To improve standards...?

The Sunday Telegraph this week had a front page article and a full editorial on the intention of the Government to pay surgeons, or at least their hospitals, extra according to good performance by the surgeons. I had to check that the date was not 1st April.

The performance relates not only to the operations themselves, but also to everything which determines outcomes. So other medical and non-medical groups are involved, including nurses, physiotherapists and other professional "hands on" staff, and presumably even "back room" and support staff, - pathologists, cleaners, etc. So to talk of surgeons earning the bonuses is a little misleading, even if surgeons lead the teams involved.

Once I had convinced myself that this was indeed serious, my reaction was to be aghast.

Staff are paid appropriately for their professional and caring services, or we hope so. Why pay them more? Is it not something of an insult to suggest to them that they will only give of their best with further inducement?

The temptation which could arise would be to attempt only the more simple and safer procedures, and somehow to "bury" or delay those with greater complexity or risk. It would only be human at least to consider this.

How are the outcomes to be measured? What will be the "trade-offs" between sheer survival, speed of recovery, quality of patient life after discharge, use of resources including staff time, etc.? These can obviously work against each other. It looks as if additional layers of management will re required in hospital and Whitehall to assign categories and values, - more bureaucrats, the fastest growing area in the NHS! If a surgeon delays discharge and in so doing increases mobility or quality of life weeks or months after discharge, will he be penalised?

Sometimes the problem is not to reward excellence but to identify incompetence, and require surgeons to undergo re-training, transfer or removal. Bonuses for good performance will do little to deal with this, except to remove the incompetent to do simple tasks or even non-surgery.

The obvious way to encourage excellence and discourage poor performance would be to supply full information on outcomes to patients, and to give them real choice. The incompetent surgeons would be under-subscribed and exposed, the good ones encouraged in their methods. Many years ago a colleague, who was very much in touch with local council and hospital affairs, said to me "If you ever have to go into xxxxxxx Hospital, whatever you do don't have an operation under Mr. yyyyyyyyyy, - he's butcher and botcher!" I suspect many voted with their feet.

There would be no need for vast armies to make complicated calculations, - merely the provision of information which is already available and ought to be the right of all patients to receive. I suspect that GPs already advise patients, on the basis of their own knowledge, about the various surgeons in the area. Making full information available would put everything on a more reliable basis and enable GP and patient to make informed decisions.