Patient choice in elective care increased emergency readmissionsBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1793 (Published 15 April 2019) Cite this as: BMJ 2019;365:l1793
All rapid responses
To the responses by Dr Ford, a retired GP, and Mr Thomas, a working orthopaedic surgeon, may I add my h’penny’s worth? I have a retrospectoscope going back to1960 - a health service as originally modelled.
In those days, a widowed old lady, troubled by a degenerated hip, living, say, in John O’Groats, who had kin living in Norwich and in Exeter, could request her GP to refer her to the surgeon at the Norfolk and Norwich Hospital or to the Royal Devon and Exeter.
No catchment areas then.
She could be so referred. No nonsense of “money following the patient”.
That was the real patient centred service.
Now? You have a clutter of economists, millions of computers, billions of software.
Instead of a hospital secretary (plus assistant), a Hospital GROUP Secretary with a treasurer, a Regional Hospital Board with one secretary and a few clerks, in the Postgraduate Teaching Hospitals, a House Governor plus Assistant Governor and three clerks, now you have Strategic Authorities and numerous other boards and clinical commissioning groups, etc.
WE DO NOT HAVE ENOUGH MONEY TO TREAT THE PATIENTS, wail the Chief Executives.
Is it any wonder? Blame patient choice.
Competing interests: Patient
This article purports to suggest that an increase in patient choice has caused an increase in the rate of readmissions of patients following joint replacement surgery. The article is based on a paper given by a group of economists to a conference of economists. Unfortunately the article does not contain a link to any conference abstract, but it is possible to find the gist of what was said online. Overall the article is a fairly typical bad news story about orthopaedic surgery.
Choice was first introduced to the NHS for elective orthopaedic surgery by the Thatcher reforms of the early 1990s, not in 2006. Real choice has been available since the 1990s, particularly in large conurbations, but it is significantly constrained in areas with a limited number of providers and it is further constrained by the actions of CCG's and advice given by GPs. There is general inertia by patients, who are no more enthusiastic to change their hospital than change their electricity provider. There is therefore some type of market operating, but in reality only the more active patients are engaged in it, and not a lot has changed since 2006.
It would be quite possible that there has been a problem with quality, and a rise in complications causing readmission, due to tariff deflation. The NHS tariff for joint replacement surgery has been reduced far more drastically than other types of surgery, such as cardiac surgery. This is obviously a reflection of the fact that cardiac surgeons and cardiologists are far more important people than orthopaedic surgeons. I think that this simple explanation of budget cuts causing poor quality is likely to be incorrect. In our hospital we have certainly become more efficient due to a focus on issues such as theatre downtime and we have also made further reductions to length of stay, but there has been absolutely no compromise on quality, we have a very active programme of quality improvement.
It is quite possible that reducing lengths of stay down to 1 to 2 days for joint replacement surgery has resulted in a small increase in readmissions, however most of our patients benefit greatly from reductions in length of stay. Short stays tend to be popular with patients and their families, and there is no evidence that they are associated overall with increased complication rates.
Another factor which has changed in recent years is the approach to possibly infected wounds. A few years ago an infected wound might be treated with oral antibiotics as an outpatient but now a much more active approach is taken with investigation using ultrasound, wound washouts and IV antibiotics. This results in the readmission of a small percentage of patients, but it is an indicator of improving quality and safety, not a decline.
The economists would have done well to study the revision rates of total joint replacements over the past 10 years which show a relentless year-on-year improvement in revision rates. These improvements have occurred both as a result of changes in surgical technique but, probably more importantly, as a result of the efforts of our anaesthetic colleagues and as a result of preoperative optimisation by well organised multidisciplinary teams.
Competing interests: No competing interests
Healthcare, correctly delivered, is not and never can be a commercial undertaking. This is a fundamental, self evident and incontestable truth that politicians seem unable to grasp - or worse, they blithely deny as they toe the ideological line. Neoliberalism has drawn us into an amoral, asocial, seedy barbarianism from which recovery will be difficult but healthcare professionals can lead.
The only choice to be made in any clinical circumstance is, or should be, guided by such reliable evidence as is available - which should include the many risks inherent in profit driven provision, especially the potential conflicts of interest and perverse incentives.
The concept of a market in healthcare, conforming to the prevailing neoliberal theology, is fatally flawed because the 'rational agent' upon whom the entire theoretical economic 'castle in the air' is founded, does not exist. The rational agent is assumed to take account of available information, probabilities of events, and potential costs and benefits in determining preferences, and to act consistently in choosing the self-determined best choice of action. Such patients are rarae aves.
The notion of rational agent's choice is further vitiated by the circumstances in which choices have to be made when illness, injury, suffering or the apprehension of death cloud judgement.
Competing interests: No competing interests