The website TripAdvisor (See: http://www.tripadvisor.co.uk/ ) allows viewers to access (and contributed to) popular ratings of hotels, restaurants and other travel related facilities all over the world. The NHS is now operating a website – NHS Choices – that performs a similar service in respect of NHS medical services: www.nhs.uk. It contains a mix of hard data, such as information about mortality rates at hospitals and the performance of GPs across a range of different aspects of performance, as well as soft data including patients’ impressions of their stay at particular hospitals and their experience of being treated by particular GPs. The rating of hospitals, GPs and other specialisations in medicine follows on from the successful UK experience of publicising cardiac surgeons’ mortality and survival rates, a Government initiative to restore public confidence in cardiac surgery following the Bristol Royal Infirmary Scandal. According to a recent article in the Guardian this has lead to a 21% drop in mortality rates for coronary artery surgery over the last five years: http://www.guardian.co.uk/lifeandstyle/2009/jul/30/heart-surgery-death-rates-fall.
The ethical case for publicising surgeon’s performance data is explored in depth in the book Informed Consent and Clinician Accountability: the Ethics of Report Cards on Surgeon Performance, edited by Steve Clarke and Justin Oakley, Cambridge University Press, 2007). Roughly, there are three sorts of arguments for the publicizing of surgeons’ performance information. First, there are arguments that appeal to the right of prospective patients to have access to such information. The case for there being a right to information that is relevant to the risks that a patient takes on when undergoing medical treatment seems particularly strong. Indeed, on standard accounts of the doctrine of informed consent patients require a full disclosure of all risk-relevant information before a medical procedure can take place. Second, there are arguments that appeal to considerations of safety and quality. As the recent experience of cardiac surgery in the United Kingdom confirms, the publicizing of performance information tends to improve quality and safety in medical services. The third sort of argument appeals to considerations of professional accountability. Society as a whole grants medical professional organisations a considerable amount of power in terms of effective monopolies of a range of services; and in return it seems reasonable to expect that society will be able to monitor the medical services provided and ensure that that power is being used appropriately.
In a recent opinion piece in the Daily Telegraph, Medical Editor Rebecca Smith has attacked the rating of GPs. See http://www.telegraph.co.uk/comment/4029519/GPs-cannot-be-rated-like-hotels-on-TripAdvisor.html. She makes two points. The first is that the posting of comments on the internet may result in GPs feeling pressured to keep their patients happy instead of ‘treating them appropriately’. The second is that in some isolated places patients may have no practical choice but to remain with the GP that they have been going to, regardless of that GPs ratings. I don’t think that either of these points is at all telling. GPs are providing a service and all things being equal a patient should be satisfied by that service. It would be concerning if the posting of comments on the internet lead to GPs providing an inferior service simply so that they might receive more positive comments. But Smith provides no evidence that GPs have provided, or will provide, an inferior service as a result of this sort of pressure. In any case, GPs are also rated on the NHS Choices website across a range of objective criteria and it is hard to believe that any GP would be willing to risk lowering his or her rating on any of these objective criteria in order to increase their rating on an impressionistic scale.
Smith’s second point is not telling either. If patients in isolated regions are receiving an inferior service and have no practical alternative to that service then it is important that they are aware of this so that they can lobby for the provision of better services to their region. Furthermore, the publicizing of the fact that they are receiving an inferior service may well be effective in prompting their GP to improve his or her service, even if that GP faces no immediate competition. But, in any case, concerns about rating GPs in the few isolated areas in the UK where patients only have access to one GP should not let us lose sight of the importance of improving services in the many places where a choice of GPs is available; and, if evidence from the experience of cardiac surgery is anything to go by, the publicizing of GP’s performance information will lead to an overall improvement in the quality of service.