Which Doctors?

When people are ill they want the best care they can get but of course professionals vary in their interests, skills and expertise. So how do you find out who the local expert is?

People imagine that their GP knows all the local consultants and will send them to ‘just the right person’. This is understandable but mistaken. Firstly there are usually several hundred consultants at any one hospital in Britain – keeping up to date with who does what, let alone who is best at what is impossible for GPs.

But even if you’re GP does happen to know who is best, they then have to manipulate Choose and Book, the new mega system to support ‘choice’ which makes it intentionally hard for GPs to use to refer to a particular named consultant. Intentionally because it’s much easier to manage waiting lists when all referrals for a particular specialty or service come into a single pool. So choice is sacrificed to shorter waiting times.

The NHS has traditionally got round this by saying that all services meet minimum standards so you don’t need to find the best. Recently the lameness of this response has triggered an interest in PROMs – Patient Reported Outcome Measures. If we don’t know who is ‘best’ then we’ll ask you, the patient. So PROMs aim to measure how you felt before an operation and then again some weeks afterwards.

The Darzi report, which is this year’s bible on how the NHS should develop, says that we should use PROMs right across the system in the hope this will help people choose who they want to see. And give a valid answer to the question that managers are also very interested in, namely ‘which of our doctors are good?’ (And, by implication, which are less good).

Trouble is that whilst PROMs are useful they are very far from perfect. To make valid judgements about outcomes you need to have a big enough sample and make sure that inputs – the casemix of people seeing different consultants or teams – is the same. If one team specialises in difficult cases their outcomes will be different to those handling easier cases. And of course you need a reasonable number of cases for each procedure and each surgeon. The danger therefore is that PROMs will just mean many more surveys for patients plus a whole new industry processing the answers and tweaking the answers to try and get a ‘true’ picture.

For our part we think that the emphasis on choice is in some ways – literally – misplaced. The 'choice' policy puts the question at the wrong point in the process. Ill people make poor shoppers, and whilst they most definitely want to be involved and informed in decisions they usually want to be looked after rather than labouring under a mountain of 'choice' decisions. Once patients have experienced a particular service (and hopefully are feeling better) they have very decided views about what they liked and what could have been better. Using these views as a quality driver makes much better sense – and is what we try to do at Patient Opinion.

How to give patients accurate, useful information to help them make better choices is an important question that keeps coming round and round like a bad penny. PROMS, Choose and Book, Information Prescriptions, NHS Unlocked, IWantGreatCare all represent different approaches to this problem. Sadly trying to find who is the ‘best’ doctor for some condition or operation is a simple question that can only ever have frustratingly complex answers.