Healthcare Management

Counting health care: is there a F in CE?

R.U. Ashford F.R. Howell
Department of Orthopaedic & Trauma Surgery, Hull Royal Infirmary, Anlaby Road, Kingston-upon-Hull, HU3 2LZ, U.K.Correspondence to: R.U. Ashford, Rose Cottage, Crooked Lane, Kirk Hammerton, York, YO26 8DG, U.K.

Introduction Materials and methods Results

Discussion References

Keywords: Finished consultant episode, efficiency, orthopaedics 
Surg J R Coll Surg Edinb Irel., 1 October 2003, 302-303

The consultant episode is widely used by health economists as a measure of delivery of care. The clinical notes of 174 consecutive patients undergoing elective orthopaedic procedures were reviewed. Just over half of the cases (89/174, 51%) were patients referred by their general practitioner, but under half of the available operating time (47%) was expended on these patients, the remainder being on patients already within the system. Under standard NHS accounting, these latter patients are not registered as new consultant referrals and, thus, the episodes of patient care of which their operation is a part, do not constitute finished consultant episodes. Our view is that the episode of care is an inappropriate measure of health care delivery applied to orthopaedic surgery in general

INTRODUCTION
The consultant episode is widely used by health economists as a measure of delivery of care. It is usually counted at completion of treatment, the ‘finished consultant episode’ (FCE). It is considered particularly applicable to such surgical interventions as tonsillectomy, herniorraphy and in orthopaedic surgery, hip replacement.1 We suggest that such a measure is simplistic, does not reflect surgical practice and is not always in the best interests of the patient.

MATERIALS AND METHODS
The notes of 174 consecutive patients undergoing elective orthopaedic procedures in one consultant’s orthopaedic practice over the period 5 February 2001 to 16 July 2001 were reviewed. Data were obtained as to the source of the referral and the nature of the procedure. Operations were broadly categorised as intermediate (arthroscopy, metatarsal osteotomy), major (primary joint arthroplasty) or complex (revision joint arthroplasty). The referral source was of four types: the patient’s general practitioner (GP), follow-up clinic, as the sequelae of trauma originally via the Accident and Emergency department or from other consultants. Patients listed for surgery from the follow-up clinics underwent further surgery for an existing condition (repeat or revision surgery) or for entirely new conditions.

The senior author (FRH) runs a typical general trauma and orthopaedic practice in a department of 10 orthopaedic surgeons, with a speciality interest in lower limb joint replacement and revision joint replacement.

RESULTS
Eighty-nine of the 174 procedures undertaken were on patients referred from their GP and 85 were on patients already in the hospital system; 41 came from follow-up clinics, 16 following trauma and 28 were referred from other consultants (18 of these from other specialities, mainly rheumatologists) (Table 1).

There was a preponderance of more minor cases in those patients referred from their GP, and the majority of operating time was spent on those patients already in the system. Using the scaling factor 1 unit of operating time for intermediate cases, 2 for major cases and 4 for complex cases, then just 137 of 289 units of operating time were used on patients referred from their GP (Table 2).

DISCUSSION
The definition of a FCE is a period of admitted care under a consultant within an NHS trust.² In this one general orthopaedic surgeon’s practice, nearly half the number of elective procedures and more than half of the operating time is devoted to patients already in the hospital system. Under standard NHS accounting these patients are not registered as new consultant referrals and, thus, the episodes of patient care of which their operation is a part, do not constitute FCEs.

These figures, we believe, exemplify in perspective between clinicians and those involved in planning health care. This typical surgeon’s practice is demonstrably inefficient, contributing modestly to the orthopaedic care of the community when the measure of care is the FCE.

Our alternative view is that the episode of care is an inappropriate measure of health care delivery applied to surgical interventions undertaken in chronic conditions such as arthritis and, indeed, in orthopaedic surgery in general. A consultant episode in such conditions does not indeed finish. A similar view has been expressed for colorectal carcinoma.³ This is not the first performance measure promulgated by the Department of Health that is flawed and poorly constructed.^4,5

We suggest that a more representative approach is needed, and that caution is required in planning orthopaedic health care. Further it would seem likely that as sub-specialisation within orthopaedics develops, then this trend will increase. The range of procedures undertaken by any one surgeon will diminish, and more patients will be referred ‘sideways’. We are not alone in feeling that the involvement of clinicians in planning health care delivery is vital and the creation of new consultant posts alone may not of itself fulfil the objective of improving orthopaedic care in the NHS.⁶

REFERENCES
1. Bloor K, Maynard A. Consultants: managing them means measuring them. Health Serv J 2002;(19.12.02): 10-11.
2. http://www.doh.gov.uk/hes/free_data/ index.html
3. Pollock AM, Vickers N. Measuring NHS  activity: Admission rates are misleading. BMJ 1995;311:454.
4. Appleby J. Promoting efficiency within the NHS: problems with the labour productivity index. BMJ 1996;313:1319-1321.
5. Radical Statistics Health Group. NHS “indicators of success”: what do they tell us? BMJ 1995; 310: 1045-1050.
6. Williams JG, Mann RY. Hospital episode statistics: time for clinicians to get involved? Clin Med JRCPL 2002;2 :34-37.

Copyright: 23 August 2003

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