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July 21, 2014

Private Eye 1370
Filed under: Private Eye — Dr. Phil @ 5:58 pm

Rate my as a doctor, but don’t blame me for a service in crisis

Health secretary Jeremy Hunt’s plan to name and shame GPs who fail to spot cancer by placing a red flag next to their practice on the NHS website has been rightly slammed. However, MD is strongly in favour of patients and relatives rating their NHS care, and encourages his to do so. There is good evidence that people who have a good experience of NHS care, and feel listened to and included in decisions about their care, get better results. Putting this information in the public domain provides important feedback to the NHS and individual staff, and guides patients where to go to find kind, competent care.

Publishing patient experience information in real time, as many hospitals are starting to do, is a good smoke alarm to step in and stop poor care before too much harm is done, and a great was of praising excellent care. Some sites such as Patient Opinion allow you to have a conversation with a willing GP practice or hospital and try and sort out problems. In some instances, this has happened commendably quickly. On the website MD uses, every word a patient or carer writes is published unedited. Doctors aren’t in the business of always giving patients what they want, and occasional patients are vexatious. But the overwhelming majority provide honest feedback on their experience of care and what could be done to improve it. If all the NHS did was listen and act on this feedback, it would improve the service far more than any political reform.

One problem with Hunt’s plan is that politicians and NHS bureaucrats are simply not trusted to provide accurate fair ratings in the same way patients are. Wrongly flagging up a practice as providing substandard cancer diagnosis could have serious psychological and legal consequences. And for the few doctors who are making fundamental errors that would fail your medical finals, a regulator should have stepped in to support and retrain them long before a red flag appears on a website.

The main reason MD gets such positive ratings in the care of young people with chronic fatigue syndrome, is that I have 90 minute consultations. Difficult diagnoses cannot be done in 10 minutes. GPs are under ridiculous pressure to manage demand and be competent in ridiculously short consultations, and patients are having to wait dangerously long times for specialist referrals, and increasingly having the referral refused. Young people with serious mental health problems are currently being denied access to the specialist care they need. Some Child and Adolescent Mental Health Services (CAMHS) are in meltdown, many staff have gone off sick and those that remain have to ‘choose’ between a child who has been self-harming for a year and a child who has been self-harming for a week. The latter may respond best to treatment, the former will be absolutely desperate. The one who doesn’t get seen gets bounced back to the GP, who has to pick up the pieces.

One of the reasons I stopped general practice is I just don’t find it safe. There is huge pressure not to refer because of the financial difficulties of the NHS, and an increasing number of referrals are refused. So to be publicly outed for not investigating sooner could lead to a huge increase in hospital referrals, and yet more refusals. One in three patients will at some stage get cancer, just as one in three will get diabetes, one in three will die with dementia and 1 in 4 currently have a mental health problem. There are all sorts of delays in the diagnoses of many of these diseases, but no evidence that blaming GPs on the brink of a breakdown will improve the care that patients get. On the IWGC website, the vast majority of ratings for NHS staff are very positive. Some staff dislike the idea of a commercial organisation collecting and publishing this information, others feel it is more likely to be accurate than letting the NHS do it, with its history of IT errors, gaming and cover-ups. I certainly wouldn’t trust any data Jeremy Hunt fed to the Daily Mail. For transparency and accountability to work in the NHS, staff have to believe in it.

Cardiac surgeons have put outcome data in the public domain for years. Surgeon Ben Bridgwater’s University Hospital of South Manchester web page shows his photo, his qualifications, his CV, his cardiac surgery and activity results, the national results for cardiac surgery, advice on how to interpret the graphs, what patients think about him, and how this patient experience information is measured. In specialties when there are clear outcomes and fair comparative measures, others should follow suit. General practice is murkier because it’s about managing uncertainty under pressure, and trying to have a sense of what might be the more serious diagnosis that needs urgent referral amongst the day’s 50 consultations. The NICE website publishes clear criteria about which symptoms and signs should qualify for an urgent two week cancer referral. The Macmillan website clearly describes suspected cancer symptoms. Diagnosis is an imperfect science, and 15% turn out not to be wrong. Patients should ask ‘What else could it be? How would I know? And what should I do if symptoms don’t improve or persist?’ If you get another opinion, you might be very surprised how different it is. And far more useful than waiting two years for a red flag to appear on the website.