Sir Bruce Keogh is in the news today because of his appearance on tonight's edition of ' The Report' - a topical programme on Radio 4 which today deals with Surgeons under Scrutiny.
I have blogged many times previously about surgical scrutiny, most recently here. I have always been a huge supporter of this initiative - after all how could anyone argue with a patient's right to know the competence of the doctor who is about to cut them open with a sharp knife with the stated intention of making them feel better! What the public and many non cardiac surgeons probably do not realise is the frantic and often difficult discussions that went on within the cardiac surgical community before the issue was forced by a Freedom of Information request by the Guardian newspaper in 2005. It published outcomes of most cardiac surgeons in the early part of that year and the cast was die. Contrary to popular folklore, there are still many cardiac surgeons who are still opposed to publication of individual surgeons' results. Interestingly, the Society of Cardiothoracic Surgeons (which is responsible for the handling and publication of this data) has not published anything for three or more years (much to the chagrin of the Medical Director of the NHS and previous Society President, the same Sir Bruce Keogh). Since then, there is no doubt that results of heart operations have improved. To state that publication of outcomes is the principal reason for this improvement is however to be disingenuous. Improvements were occurring before results were published and results for other speciality procedures have also improved. Many of my colleagues around the country argue (rightly in my opinion) that we have concentrated on this issue for far too long and have too many scars of self immolation to prove it. There are undoubted consequences of this approach and the results of the experiment in cardiac surgery prove this - the presence of the rather conspicuous elephant in the room otherwise known as Risk Aversion. This might not be very obvious to those who reside within the Cardiac surgery NHS bubble. Recently , I met up with a colleague who used to work in London and who now works in Denmark. She stated that until she moved away, she had not realised just how risk averse cardiac surgeons in the UK had become.
There is a surgical aphorism that states that 'the good surgeon knows when to operate and the wise one knows when not to operate.' Risk aversion is not always bad - it is often wise and sensible. When however, aversion becomes the default position, as it has done in many places in the UK, it does not mean we all have become wise, but that we are now doing a great disservice to many patients with treatable heart conditions.
Norman, I think you're correct. I have a great deal of respect for Prof. Sir Bruce Keogh and the work that he did in the early days post Bristol, to bring the Society (of cardiothoracic surgeons) forward in their use of accurate and risk-adjusted data.
ReplyDeleteIt was a thankless task and one that was often described as like herding cats. Many of us in the Med Tech industry and other interested parties were very supportive - but we were also amazed when Bruce was finally able to get the Society to agree to publish surgeon specific data.
Having worked amongst many of the surgeons of that era, I remember a degree of 'closed shop' and intolerance to examination. It was no mean feat to overcome this type of cultural challenge.
The key point hinges though on those three words... Risk-adjusted data...
The quality of data collection in the NHS is in my view relatively poor.
However, if good-quality data is recovered from systems, hospitals or surgical teams - then it can be used to provide accurate and independently validated risk adjustment (for things like concomitant factors and other risks).
The issue of risk aversion in practice then should not materialise. This is because any high-risk procedure will be taken into account and not adversely skew the data if the eventual outcome is not positive.
I believe the real issue is more to do with the populist idea of league tables and overly simplistic statistics. One of the worst examples in my opinion in the health sector is that of Dr Foster. I often cringe when listening to news reports that cite Dr Foster data - either out of context or where the Dr Foster data does not have any apparent statistical validation.
These issues are bad enough when they start to inform populist opinion but become seriously flawed when they are used by either government or opposition to drive policy.
I have always been of the opinion that good data can drive good and improved practice. The issue is understanding how to interpret it and use it effectively and honestly.