Muir Gray: Competition between systems for pride 2.0

Muir Gray I was born in the Borough of Partick and a couple of weeks ago watched Partick Thistle, or “Partick Thistle Nil” as they are affectionately called, for the first time for fifty years. Little had changed, with the exception of the availability of a “skinny” mutton pie on the half time menu. The competition, versus Hamilton Accies, was intense. The players committed, and the supporters were loyal.

Competition between teams for pride, could have been the title of my BMJ blog that led to many useful comments, particularly from Professor Greener. Here is my response:

  1. I stand by my original proposition that competition between systems for pride is effective and essential.
  2. The criticism that the system just had one outcome and that this made it easy for the private sector to cherry pick is explained by the need to be brief. In fact the system, like all screening programmes, had a set of objectives, reproduced below, relating to process as well as outcome:
  • To identify and invite eligible women for mammographic screening.
  • To carry out mammography in a high proportion of those who were invited.
  • To provide services that are acceptable to those who receive them.
  • To follow up all women referred for further investigations.
  • To minimise the adverse effects of screening – anxiety, radiation, and unnecessary investigations.
  • To diagnose cancers accurately.
  • To support and carry out research.
  • To make effective and efficient use of resources for the benefit of the whole population.
  • To enable those working in the programme to develop their skills and find fulfillment in their work.
  • To encourage the provision of effective acceptable treatment which has minimal psychological or functional side-effects.
  • To evaluate the service regularly and provide feedback to the population served.

Every system, whether it is for pelvic pain or frail elderly people must have a set of not more than ten objectives. These are simple to set. A group of clinicians and patient representatives can do it in less than three hours ; here is a set developed by just such a group for epilepsy

  • To diagnose epilepsy quickly and accurately.
  • To treat effectively and with minimal side effects.
  • To help the child and their family to adjust to the diagnosis and to minimise handicap.
  • To ensure that the child with epilepsy and other problems receive prompt and comprehensive assessment.
  • To involve children and their families, both individually and collectively, in disease management.
  • To promote research.
  • To develop all the professionals and practitioners involved in epilepsy care.
  • To make the best use of resources for the whole population.
  • To produce an annual report for the population served.

For each objective one or more criteria must be chosen to measure progress or the lack of it. Thus each system can produce a standardised annual report for accountability enabling the questions posed at the top of the first blog to be answered, namely

  • Is care for people with rheumatoid disease better in Liverpool or Manchester?
  • Is care for frail elderly people better in Somerset or Devon?
  • Which big city has the best service for people with bi-polar disorder?
  1. Accountability is a key issue but I am less interested in local, “democratic” accountability than to accountability to the population of people served. For example the epilepsy society could be the recipient of all the annual reports of the thirty or so seizure and epilepsy systems and Age UK could receive the 200 or so reports of systems for frail elderly people.
  2. The “competition” word was thought to be misleading but I was not calling for these integrated systems to be called a market or a competition; they would simply be called, to make up two examples, “The Liverpool, Mersey and Cheshire Epilepsy Service” and its neighbour “The Great Manchester Epilepsy Service;” can you imagine that not leading to competition for pride?
  3. In the interests of  brevity I did not stress the fact that I believe that this approach would have many benefits for clinicians; doing better makes people feel better. Physician burn out, or the flame burning low if not out, is one of the major problems we face.

Muir Gray is director, Better Value Healthcare