Friday, 19 July 2013

Bad arguments about healthcare: if you can't stop them, at least give as good as you get

Marc de La Val had built an enviable reputation for complex cadio-thoracic operations on babies, at Great Ormond Street Hospital, the most prestigious children’s hospital in Britain. But then things started to go wrong. 

The always fascinating David Spiegelhalter, Professor of the Public Understanding of Risk at the University of Cambridge, recently told the BBC what happened:

‘A cluster of his babies died when he was doing these really difficult operations for transpositions of great arteries, and then he actually wrote a paper about how he stopped and retrained and changed the way he did the operation, and after that he was very successful, but he had this real blip, this real cluster of failures, and he nearly gave up...’

Spiegelhalter: well worth listening to

Spielgelhalter maintains that it was careful analysis of the data that showed that de Laval hadn’t just been unlucky, that there really did seem to be something going wrong with his surgeries, something he had to fix.

That was one surgeon. Outstanding, a practitioner to seek out, then dangerous, a surgeon to avoid, and then outstanding again.

And no doubt many of the other surgeons at GOSH were achieving excellent results, even at that time. When de Laval was struggling, the department might well have been fine overall. It was only he who was having bad outcomes.

But sometimes it isn’t just individuals. Whole departments can be in trouble. I worked at one time with the Bristol Royal Infirmary, when there were terrible problems in paediatric cardiac surgery that led to a major scandal and the closure of the department; but much of the rest of the hospital was performing more than adequately.

In fact, I’ve spent 30 years working with healthcare information, and if it’s taught me anything, it’s that there’s no such thing as good or bad hospitals; there are often good or bad departments in hospitals; more often still, there are good or bad practitioners within departments within hospitals; and as de Laval’s case shows, there can be good and bad moments in the career of an individual surgeon within a department within a hospital.

So I look on with wry displeasure when I see yet another scandal about bad hospitals in England. A report has just been published into fourteen hospitals that were giving cause for concern. It had been extensively leaked before publication, and we were softened up for hearing of 13,000 avoidable deaths across the 14; we were told that heads would have to roll.

In fact, the report was much more intelligent than that. It identified failings and errors that needed correcting, but it pointed out that these hospitals were already correcting many of them. In addition, the heads that could be made to roll were in many cases new people in post for a relatively short time, brought in to put right what had gone wrong under predecessors who had resigned or been forced out.

But that didn’t stop Jeremy Hunt, the Health Secretary, making a real meal of the report – and, in particular, using it as a stick to beat his opposite number, Andy Burnham. He’s an unusual opposition spokesman, Burnham, in that he had been Health Secretary at the end of the previous government: most shadow ministers can’t be attacked for their own track record in the post, because they don’t have one. Burnham can.

And Hunt went for the gullet. The problems at these hospitals had arisen under the previous government and so they were Burnham’s responsibility. He should take the blame, resign his position and slink off into obscurity.

Burnham fortunately wasn’t having any of it. For instance, in connection with one of the hospitals, Basildon and Thurrock, he pointed out it was one ‘on which I placed a warning before the last Election. The news that this hospital has cut 345 nursing job from its front-line workforce should be greeted with real alarm.’

In other words, the present government has had three years to fix the problem. Instead it’s pursued policies that have led to serious cuts in staffing levels. That’s likely to have made the problem far worse.

Hard to see how Burnham’s to blame.

These exchanges do prove one thing, though. However inappropriate it may be to try to judge the quality of an entire hospital, it’s a brilliant way of turning healthcare into a political football between the major parties. And there are serious electoral points to be made from doing so.

Moreover, the attitude that says that heads have to roll is likely to be particularly out of place, as de Laval’s story shows. Sometimes, the people responsible for poor performance are actually excellent practitioners, they’re as devastated as anyone over the failures, and they only need the opportunity to improve again. But calling for retribution is much more effective with voters.

So it’ll go on happening. The mere fact that the argument is based on flawed premises doesn
t make it less effective politically. Which means the recriminations will go on being hurled.

Pretty miserable stuff. Which leaves me with only one consolation: at least Burnham gave as good as he got.

Not before time. 
This is a government that specialises in handing out low blows, few lower than trying to blame problems it’s failed to address on a man who's been out of office for three years. It was good to see him hitting back. 

It’s been one-way traffic for far too long.

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