After the Bristol Heart Scandal in the 1990’s, the speciality of cardiac surgery rose to the occasion, leading the way in publishing individual surgeon’s mortality figures and self-audit, which made it perhaps the most transparent speciality in the UK, and thus consolidating its long-held position as a world leader in the training of surgeons and patient safety.
Professor Bruce Keogh, head of NHS England, recently announced that NHS surgeons will now be asked to submit their mortality data online to public scrutiny, and failure to do so will result in medical purgatory.
The cardiac surgery experience suggests that ‘league tables’ will improve outcomes; I disagree. The public deserves competence from their surgeons, something prevalent in the NHS 99.9% of the time. It cannot be denied that there is a significant gap between a merely competent surgeon, and an excellent one. Many excellent surgeons have extremely low complication rates, others have significantly higher ones due to the fact that they engage in higher-risk procedures, surgical innovation, and operate on high-risk patients. Were this cohort then compared to incompetent surgeons by the use of crude data, they would fare badly. Consequently, reluctance to engage in positive behaviour resulting in ‘outlier complications’ affecting their published figures will culminate in patients at higher risk of complications being denied surgery. I have direct experience of this. Such an environment will deleteriously affect surgical training.
Surgery is a team endeavour, with the Consultant the most visible member. In the modern NHS, the surgeon is the de jure team leader; that authority does not extend to non-medic members of the team, and it is facile to hold them singly accountable for complications that might arise from the actions of others. The quality of pre and post-operative care is essential to surgical success, and this care is rendered by others, in conjunction with the surgeons. There will be times when an adverse outcome is due entirely to surgical incompetence, lack of skill or an unforgiveable mistake, but this is invariably obvious.
‘League tables’ obscure this rather more complicated picture in preference to what is termed epidemiologically as a ‘surrogate endpoint’, a polite way of saying ‘well, we can’t really measure the outcome we want, so we’ll stick something in that is easy to measure so that we can present the data in a way that appears to be meaningful’. Crude data of the kind found in league tables says nothing about why those complications arose, and is merely a shamelessly over-simplistic version of a more profound and intricate set of circumstances; it places sole blame on the surgeon when in reality the procedure itself is but one piece of a complex puzzle.
How are patients to be kept safe? The formal, structured and competency-based training of NHS surgeons, more stringent surgical privileging and closer supervision of trainees that already occurs, all contribute. Surgical units in the UK regularly audit their results; when complications arise, these are forensically examined via root-cause analysis. Audit is on-going as it is a requirement of the training of surgeons; bad outcomes cannot simply be buried, unless there is a conspiracy in place that belongs in a Robert Cook novel. There is a rich research tradition in the NHS and this further exposes negative outcomes to scrutiny, sometimes internationally. Studies have established that higher complication rates are seen in teaching hospitals, but that this is balanced by a higher quality of care.
The adoption of the WHO ‘Surgical Checklist’, demonstrated to lower complication rates, has served patient interests. Five-yearly competence requirements are de rigueur, incentives are given for excellence in clinical care, and the fact that the GMC aggressively investigates any complaint of alleged negligence or malfeasance, and does not grant licenses to practise willy nilly, means that patients are not being left to the tender mercies of doctors. Lastly, never underestimate the power of peer pressure; no surgeon wishes to be known to his colleagues as the fool who harms his patients. This normally serves as a most formidable deterrent to deleterious deviation from appropriate care.
Can the system be improved? Undoubtedly, by consolidating current measures. Additionally, whistle-blowers must be able to act without fear of retribution. Their input represents ‘real-time’ intelligence vastly more useful than a set of numbers. Trusts must be forbidden by law and punished with fines drawn from the salaries of their Chief Executives for attempting to gag, silence or harass them.
Instead of crude ‘league tables’, a surgical system similar to the ‘Confidential Enquiry into Maternal Deaths’ that my own speciality uses as a marker of quality of care nationwide, should be introduced.