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Editorial Friday 4 January 2013: The Politician's Syllogism and healthcare quality

Happy new year to all Health Policy Insight readers: best wishes for 2013.

We return from our festive shenanigans to the latest phase in Project Francis Is Coming: Look Busy!, in the shape of the announcement that the Friends And Family Test is to have a PR push.


Click here for details of 'Francis is coming. Look busy!', the new issue of subscription-based Health Policy Intelligence.


As well as the previously-announced roll-out of F&F into hospitals as of 1 April, "the Prime Minister wants that to go further, with GP surgeries, district nursing and community hospitals all adopting the measure".

This will of course resolve all problems with care quality in the NHS.


Erm ... no, probably not.

This is not to say that measuring patient experience is not worthwhile. The valuable work of the Picker Institute and other individuals and organisations who promote the often-overlooked patient voice, play important parts in the overall mix of assuring and improving quality.

No, the problem is that the evidence base for adopting the F&F test (with the consequent financial and opportunity costs) is, to put it mildly, a bit scant.

This review by Picker, commissioned by the Care Quality Commission, says it is asking the wrong questions.

So does Andrew Lansley's shrewd former special adviser Bill Morgan, now back in his old berth at leading comms agency MHP Health Mandate, and blogging here about the issue.

F&F is based on the 'net promoter index', and this research suggests that its limitations are not minor. The irrepressible Roy Lilley gives F&F a good kicking here in his latest blog.

I asked on Twitter about the F&F test's evidence base: there doesn't seem to be one. An interesting conversation developed with Dr Stephen Dunn formerly of NHS East of England and now a director of the NHS Trust Development Authority, who introduced the test on his old patch.

The politician's syllogism
What we may be witnessing is the first 2013 health policy vintage of an old familiar friend: The Politician's Syllogism. First defined by the authors of Yes, Minister, the politician's syllogism goes as follows:

"Something must be done.

"This is something.

"Therefore this must be done."

It can also be defined as affirming the consequent.

Solving the problems which lead to poor care in the NHS is a difficult and multi-factorial challenge. It is silly to pretend that there can be no value in asking patients about their experiences of care; equally, it would be silly to treat it as a stand-alone panacea.

There are specific challenges in where, when and how to ask patients about their experiences of care. Complaining about a healthcare provider whom we may have to use again does not come naturally to very many people, and perhaps less so among the generation who are major net uses of healthcare: those with long-term conditions and the frail elderly.

Regulation does not appear to be great at picking up these issues.

There is also a fairly well-acknowledged phenomenon that the doctors and nurses who get sued are the rude ones. This publication by Gerald B. Hickson MD, assistant vice chancellor for health affairs and director of risk prevention at Vanderbilt University School of Medicine in Nashville, reveals that "cause then and now, the reality is that 2% to 8% of physicians by discipline account for 30% of all litigation risk".

Hickson also observes that the most-sued clinicians "either because of the system of care they practice in, or their own personal characteristics, just don’t work quite as well with other humans". Fascinatingly, he goes on to point out that "survey checklist items are nowhere as powerful as unsolicited complaints to reliably sort risk status ... existing satisfaction metrics won’t get it done".

Quality is systemic. It's also systematic. And it's also about every individual's own duty for assuming a responsibility for their part in the process.

The NHS staff survey is also not a bad way to have a look at what the people who work in the system think is happening to care quality. The iridescent Professor John Appleby, chief economist of the Kings Fund, once pointed out that it showed a not insignificant number of NHS staff would not want to be treated by their own organisation. The question was removed from the following survey, but thereafter reinstated.

I looked at the latest version last June, alongside the British Social Attitudes survey.

The politics of pre-emption
The politics of this are, as I previously wrote, about pre-empting the need for immediate action in response to the Francis Public Inquiry report in early February.

There are several reasons for this, not the least of which is that early February is mere weeks away from the Secretary Of State for Health's 1 April 2013 King Lear moment of "fast intent to shake all cares and business", when the NHS Commissioning Board, under Chairman Mal and Comrade Sir David, assumes the reins of power.