(below is the full text of an open letter from THE LANCET to Ian Kennedy, Chair of the newly established UK healthcare commission).
On July 21, 2004, the UK's Healthcare Commission--a new independent inspectorate chaired by the lawyer and ethicist, Ian Kennedy--published its annual performance ratings of National Health Service (NHS) Trusts in England. Although the commission concluded that "the NHS is improving", the newsworthy message was that there had been notable slippages in the star ratings of several hospitals, among them Addenbrooke's Hospital in Cambridge. The headline in The Times, for example, ran: "Elite hospitals shamed by loss of 3-star status". Kennedy defended his star system. In The Guardian that day, he wrote, "star ratings have been useful. They are a wake-up call to the health service". Here, The Lancet publishes an open letter to Kennedy.
Dear Ian,
The star ratings that you published and defended last week are having a damaging effect on the health service you and I care about. Worse still, they are likely to undermine public confidence in a health system that enjoys an unparalleled commitment from its doctors, nurses, and allied health workers. I wonder if you fully appreciate the harm that your commission is causing.
Let me quote from a letter sent to reassure demoralised staff at one hospital that not only lost a star but also had its clinical care rated as "poor". They are horrified at the damage your report has caused to their community's confidence in the hospital. Did your evaluation reflect accurately the hospital's achievements? Here is what the chief executive wrote:
"[We] met seven of the nine key targets, including shorter inpatient and outpatient waiting times, two week maximum wait for all cancers, commitment to improving the working lives of staff, and hospital cleanliness...star ratings are based on last year's information. During that year, we have made significant improvements but this information takes time to filter through". The local newspaper for the hospital's catchment area headlined your commission's rating in this way: "'Worrying' practices exposed at hospital".
Do you believe that the public humiliation your commission has inflicted on this hospital will improve the quality of care that patients receive? How can you, when the very basis for your judgment is so evidently weak? For I question your commission's work and your defence of it on grounds of science.
Where, for example, is the transparency surrounding your precise methods of measurement? Where is the attempt to review systematically the work of all those employed by the hospital or primary care trust you are evaluating? Where is the estimation of your own measurement error? Where is the effort to investigate success outside of your narrowly drawn targets to give a properly balanced picture of an institution's work? Where is the qualitative information to add to the reductive numerical approach that you currently endorse? Your report answers none of these questions.
Why is there this utter failure of scientific rigour? For an answer, one has to look no further than the make up of your commission. Only two of your 14 commissioners have daily front-line responsibilities for patient care. It is hard to respect your commission's judgments when you have a board with such limited ongoing clinical service experience.
Indeed, your commission's dubious methods are creating a culture of waste, deception, and fear among NHS staff. Those within hospitals and primary-care trusts who are responsible for submitting data to your commission spend enormous amounts of time on these bureaucratic exercises, time that would be better spent improving the quality of services. The perverse incentives your commission has introduced encourage manipulation of figures to meet targets that may bear little relation to local priorities. And the power that you wield has inculcated an environment of prejudice, anxiety, and resignation into the workplace.
As a consequence, your commission is publishing evaluations that are obscure, unrepresentative, unreproducible, unaccountable, anti-scientific, misinformed, tendentious, and unjustified. In a word, they are untrustworthy. You say that your system of performance measurement will change. But not until after 2005. And then not in ways that will resolve concerns about its fairness or validity. It is, and it will remain, a star chamber and not a star system that you preside over. I know that, as a lawyer, you must understand the reality of this injustice only too well. End it, and end it now before your Healthcare Commission does irreparable harm to already overstretched individuals and the services they deliver with diligence and pride every day.
Yours sincerely,
Richard Horton
The Lancet, London NW1 7BY, UK
Contact: The Lancet Press Office 44-207-424-4949/4249; pressoffice@lancet.com
Journal
The Lancet