David Oliver: The media narrative on quality in healthcare—helpful or harmful?

david_oliverOn 28 October, I was part of a Health Foundation and Nuffield Trust “Quality Watch” panel, speaking on the media representation of quality in healthcare. Truth be told, I had been on call for four straight days, then that morning my ward doctor had gone off sick, and it had been touch and go as to whether I could get into London at all. I felt guilty that my preparation consisted of hastily scribbled notes on the train; although, as my wife pointed out, this is a subject I have spent much time thinking and speaking about.

As well as writing my own various columns and blogs, I confess to being a news media junkie. I have BBC Radio 5 and 4 and TV news on non-stop, and tend to read two or three newspapers every day. I also keep an eye on local TV and newspaper reports and the “trade” press, such as The BMJ and Health Service Journal. Stories about health and social care, policy, and related ethical and legal dilemmas always pique my interest—and there are a lot of them.

As we head towards the 2015 general election, we have learnt that “the NHS” is the biggest concern mentioned by voters, so prepare for more reportage, much of it driven by political parties and ideologues with an axe to grind—by talking services up or down, by pushing or trashing market delivered solutions, by acknowledging or denying the effect of the funding gap or recent “reforms.”

So before the debate, I had plenty of material to think about. As fellow panellists pointed out, newspapers are an industry in serious decline. There are notable exceptions, such as the Daily Mail—the world’s most read English language newspaper—with editor in chief Paul Dacre named 13th most influential person in the NHS by the Health Service Journal. The BBC is also big enough to be bomb proof. But by and large, there is big pressure in a contracting industry to publish whatever sells and generates online hits. They are there to generate custom and interest, not to be apologist or PR for the NHS or its clinicians. Inevitably and understandably, this skews the content and style of reporting away from emphases that those working in or leading health services might prefer to see.

So what kind of stories do they tend to cover and how? The first group are features on wellbeing and health: how to stay healthy, live a longer life, keep the weight off, or spot early signs of cancer or dementia. So long as the information is accurate, this is a great function and one we shouldn’t knock. Beyond this, we know that “Freddie Starr ate my hamster” is old hat, but “My hamster ate Freddie Star” sells papers. Keep a log of national news media for a month or so and you will see what appears. I guarantee you, most of it is in these categories:

• Cutting edge technology (near Sci-Fi)—eg, hand transplants, cloning, or genetic engineering.
• Miracle cures for formerly fatal diseases.
• Survival against all odds (eg, stranded mountaineers amputating their own limbs with pen knifes).
• People being denied potentially lifesaving treatment (especially for cancer—always an attention grabber) because of “rationing.”
• Fertility and treatment for it.
• Wicked ethical dilemmas eg, around end of life care—including assisted suicide and “right to die” cases.
• “Wasteful” spending on salaries, pensions, and payoffs for executives.
• Child abuse and neglect—especially serial failures to protect vulnerable children.
• Much the same applies to the care of learning disabled adults.
• Most of all, though, it’s scandal that sells. Notably around the care of vulnerable older people—referred to, self defeatingly, as “the elderly.” Serial “exposés” have focused on poor or neglectful care in nursing homes, or in hospitals, or by poorly paid home care staff. This isn’t surprising, the stories are shocking and make us fear for ourselves or our own older relatives should we require care. And many readers have seen these issues at first hand. We shouldn’t seek to defend the indefensible when it happens.
• When studying for my maths A level, our teacher’s favourite book was How to lie with statistics, which was all about how the same numbers could be spun in several ways and thus manipulate opinion. Nick Black, one of the debate panel, highlighted the misuse of numbers to exaggerate excess mortality figures in hospitals and to whip up more scandal—especially when the methodology itself is open to question, never mind the spin.

Those members of our panel who came from a journalism or communications background cautioned against snobbery towards mass circulation outlets, such as the Daily Mail, firstly because of its reach and influence, and also because the readers are ordinary voters and service users—so it’s not too “patient centred” to disparage them. They also argued that if we want to provide balance or correct misinformation, we have to engage with the journalists. Most reporters I have helped have been fair and honest. However, there have been occasions where any medic trying to provide balance would be shot down in flames. This was apparent in the Mail’s campaign to stop the Liverpool Care Pathway (LCP) for dying patients. Columnist Melanie Phillips aggressively and publicly slapped down clinicians who wrote in trying to rebalance the story.

The issue of the LCP was a prime example of how media coverage can cause real problems in frontline service, and harm care and public confidence. At least once a year, a similar piece of scandal and scaremongering means that frontline staff have to spend a lot of contact time with patients and families combating misinformation and bogeymen.

I would like to finish by thinking about what aspects of quality the media don’t tend to cover. There is remarkably little coverage of outcomes, such as survival rates; of serious gaps in the provision of treatments that can deliver those outcomes (as exposed by national clinical audits or reports from the National Confidential Enquiry into Patient Outcomes and Death); of huge unwarranted variation (for instance, in rates of hospital admission or care home placement); of inefficiencies at the interface between services (eg, delayed transfers of care or people defaulting into hospital beds because of social care funding cuts). Social care itself receives far less attention than the NHS, and local government cuts have been under-reported. These are all things to get legitimately steamed up about, but they get little air time.

There is also remarkably little on delivering constructive solutions or on celebrating service models that can deliver them. There is plenty of good news from people leading innovative services around the country—despite austerity and reorganisation. These are well covered in local newspapers, which often celebrate their local NHS, and in the professional press, such as Nursing Times or HSJ, but it seems that with the odd exception, such as Camilla Cavendish’s work on the role of healthcare assistants, solutions don’t sell. Take a look at the coverage around poor “basic nursing care” and solutions don’t go far beyond “bringing back matron,” “accountability,” and “stop degree level nursing”—completely unhelpful “golden age thinking” and deeply flawed.

Finally, as someone who is part of the health policy “commentariat” and clinical leadership community, I am struck by the mismatch between some of the zeitgeisty groupthink in those echelons and the priorities in the news media. Everyone is talking about “asset based approaches,” “developing community resilience,” “prevention,” “integration,” “care closer to home” with “new models outside hospital,” “supported self care,” “personalisation,” “activist patients,” “personal budgets,” and “person held records.” All this magic thinking comes from a select group of self styled innovators and thinkers, and a small empowered group of largely middle class, educated service users. I am not saying any of these priorities are wrong, but it’s like a small policy elite is trying to dictate to the wider public what its priorities ought to be.

Out there in the press and the opinion polls, the public still use and want the reassuring old fashioned terms of “doctor” and “patient.” They still have confidence in buildings (their local hospital or GP surgery) and basically want the care from those organisations to be caring, responsive, and accessible. The media haven’t caught up with the zeitgeist and neither have the public. But who’s to say they are wrong?

David Oliver is the president of the British Geriatrics Society, a consultant geriatrician at the Royal Berkshire Hospital, and a senior visiting fellow at the King’s Fund.

Competing interests: None declared.