1. MANAGING MEDICAL PERFORMANCE Mark Exworthy 21 May 2008

2. Outline Professional performance Clinical performance Disclosure of clinical performance data Current ESRC project St George’s Hospital Theoretical perspectives – Micro, meso and macro levels

3. Professional performance Professional resistance: – External accountability – Systemising work – Managerial control Minimalist strategy: – Notion of equality of competence – Only peer review permissible New frontiers of control? – From internal to external, implicit to explicit Performance = test of professional power

4. Professional performance is about power TraditionallyIncreasingly Who sets standards of `acceptable’ performance? Individual doctorsMedical profession Who monitors these standards? Medical peersExternal agents (eg. Healthcare Commission) Who takes remedial action, if required? Local medical peersExternal agents

5. Clinical performance issues Attribution Cause /effect relationship Unit of analysis Anonymity Choice of performance measure Input / output / outcome Audience Multiple audiences Purpose QI / managerial / regulatory Incentives: rewards and penalties Voluntary / compulsory? Case-mix / severity / risk?

6. Factors prompting disclosure of clinical performance 1.Patient `revolt’ – Consumerism in health-care; `expert patient’ 2.Media reporting of scandals – Bristol RI, Shipman, Neale, Ledward, Alder Hey etc 3.Freedom of information – 2000 Act applicable in UK since 2005 4.Modernisation of welfare – Challenge to established professions 5.Changing professionalism – Evidence-based medicine – Professional re-stratification – Re-professionalisation 6.International policy networks – Policy transfer

7. History of attempts to publish surgical outcome data in England Health Secretary promises to publish hospital death rates for individual cardiac surgeons by 2004. Deadline missed. Guardian newspaper uses Freedom of Information Act to gain and publish results – data variable and sometimes raw Healthcare Commission requires all hospitals doing heart surgery to publish risk adjusted data on death rates for individual surgeons. 17 units provide data on individual surgeons – 13 units only provide aggregate data – 3 fail to provide any data by deadline. Healthcare Commission website publishes results for units Rate of survival said to be well above expected range – overall survival 96.6% - expected range 93.7% to 94.5% 2002 2006 2007

8. NHS surgery success rates to be made public John Carvel, Guardian Tuesday 28 August 2007 A radical overhaul of NHS strategy which will give patients a right to know the success rates of every specialist unit in every hospital is being planned by leading surgeons and government officials. For the first time, patients will be allowed to compare the quality of the clinical care provided in each NHS department. People with a particular medical condition will be able to assess the quality of the relevant specialist teams at rival NHS hospitals before choosing where to go for treatment. In some specialties, results for individual surgeons may be available.

10. Mortality at St George's http://www.stgeorges.nhs.uk/mortalityindex.asp “At the time of writing we are the first hospital in the UK to publish inpatient death rates by clinical specialty. This means that if you are a patient, relative, or member of the public, you can see how we have been performing in different clinical areas. Included is a careful explanation of how the graphs are worked out, how we adjust for risk-factors, and important caveats about what this information should not be used for. As a leading centre in cardiac surgery, we also collect and analyse very detailed information about our performance in this area. This section of the site contains 'raw' and risk adjusted mortality rates for individual surgeons, as well as information about post- operative quality.”

11. Risk adjusted mortality for Coronary Bypass Graft (CABG) - Individual Surgeons - (01.04.2002 - 31.03.2005)

12. Risk adjusted mortality data for Thoracic Surgery (October 2002 - March 2007)

13. Complications following all operations and coronary artery bypass graft (CABG) All cases2002/032003/042004/05Total Balloon Pump 2.7%1.6%2.3%2.2% Re-sternotomy for bleeding 3.6%3.8%2.8%3.4% Re-suturing for infection 1.3%1.4%1.9%1.5% Laparotomy 0.5%0.4%0.3%0.4% Tracheostomy 1.7%1.4% 1.5% Stroke 2.3%2.0%1.0%1.8% Haemofiltration 4.0%2.8%3.6%3.5%

14. International experience Sweden – National quality registries, mainly since 2000 Australia – Public hospital report, announced 2008 Germany – Hospital reports, since 2005 USA – Report scorecards. Eg. New York from `89

16. Pennsylvania: cardiac surgery, 2005 http://www.phc4.org/reports/cabg/05/docs/cabg2005report.pdf

17. Pennsylvania: cardiac surgery, 2005 http://www.phc4.org/reports/cabg/05/docs/cabg2005report.pdf

18. Disclosure of clinical performance data Extant evidence suggests... Limited use of published performance data Data are often crude, ambiguous, difficult to interpret Published data are available to managers / external agents previously Reasons for disclosure are complex and overlap: – Perception of transparency Avoids potential intrusive surveillance later – Reputation (Patient Choice policy)

19. Project: Managing Medical Performance: a pilot study to investigate the impact of surgical performance upon clinicians and managers Team: Dr. Mark Exworthy (PI; RHUL) Prof. Jon Gabe (RHUL) Prof. Ian Rees Jones (Bangor University) Dr. Glenn Smith (RHUL, from 1 July 2008) Time: 1 year, 2008-2009 Funding: ESRC Public Services Programme (3 rd call) www.publicservices.ac.uk

21. Managing medical performance Research questions 1.To investigate the inter-connections between theoretical perspectives in terms of the motives, meanings and impacts of competing notions of performance upon cardiac surgeons, other clinicians, hospital managers, regulators and policy-makers. 2.To conduct an empirical investigation of the motives, meanings and impacts of (published) performance data upon cardiac surgeons, other clinicians, institutional managers and external regulators and policy-makers, so as to inform a wider study of medical performance and governance.

22. Managing medical performance: multi-level analysis Micro-level: – Inter-professional relations – Socialisation of surgeons Meso-level: – Use of data by managers – Impact on organisational culture Macro-level: – Impact of / on regulatory regime of performance disclosure

23. Theoretical perspectives Micro-level Soft governance – Complete control impossible – Rigid exterior with loosely coupled practices – Senior professionals Key organisational role but possess weak external powers Senior professionals play role in legitimation Re-stratification – Not de-professionalisation but re-professionalisation – Disclosure promotes admin elite interest vis-a-vis rank-and-file professional

24. Theoretical perspectives Meso-level Panoptic surveillance – External gaze at internal practices – `Calculating selves’ – Control at a distance Structural interests – Do managers challenge or collude with professionals? – Is there a challenge to medical power (eg. questioning merits of surgery)?

25. Theoretical perspectives Macro-level Regulation – Self-regulation under threat? – Role of the GMC and Healthcare Commission State-profession `contract’ – Re-alignment between state and profession relationship – How far is the profession itself changing? Role of Royal Colleges & professional bodies