Power corrupts. So do government targets.

I get Medscape news sent to my inbox; a lot of it is news of trials and so forth, but some of it is news-news: what people did, to whom. Since Medscape’s an American site, the news is American too.

It really is a different world over there.

Yesterday’s inbox gave me the story of Farid Fata, the American oncologist who gave hundreds of patients chemotherapy unnecessarily. He did it not because he enjoyed watching people suffer, or just liked to kill people (Dr Shipman, I’m thinking of you), but for the money.

In America, unlike the UK, doctors like Dr Fata get paid more, the more treatments they give, because it’s paid for by insurance companies. This has a predictable effect on healthcare efficiency, as demonstrated by efficiency rankings. Whichever ranking you pick, the US is generally somewhere near the bottom of the list. The UK, on the other hand, comes consistently somewhere near the top.

This is unsurprising when the US system encourages doctors to give more and more treatments to the same patients, as doctors are paid for giving treatments, not for making people well. On the other hand, in the UK system, as the state is footing the bill, there is a scrutiny of every penny, and examination of every waiting list. Woe betide the doctor who is more expensive, or has longer waiting lists, than his colleagues.

Hooray for the NHS.

However, all is not rainbows and unicorns over this side of the pond either. America has Dr Fata. We have Stafford.

At Mid-Staffordshire Hospital, in Stafford, the final report after a major healthcare scandal found that a focus on finance and meeting government targets, rather than on quality healthcare, resulted in the deaths of probably between 400 and 1200 patients over several years. (It was a bit more complicated than that, but the drive to meet government targets was a major part.)

The trouble with government targets like “patients must wait no more than 4 hours to be seen in A&E” is that when making real, useful differences is difficult, easy solutions present themselves. For example, if the clock doesn’t start ticking until after the patient enters A&E… just stop them coming in. Make the patients wait outside until you’re ready for them. Problem solved.

There are many inventive ways in which managers – particularly those whose experience and training is administrative rather than clinical – can come up with to meet government targets while simultaneously compromising the quality of healthcare to the point that patients start to die. This is not usually (I hope) because they just like people to suffer (whether staff or patients), but often because they are concentrating completely on meet the target and they don’t know, and don’t think to find out, what effect their schemes have on the real business of the hospital – which is making people better.

In a similar vein to Stafford, we had Bristol, where children more children died after heart surgery than should have. This was down to, among other things, an ‘Old Boys’ Network’ between the doctors: we’re all mates together and we don’t criticise each other, and we do things the way we always have.

The link between these three is that people are people. Doctors (and other healthcare professionals, although it’s doctors that generally get the headlines) and senior managers are human. Like everyone else, they have the tendency to do what’s easy, not what’s right.

In the case of the American system, doctors are put the way of temptation every single day – just order another test; what does it matter? Who’ll know? And the money will add up.

In the case of Stafford (and other places who were exactly the same but just didn’t get found out), it’s easier to just fudge the figures or satisfy the targets the easy way. After all, the government isn’t interested in excuses or reasons. All they’re interested in is did you meet the target? If you do, they’ll get off your back. Making real improvements can sometimes involve major changes that are difficult to organise – or even impossible without more funding, which the government will not provide.

In the case of Bristol, it’s classroom peer pressure writ large. Instead of being about having the right trainers, or the right phone (nowadays, I suppose), it’s about not challenging your colleague who is using a surgical technique last used in 1850, because he hasn’t done any CPD since he graduated from university. It’s easier not to get in his face, easier to just let it slide, not rock the boat. Someone else will notice and do something, surely. Maybe he’ll figure it out on his own and up his game…

It takes effort to turn away from the easy road (of making pots of money by giving patients treatments they don’t need, or of satisfying government targets by compromising care, or by letting your colleagues’ substandard practices slide because you don’t want to rock the boat).

The only way we will stop these health scandals that seem to hit the headlines every couple of years is if the right thing is also the easy thing. If it doesn’t pay to treat patient unnecessarily, or if the government’s attitude isn’t We know it’s impossible to improve services without more money. Do it anyway.

But I don’t hold out much hope of that. So what will be the next scandal, I wonder?


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