To laugh or cry about 'iGP' proposals? Health Policy Today 12th March 2009.

Guest contributor James Gubb, director of the health unit at Civitas (www.civitas.org.uk/nhs), reflects on the new proposals for publishing public feedback on NHS services

The dangers of 'iGP'
I’m not sure whether to laugh or cry at the Government’s latest gimmick in public service reform: government-sponsored websites on which people can rate their school, GP practice or nanny.

Postponing the tricky 'laugh / cry' dilemma for now, I will instead settle for outlining four points specific to healthcare:

1.   There are already websites that perform such a function. The government-sponsored NHS Choices is one, but there are others, such as Patient Opinion and IWantGreatCare.  Web 2.0, as the former editor of the BMJ, Richard Smith, has passionately argued does, indeed, offer the potential to revolutionise and democratise healthcare.  Patient-owned health records and Smith’s own Cases Journal are two such examples.

However, as the founder of Patient Opinion has argued, Web 2.0 must be managed and used effectively to be - well, effective.  

Research suggests, unsurprisingly, that people are more likely to invest their trust in a site if it is independent and has transparent values and motivations. What’s more, such trust has to be earned – it is this trust that sites such as iTunes and Amazon have paid great attention to building and nurturing. They know that without it, their business is nothing.

The Government do not face the same incentives, and – particularly given the target culture over which New Labour has presided – people are, rightly or wrongly, likely to perceive government-sponsored sites of such nature to be subject to spin.

"Ministers apparently see Web 2.0 as a convenient tool by which to bash ‘unresponsive’ GPs rather than as a useful feedback mechanism to improve patient care."

Ben Bradshaw’s accompanying comments in an interview for the Sunday Telegraph that GPs ‘could be forced out of the NHS if they do not adhere to rules which say they should offer their patients a choice of where to go for hospital care’ are not exactly a sign of promise.

Ministers apparently see Web 2.0 as a convenient tool by which to bash ‘unresponsive’ GPs rather than as a useful feedback mechanism to improve patient care.

2. Using healthcare, as the Cabinet Office report acknowledges, is not simply the same as buying music or books.  Yet despite this acknowledgement, the report simply says: ‘the same principle of valuing the opinions and views of others applies in the decisions we make around our health and care as well’.

Well, yes, but that doesn’t mean that simply trying to imitate or replicate Amazon, TripAdvisor or iTunes in the field of healthcare will work - at least, not without the due care and attention described above. Healthcare is extremely complicated, and has profound asymmetries of information between providers and users.

As such, it’s unlikely that consumerism can ever reign as it does in other sectors.  And this is to say nothing of the desirability of greater consumerism.

Patient experience, though vital, can never be all: most of top UK serial killer Harold Shipman’s practice patients thought he was one of the most caring doctors around. Even once Shipaman was convicted and In prison, many fellow inmates preferred to seek advice from him than from the prison doctors and medics.

This is an extreme example, but we must forever remember that medicine is both an interpersonal and a biomedical discipline.

As the respected doctor, philosopher and cultural critic Raymond Tallis has astutely pointed out, a breakdown in communication lies at the heart of the consultation between patient and doctor. A patient’s thinking about an illness will typically start long before they see their doctor. They will, internally or externally, have developed an idea of their symptoms, and an idea of which of them they think are relevant.

Crucially, the doctor is a late entrant to this conversation and will have a mass of stories and evidence-bases about illness, their mechanisms and presentations him/herself.  The doctor may well, on this basis, need to discard some things the patient sees as important; upgrade others the patient doesn’t; and ask questions the patient may not like along the way.

Of course some doctors will be better than others at such communication, and it is vitally important in medicine, linked to many positive outcomes.

However, the facts remain that:
A. For all the modern mantra of patients as partners in care, sometimes doctors will have to tell patients things they won’t want to hear. This could become particularly acute with the invasion into medicine of the ‘sick note’ - sorry, 'well note' culture around return to work ... though of course, that was planned before the economy tanked.
B. The process often weighs more in a patients’ judgement of care than the outcome.
In opening up to Web 2.0, we have to be very careful.  Without proper checks, we risk opening doctors – who work day-in, day-out in on the margins of knowledge, and with a burden of responsibility we cannot know – to unfounded slander.

"If the Government ultimately intend to link performance and pay based on such feedback, we should be very, very concerned."

3.    For the future, there seems to be an implicit link drawn in the Cabinet Office document between performance on such websites and pay (‘..at the same time payment to hospitals for services is being linked to patient-reported experiences and outcomes as one way of driving improved quality and patient-focus across the NHS’).

If the Government ultimately intend to link performance and pay based on such feedback, we should be very, very concerned.  

For one, there is a risk that such websites essentially become a means for complaint rather than praise, which, as described above, may or may not be representative of standards of care.  Satisfied customers – unless prompted – are much less likely to actively express their satisfaction than dissatisfied ones are likely to complain; and, what’s more, the inclination to complain is likely to be dependent on many socio-economic characteristics independent of healthcare.

This is important.  As it is, the jury is still out on whether financial incentives are an effective means to lever improvement in quality of care (a literature review by the Health Foundation’s QQUIP team, for example, found that the ‘effect of payer initiatives that reward providers for quality improvements or the attainment of quality benchmarks to be mixed’ with ‘relatively few significant impacts reported’).

However, what the literature does say is that to have a positive effect, pay-for-performance must be carefully designed, implemented and evaluated; and whatever outcome that is incentivised must be closely linked to the actions of those receiving the incentive payment (i.e. there are few independent variables).

Without this, any introduction of pay-for-performance would be inequitable and morale-sapping, because they risk both false-positive and false-negative signals of actual quality.  Gaming would be inevitable, and thus trust - the cornerstone of good medicine - could go out the window for good.

What markets do, and why
On a related note, if the government thinks such payments –and, indeed, such websites – will help the transition to a more market-based NHS, they are also wrong.  Markets work by consumers voting with their feet and businesses innovating to attract them; not by some external party (i.e. the government) deciding who and on what basis extra income should be garnered.

4.  A wider point about the Government’s ideas around quality improvement.  The government persists in pursuing all these grand ‘quality initiatives’ because they undoubtedly believe this will ultimately drive the NHS to achieve better outcomes for patients.  Specific to this topic, Web 2.0 surely can offer huge opportunities for more personalised care - which in turn, offers very real opportunities for better healthcare and health.

"Quality improvement is a messy, complex, and dynamic process: a function of external stimuli, but also many internal challenges – structural, cultural, educational, political, emotional and technological – not least of which is to divine the processes by and through which all these fit together."

However, quality improvement is not simply a function of individuals and organisations that need buttons pressed and levers pulled to deliver optimal performance. Quality improvement is a messy, complex, and dynamic process: a function of external stimuli, but also many internal challenges – structural, cultural, educational, political, emotional and technological – not least of which is to divine the processes by and through which all these fit together.

Crucially, both technologically-driven quality initiatives (such as this one) and external stimuli are only likely to work if those on the ground know how to use it and it is perceived as useful and important.  Quality improvement, as Paul Bate and colleagues have argued, is ‘simultaneously as much, if not more, a question of value orientation and outlook than one of scientific method ... We should perhaps be spending more time developing professional and corporate commitment than directly trying to improve quality: programmes or projects quickly run out of energy; being professional is a lifelong vocation and the very fuel of giving service’.

So is this latest initiative is going to work?  Why, of course!