Liverpool activist Greg Dropkin has weighed the claims of the NHS’ RightCare initiative, and found them wanting. (RightCare: wrong answers Journal of Public Health November 2017). RightCare is an NHS England programme that identifies opportunities for savings and quality improvements and describes itself as ‘a proven approach that delivers better patient outcomes’.
Greg Dropkin’s challenges the modelling assumptions made by RightCare (which have that all-to-easy flavour of a corporate consultancy about them), and the misinterpretation of dissimilar outcomes as opportunities for improvement. The difficulties of measuring unwarranted variation are well known, and have been documented by Appleby and others in a 2011 Kings Fund report (Variations in health care: the good, the bad and the inexplicable). Unwarranted variation is a slippery notion, even though it appears to be widespread in clinical practice.
The RightCare approach has advantages for the NHS, giving NHS England, the DoH and the Treasury the results they want – the appearance of better quality care with the impression of lower costs. It contributes to the current magical thinking about NHS finances, well displayed in the November Budget’s allocation of insufficient funding to services under considerable strain. Sadly, Dropkin’s argument is unlikely to dent this magical thinking much, first because the NHS being a centralised hierarchy within which conformity is highly valued, and secondly because the May government is as intransigent about the NHS as it is conflicted in the Brexit negotiations.
Worse, from the public’s point of view, is that faulty RightCare judgements may result in misallocation of resources through the allied CROC (Co-ordinated Reallocation Of Capacity) programme. For example, if the solution to unwarranted variation in cancer outcomes seems to be proton beam therapy (as some specialists and some commercial companies might suggest), the NHS will have to invest in plant and machinery, or buy treatment time in the small but growing network of commercial proton beam treatment centres.
However, if RightCare did not exist we would have to invent it. It attempts to address variations in the five tractable conditions that drive secondary care use (heart disease, hypertension, COPD, CKD and atrial fibrillation), and it is interested in under-use as well as over-use of services. Given that the care pathway standardisations introduced by QOF seem to have only limited impact on clinical outcomes or service use, this makes sense.
An example is RightCare’s Falls and Fragility Fractures Pathway, which defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures. The NHS claims to be working on this, but other priorities have overshadowed falls and fractures, despite their huge cost. The Royal College of Physicians 2010 report Falling Standards, Broken Promises, documents the neglect of this problem. RightCare is right to pick up the problem, and its proposals for a pathway are appropriate and overdue.
The 2011 King’s Fund report recommended changing the focus of initiatives against unwarranted variation from achieving outcomes to fixing care processes (especially shared decision making). This favours pathways, which may be picked up by the Get It Right First Time initiative (GIRFT) as much as by RightCare. (Digression: Why does the NHS have two organisations trying to tackle unwarranted variation? Because they have both evolved from different NHS fiefdoms! The NHS may be centralised but it is not monolithic)
Shared decision-making is a noble enough idea, but in the NHS’s current toxic climate it too can be warped. ‘Choosing Wisely’ is a programme that aims to discourage doctors from using interventions that are not supported by evidence, free from harm and truly necessary. (Malhotra A et al Choosing Wisely in the UK BMJ 2015;350:h2308). The NHS in North West London recently asked the public their views on Choosing Wisely, a scheme which it said was “to help reduce waste”. Its proposals for consideration were: encouraging patients to buy medicines over-the-counter when they could; GPs to avoid prescribing medicines that could be purchased; and patients to collect their own repeat prescriptions rather than let pharmacies collect them. What begins as an attempt to improve the quality of care ends as a means to transfer costs to the user.
An incoming Labour administration should change RightCare without abandoning it. Duplication of effort is usually unhelpful, so RightCare and GIRFT should be merged. The emphasis on outcomes and the optimistic claims of savings must both go, to be replaced by evidence-based pathways that regulators could audit and evaluate. And campaigners could harry those in NHS middle management who try to sneak in service reductions or co-payments as part of a quality improvement drive.
Steve Iliffe, November 2017