Dr. Tony O'Connell:

What we are getting to here is this issue of how does one improve performance in a sustainable way. The way to do this is to do it at a local level. This requires clarity about what the targets are, what the metrics are, and an audit approach to check on them. In the end, especially when we have a health system - as we do in every Western democracy - where individual clinicians are making patient-by-patient decisions, a better way to change their behaviour in a sustainable way is to do it much more at a local level. This is why the movement towards hospital groups is so important. We have clinical directors who are now responsible for only a handful of hospitals rather than, for instance, me being responsible for all 50 of them. It is not possible for me to dive down into the individual performance and check the clinical indication for day case versus inpatient case by individual surgeons without doing an enormous amount of work. Having a clinical director for just a handful of hospitals with sub-clinical directors in each individual hospital is a much better way to get a mindset and an approach and a consensus change in practice rather than doing it on a national level. They have to be complementary, but the sustainable change comes from much more local implementation of the principles and the clinical champions.