts as soon as they arrive at the reception desk".

The piece reminds me that we sometimes want doctors to disappoint patients.  We need doctors to advise against expensive treatment that are not needed.  Such patients may well give their GP a very low ‘listened to me’ score.

It must be a good idea for patients to have information about doctors and to help them make important choices in healthcare.   But is this the right unit of analysis – patient perceptions of whether they trust someone? Does it allow people to distinguish between whether they trust someone to be competent at a procedure or whether they trust them as people?

What is ‘trust’ in this context?  Doesn’t it mean different things to different people – a bit like clinical governance?  Are we all talking about the same thing?  Would politicians or managers (also doing difficult jobs) like their fortunes to be based upon the sum total of average ratings from constituents or patients, based on three questions of whether they would be ‘trusted’, ‘listened to’ and would recommend to others?  Would Gordon Brown take that test today?

"It would be of great concern if any doctor was put in jeopardy through a malicious campaign, maybe through viral email, to attack or undermine a doctor at a hospital or GP's practice, which could easily happen." – Richard Vautery, BMA

In my meeting with Neil Bacon I suggested that he might be getting hold of the wrong of the stick and that such a tool might better be supplied to GPs, who could shape the methodology, and learn from their patients about satisfaction rates in hospitals.  I said I thought it could be a commissioning tool to help PBC.

To my mind, that would be a better approach than what the Daily Mail reports, that the scheme is designed for GPs to rate their GP.

It is the application of this tool to primary care worries me the most.  In the absence of more established quality indicators, this data could be used to give a fuller picture than it was designed to produce.  

It is becoming clear that with a policy push on patient information that a range of different groups are working on different kinds of information and methodologies, covering PROMs, outcomes, process tools, such as clinical guidelines, as well as a range of approaches to gathering patient satisfaction rates.

There is a risk that there will be no common currency within different domains.  There is a risk that different groups will afford different weight to different information.

But if the focus on quality is to be effective, we need to have a broad picture of quality and an appreciation of its different dimensions.  It is also critical that we negotiate the information that is going to be used to signal quality – signals which policy says will change commissioning patterns, lead to patients choosing new providers and create a self-perpetuating improvement dynamic.  

Sky News reports that the new website is the only independent source of information in the UK to allow patients to choose a doctor based on the experience and opinion of fellow patients. But it is not the only site – there is another: www.patientopinion.org.uk.  Patient Opinion does not ask patients to rate doctors out of a hundred, it asks them for qualitative information on their consultation or operation.

Perhaps it is more difficult to press release a site that wants to gather a rich picture of health encounters than one which gives a percentage rating of how much a doctor is trusted.