News analysis - Why inspection can be a risky business, by David Walker

31 Jan 02
A backlash against audit and inspection may be gathering force. New studies just published in the US say league tables for hospitals and schools can push up spending while reducing quality of service.

01 February 2002

'Report cards' for individual surgeons – which the government is about to introduce in the UK – are criticised for their effects on the sickest patients.

Meanwhile, external audit and inspection, especially of police, immigration and tax administration, can lead to risk avoidance, inefficiency and a worse overall service to the public.

The studies, from the National Bureau of Economic Research (NBER), a non-partisan and non-profit organisation based in Cambridge, Massachusetts, warn of 'adverse incentives' from external monitoring of public service professionals.

Unusually for studies emanating from the US, they dismiss private market solutions and suggest that, while trusting the professionals also has its problems, it may ultimately lead to more effective public services.

One of the investigations looks at the Los Angeles Police Department. After heavy criticism for alleged racism – especially after the beating of Rodney King was captured on video in 1991 – and excessive use of force, a 1998 board of inquiry made a tough set of recommendations on police conduct.

But Professor Canice Prendergast of Chicago University found the result has not been better policing but less policing. Crime rates, notably offences involving gangs, have increased because, he says, police are avoiding situations where their judgement may be called into question in subsequent inquiries. Officers prefer to drive through the mean streets of LA in their patrol cars rather than get out and potentially hit trouble.

Something is going fundamentally wrong, he claims in an impressively mathematical study. Police officers need to be suspicious: tough complaints procedures lead them more readily to accept claims by the public of their innocence, even if they are guilty.

In the past, US influence on British thinking about public services has tended to go in a pro-market and pro-audit direction. The 'new public management', with its emphases on contracting out and regulation, relied on US-dominated economic modelling.

But now US economics may be taking a different turn. The other recent NBER paper takes a cool look at the collection of clinical performance data for surgeons.

In the UK, such data has been collected privately for years: as part of its response to the Kennedy inquiry into the Bristol Royal Infirmary, the government says it intends to publish individual figures soon.

A scheme in operation in New York and Pennsylvania since the early 1990s required cardiac specialists to fill in 'report cards'. A team led by Daniel Kessler of Stanford University compared these two states with others where no such audit had been introduced. The economists found two striking things. Overall spending on heart surgery actually rose, because doctors substituted medically safer coronary bypass surgery for other heart procedures – even though 'it produced no measurable health benefits'.

Meanwhile, patients who were more ill when they were first seen by consultants tended to get less treatment – presumably to avoid them showing up as failures.

Similar effects, the economists speculate, could result from attempts to audit the performance of individual teachers.

Health Secretary Alan Milburn recently announced that every heart surgeon's patient death rate is to be made public within two years. But specialists have warned against correlating low patient mortality and surgical skill.

Bruce Keogh of the Society of Cardiothoracic Surgeons says some of the best cardiac surgeons have been those with the highest mortality rates in operations.

David Walker writes for the Guardian


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