Monday, March 11, 2013

Accountability..what are you waiting for?

Accountability is the new buzz word,isn't it? Recent events have put the term in sharp focus and over a round of drinks,a  few friends were discussing how one could define it for doctors in general. Truth be told, who are we to dictate to politicians or managers about what accountability stands for when our own definition continues to be perhaps a bit hazy. And it indeed is a conundrum..how DO you define accountability for a doctor? Inevitably the question came to me as the youngest Clinical Director amongst the crew..how had I defined accountability for my colleagues?

So far for me, accountability has come down to 3 and only 3 basic things. I can't comment on general practitioners except my own view has been that I don't subscribe to the view that ALL GPs are hard working and NO one provides poor care. Leave alone the politics of it all, statistically it simply isn't possible. I may not be that old but have spent enough time in the system to know that the vast majority of GPs do indeed provide great care, but there are some who simply don't. Saying " all" do it is akin to saying all Consultants are amazing. Lets not try and make doctors into heavenly beings- we are as much human as the other person- and we are as much fallible as any one else. Don't believe it? Don't take my word for it- come to twitter and listen to the public.

So, point 1? Accountability as per job plan. In short, the taxpayer pays a significant salary to a Consultant. Job plans, if done well, should be able to define where the Consultant concerned is supposed to be at a given point of time. So, for example, if a Consultant is not there doing his ward rounds at 8 am on a Monday morning as per his agreed job plan, then there can only be two plausible explanations for that. a) He is busy doing other clinical work- in which case back to the drawing board as regards job plan and he has too much on his plate or b) he is doing something else not related to the hospital. The vast majority will indeed be a) but there's also a group which nonchalantly embrace option b). And if he or she is found to be doing something else (let's say, private practice) at the time the NHS is paying for their time, that, in simple parlance is called, fraud. Tackling that is important and such incidences, simply put, are inexcusable.

Point 2? Accountability for the services. And it does get a bit tricky here. How do you measure a Consultant's worth as regards outcomes? It maybe a tad easier with say, general surgery- what are your mortality rates, morbidity rates etc but falters when general medicine comes to play. Length of stay is used as a marker but I can get the best LOS in the country but the highest re-admission rates...doesn't make me a good doctor, does it? In our department, one of my colleagues recently said that his "antenatal diabetes service was excellent". In my usual cavalier style, I said "Says who?" Because as far as I am concerned antenatal diabetes is about delivering a safe mum and baby, little else. To his credit, he went away, collected data on neonatal high care admission, caesarian section rates, infection rates etc. Perfect. But as mentioned, this area is indeed complicated especially in services where multiple providers are present and the Consultant is part of only one little niche of it. 
If you switch to GPs or even surgeries, here's an example. In our region, out of 52 surgeries, a couple refused to engage with the community team in spite of umpteen emails and phone calls. They didn't need any diabetes support. In my book- to be honest- fair enough. Then it boils down to how those surgeries perform in contrast to their neighbouring surgeries. If they are at par or better, then clearly they don't need specialists and well done on them. If however they are failing, then its simply stubbornness which is resulting in patients suffering poor care. We shall see- but as far as I am concerned, in our part of the world, I make no distinction between primary or specialist care. The distinction mark is whether you provide good care or not. As simple as that.

Point 3? Accountability to the public i.e. the people you do it for. What do they say about you? Lots of debate continues about the right tools for it (is it a randomised feedback form to 50 patients, is it the Tripadvisor style "I want Great Care")...the point is not what you use to collect the data, but whether you do so honestly and what you are willing to learn from it. A caveat as always- we also need to bear in mind that as clinicians we also make decisions which are in the best interests of the patient- which also may not please the patient. A negative feedback thus needs to be in context too. If we only go on point 3 to judge doctors, feedback done on ED doctors after a Friday night may not be seen as necessarily "patient-focussed".

That's pretty much it, isn't it? Why overcomplicate the whole process when all the public who funds our salaries wants to know one thing "Are our taxes going to doctors who care and strive to make us better?" To all the evangelists who have their hackles raised as soon as something negative is said about clinicians, remember this. For ever thus, it was the good eggs who stayed longer and worked harder and ground themselves into the ground more...to cover for their failing or skiving colleagues. If you work in a team, then all need to play their part. Trying to root out or improve a poor performer makes the team stronger, not show the whole team in poor light. Of course there are many ways of tackling poor performers but the process has to be transparent. I am tired of people taking potshots at the NHS based on some poor performers and to be honest, I am tired of carrying them. We all know who they are, we talk about them regularly under muttered breath, we moan about them when we get home...we may as well open up a transparent system of accountability.

Thomas Paine once said " “A body of men holding themselves accountable to nobody ought not to be trusted by anybody" After all, if YOU are doing all the right things, what exactly do you have to worry about?

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