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Referrals by numbers: consultant league tables

What are the criteria you apply when you refer a patient for a surgical opinion and possible operation? How much of your decision is based on evidence, and how much on ‘gut feeling’?

The likelihood is that, as an informed professional, you base your consultant referral decisions on judgments that include a bit of both: some quantifiable data (e.g. waiting times, lengths of stay, readmission rates etc) with a number of ‘softer’ measures about the consultants concerned (such as how nice they are to patients, whether you get on with them, your kids go to the same school, and so on) and about the patients being referred (will they get on with the surgeon, how far will the relatives need to drive to visit, whom do patients actually want to see, and suchlike).

What you are unlikely to do is base your decision on any one of these factors on their own; the social skills of a doctor are important in diagnosing and treating patients effectively, but are not enough to predict good results. Similarly, any single technical measure is too reductive to be of much use; it is too linear in the same way that the price of a computer is too linear. In the case of the latter, I need to know more about the size, computing power, display, operating system, and software (to mention but five factors) before I can make any kind of informed decision.

Thus, I would suggest that new ‘league tables’ such as the National Vascular Registry are just as unhelpful on their own, because missing out on most of those other markers of complexity makes them impossible to interpret on their own: their bald figures give little if any sense of context. If Prof X in London has a higher mortality rate in his surgery than Miss Y in Leeds, is that because he is a worse surgeon, takes on more risky patients, works with less able junior doctors, or has recently had a messy divorce? Is she a better surgeon, or does she only do a few simpler procedures that are intrinsically less dangerous? On their own, the figures don’t tell us any of this.

And even if the figures do reflect the quality of the surgery itself, it is worth remembering that surgical statistics, like all statistics, deal in probabilities, not in certainties; using Miss Y’s figures tells us what happened in the past, but her future results can only be inferred from them. For that reason, one needs to challenge how much weight to give them against issues such as distance of treatment from home, hospital ‘hotel’ facilities, and other extrinsic factors that may influence the whole patient experience, to say nothing of the intrinsic factors such as age, gender, social situation and co-morbidities.

As professionals who spend their whole working careers dealing in ‘soft’ variables like these, GPs are better placed than most to make the appropriate interpretations; patients, whose experience is limited to events in their individual lives, and perhaps those of a few family and friends, are less well prepared. That being the case, how useful is it to publish such information in the public domain, politically incorrect as it may be to suggest such a thing? Publishing the surgeons’ ratings in the Daily Mail is probably the least desirable outcome of all.

In other areas of consumption where consumers are not experts, there are often guides produced to help them make more informed choices; thus for example, the Consumer Association will list the criteria they use in assessing the quality of any particular product, and even make explicit the weightings they give each one; they will (to mixed effect, it has to be said) try to contextualise their findings, so that any reasonably bright but uninformed reader can gain a more ‘three dimensional’ view of the product, and make reasonable, logical, and effective choices. Alternatively, shoppers can follow the ‘Apple Store’ route and go to a reputable shop, where the assistants are trained to offer advice and informed guidance to the customers (although this is usually biased towards making a sale….).

Whatever the ‘purchase’, the messages are the same; in areas of complexity, simplistic measures are not helpful, and may indeed be perverse. Expert knowledge is required, which may be learned by the dedicated consumer, or offered by a guide, that may be written, or embodied in a good sales rep, or an objective, informed ‘care manager’. In health terms, that person is (or should be) the GP, with a good working knowledge of the medicine, the local NHS Trusts and their consultants, and an ongoing understanding of patients’ context and needs (preferably both physical and social/psychological). It is the GPs who should be the main customers for the ratings, not the red top daily papers.