‘Cherry-picking’ health care

Civitas, 19 November 2009

Catching up on health news after getting back on holiday I cannot resist commenting on this two-week old story.  ‘Treatment centres accused of cherry-picking less complicated patients’ scream The Times and the HSJ.  Well, surprise, surprise; as good ammo as it is to bash the independent sector (ignoring the fact that there are also well over 40 NHS-run treatment centres), that was the point of them.

As the DH put it, it was to ‘help meet NHS waiting time reductions and provide more rapid, convenient and improved outpatient and diagnostic services in the community […] diversify service provision and … relieve pressure on mainstream NHS hospitals’.   They were an attempt to ring-fence high throughput elective procedures, such as hip replacements and cataract removals, building on the intuition that ‘the separation of elective surgery from acute services should allow for the more efficient operation of both.’

It seems to make sense doesn’t it?  Here’s an indication of why, from the former President of the Royal College of Surgeons, Bernie Ribeiro, in answer to questions by the health select committee: “On Monday, I had an operating list at Basildon. I had two laparoscopic cholecystectomies and three hernias to do, ideal training operations. I now act more like an assistant to my trainees who do the operating. At two o’clock when we were about to start, a ruptured aortic aneurysm came in. Mine was the only theatre that did not have the patient asleep. My patient was moved into the recovery area where she stayed for three hours until the aneurysm was dealt with. I had to cancel three hernias who went home. That is the day to day reality of working in the NHS.” (Q. 108)

Once a sound evidence-base has been established for particular (largely routine and uncomplicated) procedures, lessons from the world of health care – such as the Shouldice Clinic and the Texas Heart Institute reference in Lord Darzi’s review –suggest it is both more efficient and better clinically, to perform them in high-volume, dedicated centres (as, contrary to the suggestion of The Times, ISTCs seem to be achieving).  So ‘cherry-picking’ ain’t necessarily a bad thing.

What does need to be sorted out – as the researchers behind the report rightly conclude – is payment.  Clearly more complex procedures (often on patients with complicated co-morbidities, with longer lengths of stay) cost more.  This is where attention should be focused.