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Guest editorial Wednesday 15 June 2011: Eliminating ‘cherry-picking’

Dermot O’Riordan, Consultant Surgeon and Medical Director of West Suffolk Hospital and member of the NHS Future Forum, outlines the crucial case for the NHS reforms to successfully eliminate ‘cherry-picking’.

When I joined the Future Forum I specifically asked to join the panel on choice and competition. This is an area that I feel is critical, and I wanted to ensure that there was an acute trust voice represented in the discussions.

The fear of “cherry-picking” was one of the topics that had alarmed commentators, and I wanted to ensure that protections were put in place to deal with the issue.


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As both a surgeon and medical director of an acute trust, I admit that I come from a particular perspective, but one that I think is valid.

Cherry-picking is an inevitable risk that can arise due to the nature of the Payment By Results tariff system. Within a tariff band (for example a hernia repair) there are usually only two payment bands that cover all patients whatever their complexity and co-morbidities.

The risk is that some providers could seek to identify and treat low-risk patients within these bands, and leave the NHS providers to care for the remainder. This would inevitably create a non-level playing field and give such providers a commercial advantage.

Cherries are already being picked
This is not a hypothetical risk. It is happening already. Under “Free Choice”, many private hospitals are treating NHS patients - and have a list of exclusion criteria. Those patients not meeting these criteria end up having no choice but to be seen in an NHS hospital.

This NHS hospital will inevitably have to bear the cost of longer lengths of stay, back up critical care services etc. All this for the same fee. This is unsustainable.

That is why I was insistent that the issue of cherry-picking was addressed in the forum - because it can distort the market. I am not necessarily against competition. Indeed, it can be a powerful stimulus to improve quality.

Locally, for example, our orthopaedic surgeons provide a recognised excellent service with short lengths of stay, excellent outcomes and very good Patient Reported Outcome Measure scores. Amongst the main drivers for this improvement are the threat of competition and to attract more referrals.

Defining the problem
I would define cherry-picking as the circumstances where a provider does not accept all patients within a PbR tariff band. If this is the case, there must be a duty on the commissioners to make an assessment as to whether cherry-picking is occurring and if so, there should be an adjustment to the tariff payable.

I would emphasise that I have no issue with appropriate case selection. Indeed, there is a clinical case to be made that specialised elective centres focusing on performing selected operations in high volumes can potentially get excellent outcomes. Indeed, Professor Paul Corrigan wrote recently in his blog of such a set up by Dr Devi Shetty in his health campus in Bangalore, India.

The problematic situation occurs when a “competing” NHS organisation has to bear the disproportionate additional costs of treating the sicker (and potentially more costly) patients. This would undermine the universal nature of the NHS.

To ensure a fair market, there must be a proportionate ability for a provider that believes another provider is cherry-picking to request commissioners to make an assessment. If there is cherry-picking, then the payable tariff should be adjusted.

The threat to training
Another risk of cherry-picking is the threat to training. The next generation of NHS staff all need supervised clinical exposure to the more straightforward patients before they can move onto the more complex cases.

If only the NHS providers have to deal with a more complicated case mix, whilst also training surgeons (which inevitably takes additional time and is more costly), then they face an even greater financial disadvantage.

This is why I welcome the Future Forum report’s specific recommendation that safeguards be introduced to prevent cherry-picking which “distorts the market”. To implement this, I believe that the NHS Commissioning Board and individual commissioning consortia must specifically address this issue.

The problem is real, and it is happening now. This isn’t shroud-waving by a vested interest, but rather a plea for fairness.