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Friday, 23 November, 2001, 12:43 GMT
Should hospitals be ranked?
A national newspaper has published a league table of hospitals based on how many patients die after under-going surgery to have coronary artery bypass grafts fitted.

The Department of Health is also soon to publish more data on a range of hospital performance indicators.

Proponents say that this information is valuable to patients, who can clearly see which hospital is performing the best, and to surgeons, who can use the data to argue for more facilities and support.

However, the National Heart Director Dr Roger Boyle has warned that placing too much emphasis on death rates could back-fire. He fears doctors will simply refuse to take on tough operations with a higher degree of risk associated.

Are performance tables a way to drive up standards? Or do they force doctors to look out for their best interests ahead of those of the patient?

This debate is now closed. Read a selection of your comments below.

Your reaction

I wonder, were the Doctors, nurses etc asked what their opinions were?

Rob Morris, UK
There has been a lot of stupidity about the NHS over recent years, starting with the Conservatives and now with Labour. Personally, I think to publicise league tables for hospitals is wrong as it panics the general public unnecessarily. There should be internal league tables as that is a matter for the Govt and the relevant hospitals. I wonder, were the Doctors, nurses etc asked what their opinions were? Or was this another business objective brought about by Hospital managers who know nothing about the medical service? If it was, why can't they leave the NHS in the hands of people who know how it works?
Rob Morris, UK

Forget the NHS tables, - there are bigger problems out there. Germany has too many qualified doctors, - the UK has an acute shortage. Why? Ask the BMA and the Government. Junior Doctors and nurses are working too many hours in intolerable conditions for very little money. Why? You can have a hernia and be placed on a waiting list by a NHS consultant which is over a year long, and yet the same consultant will do it for you privately with 2 days. Why? Ask the BMA and the Government. I think there is a cosy little club going on between the Government and the BMA, and this has been going on since the NHS foundation. It needs one hell of a shake up.
Anthony, England

Just as selective schools can avoid low ability pupils entering and so maintain their high league table positions, will we see surgeons being reluctant to operate on old, frail or weak patients in order to avoid producing poor mortality statistics?
Helen, UK

Why do health services think they are the only people in the world who should not be judged as to whether they do a proper job? This isn't about blame, but about finding out who does well, and who doesn't, so that the best practices of the good ones can be spread to the rest, and any who are really not up to it can be moved to where they don't actually do harm.

Those who object, just remember that almost certainly one day everyone needs health services, so when you find yourself on that operating table about to slip under the anaesthetic, would you want to know that everything had been done to make sure the man with the scalpel above you was as good as possible, or would you want to think that he could be a butcher with a 90% mortality rate who had only kept his job because of lack of monitoring.
Bernard, UK

Statistics and league tables are a dangerous tool in the hands of the intellectually challenged

John, UK
Statistics and league tables are a dangerous tool in the hands of the intellectually challenged. The other day I heard an MP, no less, say "I want us to be in a position very soon where ALL hospitals achieve above average results!" It makes you wonder, doesn't it?
John, UK

As Head of Communications for the hospital with the highest mortality rate I would like to make the following comments.

Data on performance should be published and we should have more of them, but it must be produced in a way that people can understand and make judgements about relative risk. In fact the difference between the best and worst performers is very small.

In the case of cardiac bypass we also need to make sure that all the risks of patients are taken into account so that true comparisons can be drawn between units. In this way people will be able to make judgements and surgeons will not be pushed, however unwillingly, into not taking a risk on behalf of their patients.

The surgical teams at the Walsgrave Hospital have been collecting data for over seven years with a continuous improvement in their mortality rates. They know and can explain why the results are as they are and it is not due to poor surgeons, lack of resources or poor team work, but the high level of very high risk emergency patients which they treated in the past. Their latest figures are as good as any in the country.

People need to see more than one set of information to make a judgement and also need a responsible media to help explain what these figures mean. There has to be a start and it is perhaps inevitable that in the beginning simple questions to complex problems are asked. I hope over time the media and in turn the people gain a much clearer understanding of what these figures mean for patients. Only then will releasing the information be of real use.
John Richardson, UK

We're consumers and we want a choice.

Roger Morton, UK
When you're buying a car, you check out the Which or J.D.Power reports on reliability, running-costs, performance, value-for-money. And as a consumer of health-services, I think I should have the right to be able to consult the performance-figures of the various hospitals before I decide which one I want to go to. Anything is better than the current "know your place and be thankful for what you've got" attitude that seems to pervade the health-services at present. We're consumers and we want a choice.
Roger Morton, UK

The US already has an informal private ranking system. It only lists the best hospitals in a field. This holds two advantages: 1) Honours those hospitals doing well 2) Creates incentives for the rest to catch up without destroying its reputation or morale.
Naveen, USA/India

Statistics are useless - if you have a hospital in an area of elderly people, their stats are going to be worse than in a younger area. Stats prove nothing and will only further undermine people's confidence in the NHS. If the resources spent on providing useless stats were spent on improving "underachieving" hospitals, we wouldn't have a need for a ranking system.
Sandra, UK

The release of these figures is government spin to try to switch the blame from them to surgeons

Andy, England
The release of these figures is government spin to try to switch the blame from them to surgeons. Having waited 3 years for a bypass operation the biggest factor in you living or dying is how long you have to wait before the operation - something that the government are not capable or willing to address. The unfairness of some areas having to wait twice the times of others is shameful and any caring government would do something about this. So do not listen to the spin. The quality of surgery is a small factor in whether or not people survive.

When I was waiting for my operation I wrote to the Minister and asked how many people where dying while waiting for operations. He refused to give me the figures. I would guess it would be ten times the number who die after the operation.
Andy, England

I wonder what rating the hospital up the road from me in Manchester would be rated at, since they failed to diagnose someone with cancer in nearly every part of his body. I think we should have ratings, at least then you would know what sort of service to expect. Personally though, I would like to see a 20-40 a month reduction in my NI contributions so that I could pay for private medical cover and know I was getting a good service.
Neil, UK

If I am rushed to hospital I have no choice as to hospital, consultant or treatment

Barry P, England
When I use a supermarket, motorcar or telephone company I have a choice as to which service provider I use. If I am rushed to hospital I have no choice as to hospital, consultant or treatment. By all means have means of measuring the efficiency of sections of the NHS, but it only makes sense if the standard of MY hospital is brought up to the highest level, otherwise the vast administrative effort involved is just more wasted taxpayers money.
Barry P, England

It is clear to all but the brown noses, that all the activities of the Medical profession do more harm than good. A group that has to surround itself with security guards so as to force upon the patients its arrogant disregard of their wishes, because they have been fired up with false teachings, should be prevented from conducting their rotten business.
David de Vere Webb, England

If this information is not openly published it will still leak out, and we'll go back to a culture of rumours and quiet accusations. It has always been the case that some hospitals were thought to be safer than others, just as it has always been the case that some schools were reputed to be better than others, but it would be better to have objective facts to judge this on than unsubstantiated claims.
Jon Livesey, USA

In an emergency you can't choose what hospital you are taken too. Yes there needs to be internal investigations to check upon quality of service but do we really need to worry people and lower the morale of the staff in the lower scoring hospitals which may be down there for a whole host of issues that could not be avoided, for example a hospital may serve a population which is generally more over weight than the average and this may cause deaths which may not occur in other areas.
Andrew C, England

Comparing like with like would be fair. However, this is not what is being done. There is no even playing field. Crafty hospital managers will introduce policies where they ensure 'risk taking' by medical staff is reduced to a minimum e.g. screening out those with a poor prognosis in favour of those with a good prognosis.
Janice, England

There are 3 types of lies: lies, damn lies and statistics. Obviously, a hospital which has a survival rate of 98% will have double the mortality of one with a survival rate of 99%. I suspect Prof Jarman has a hidden agenda. He has to justify the huge costs in compiling the data, and is under pressure to come up with some 'damning statistic'
Roger Evans, UK

A doctors or nurses job is principally to get the government re-elected and league tables reflect this
Chris, UK

Given the fact that we live in a democratic world, not making these investigations would be questionable

Peter, Finland
Performance tables can largely improve the quality of service. On the other hand, it might backfire, enraging the doctors and leading to mishaps and decreased quality. This seems a two-folded question. Firstly, the characteristics of the nation, in this case Great Britain, should be considered. As an example Finnish people are easily depressed and here the practice would have some negative effects. Secondly, the patients' best should be considered, and this promotes the performance measuring procedure. Given the fact that we live in a democratic world, not making these investigations would be questionable.
Peter, Finland

Peter from Finland states "Performance tables can largely improve the quality of service." We have had league tables for schools in the UK for a while, but this has not led to a rise in standards. What is has led to is a widening gap between schools with very good results and schools with very bad results, and the phenomenon of house prices in catchment areas for "good" schools rising rapidly.

I fear that if hospital league tables are introduced we shall see a similar effect in health as we have seen in education. Also, school league tables do not take into account the ability of the children when they enter the school, and are thus useless. Will hospital league tables take into account how ill (or close to death) incoming patients are?
Steve Hodgson, UK

Imagine the costs, and the waiting time in the best rated hospital

Vijay Rajanala, USA
Imagine the costs, and the waiting time in the best rated hospital. And we might as well close the worst rated ones because all the patients who were supposed to go to those ones, will now be spooked and will go to the better rated ones. And since he/she may still not survive, the ratings of the better rated hospitals will fall down eventually and become the worse rated and become a prime candidate for closing down!!!
Vijay Rajanala, USA

You can only compare things when situations are the same. Some hospitals serve very different patient groups from others and, unless you make sure all patients are "equal" before surgery, you can't compare them afterwards...simple mathematics really!!
Sue, UK

Hospitals should be ranked, though the information should not be made available to the general public. We need to have some way of monitoring the performance of hospitals, but only the people that can make a difference to this must know. I see no point in naming and shaming certain under-performing hospitals, this will cause more trouble than it is worth. We need to address why certain hospitals are doing better than others and take appropriate action.
Will Faulkner, Hale, Cheshire, UK

League tables are completely unacceptable. Medicine is not a sport, people have to stop trying to judge every action a doctor takes. I for one am ashamed at the way the public treats its doctors, yes mistakes are made, and yes we should try and stop these mistakes, but the manipulation of the health service by politicians and the media to try and achieve political goals has gone on long enough.
It is unrealistic to expect a consultant seeing patients solidly from 9am to 6pm 5 or 6 days a week, to never make a mistake. We need to give health staff a substantial rise in pay, as they are all heavily underpaid, considering the importance of their jobs. Maybe if we do this and leave the blame culture behind we can get somewhere.
Michael, London, England

See also:

12 Nov 01 | Health
Steps to speed bypass surgery
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