Read part one of this blog here.
Bad outcomes
Ben Bridgewater thinks there are three main reasons why some consultants have opted out of reporting outcomes: data quality, risk adjustment, and the multidisciplinary nature of the work.
Looking back at the cardiac surgery data, he says, “Before we published the data, there were some units in this country who weren’t submitting data to the audit and there were some data quality problems. But actually as soon as we published the data, everybody submitted their data and the data quality improved. Publishing data gets complete compliance with audit programmes and… leads to improvements in quality.”
He admits that in some specialties, risk adjustment may not be accurate yet, but hopes that this will be refined with each cycle. With adequate risk adjustment, as in cardiac surgery, he does not think there will be an avoidance of high-risk cases. “Ten years ago, we didn’t operate on people who were in their nineties or people with multiple valve disease. The data show that we’re not responding as a group to turn down high risk patients.”
He feels most strongly about the issue of team responsibility: “If you were coming to see me for a heart operation, you would see me in the clinic and I would discuss the options with you. I would discuss the risks and benefits of surgery with you. I would explain the choices that you have about the treatment options. I would get you to sign the consent form. I would do the operation and it would be my name above the bed. That process can be supported by a multidisciplinary team but at the end of the day there is somebody who is responsible for you.”
He says we now have a performance standard for surgeons in these specialties and have defined what is unacceptable. A “pyramid of investigation” is triggered for any outlier—in vascular surgery, this means a surgeon with complication rates that are 2 standard deviations above the mean risk-adjusted rate. The first step checks data for accuracy. Next the case mix and the surgical procedure is assessed to take account of high-risk patients or very specialist operations. Then any organisational factors are reviewed, such as post-operative facilities. Finally, the individual is investigated. If complication rates are 3 standard deviations above the mean, then the hospital may need to suspend the procedure under investigation.
I asked Bridgewater about two other common concerns.
What about the implications for surgical training and trainees not being allowed to operate? “I think patients get a better deal and trainees get a better deal actually… I think that delegation is smarter. The right trainee will be doing the right parts of the appropriate operation on the correct patient. The idea that a non-experienced trainee will do a high-risk case without a consultant with them is something that doesn’t happen anymore.”
Why not share the data amongst healthcare regulators without public reporting and the risk of misinterpretation? “That strategy of the NHS in its wider context keeping all that stuff to itself and doing the right thing to keep the patient safe has clearly failed on multiple occasions despite expensive repeat public inquiries. That’s what happened in Bristol. There was an inquiry and some recommendations and it failed again. It failed with Harold Shipman and it failed at Mid-Staffordshire NHS Trust so that strategy of keeping this all secret and trusting the profession to regulate itself and organisations to regulate themselves has clearly failed. You only need to look at the media coverage of the CQC in the last week to see it has to be done in a different way.”
On the Thursday afternoon that national newspaper editors went ahead with naming Simon Payne, Ben Bridgewater and I were finishing our conversation at the Royal College of Surgeons.
“Do you see any possible disadvantages from public reporting of individual consultants’ outcomes?” I asked.
“You hope that some newspapers will not decide that the story of all of the positives to patients and the public should get destroyed by adverse coverage of one individual, which then makes the profession nervous about engaging in this,” he expressed. “I hope that doesn’t happen.”
Simon Payne says “I have been heartened by the passionate messages of support from patients, colleagues, managers and GPs. Patients have even said they want to travel to London to ‘sort out’ the newspapers. Thankfully no patient has cancelled an appointment but I’m worried about the future.”
He is proud of his carotid surgery figures and explained, “The primary reason for going into surgery or medicine is the personal reward for doing good for patients. Although I know I have been doing good, I want everyone else to know that too.”
The future
Keogh says “The NHS is on a journey with transparency. The more we shine lights into corners of the NHS the more you will see. That can be hard for NHS staff and policy makers. But it is the right thing to do.”
From next year, Keogh and Bridgewater think that commissioners will stipulate outcome reporting for surgeons in contracts. In Bridgewater’s local Trust, he is setting up reporting for all consultants. It will include a mix of the volume of cases seen, outcome measures, and an indicator of patient experience. NHS England is supportive of such developments and HQIP may support more national audits in other specialties as a consequence of this.
“One of the cardiac surgeons was a bit reluctant about doing this and didn’t think it was a particularly good idea. He changed his mind when it came to MPs’ expenses. He felt that he had a right to know. He changed his mind and his own perspective on whether the public had the right to know about his results when he felt he had the right to know how much his MP was earning,” Bridgewater says.
“It’s the world that we live in.”
See also:
Krishna Chinthapalli is the BMJ clinical fellow.