Saturday, 11 April 2015

The Stick and Bigger Stick Approach to Health Outcomes Publication


The Bulletin of the Annals of the Royal College of England (RCSEng)is this month dedicated to the thorny issue of surgical outcomes reporting. The editorial team should be commended for publishing 2 very opposing views of the reporting of surgeon specific mortality data.
The first account is by 2 senior cardiac surgeons and a senior interventional cardiologist. It takes the contra view that as surgery is a team sport, whose outcomes depend on facilities of the organisation, it is fundamentally unfair to load all outcomes on the one person.  This argument is backed up by several studies showing that mortality after surgery is more often related to a failure to rescue (FTR) rather than surgical ability. This ability to rescue is a strong reflection of the quality of a health organisation.  They also argue that it is the natural human response for surgeons to become risk averse if their personal published mortality rises. These are very potent and well rehearsed arguments against the reporting of  outcomes for individual surgeons as opposed to those of institutions. They also make the additional point that in the USA and in many countries in Europe, there is a tasty carrot or positive incentive to publicise outcomes - more referrals. In a centrally planned NHS, this is clearly not the case.
An additional point that I would make relates to the findings of a study presented recently at the annual combined meeting of the Society of Cardiothoracic Surgery (SCTS) and Association of Cardiothoracic Anaesthesia (ACTA). This study from Wales suggests that most patients waiting for heart surgery still do not make an effort to look up the outcomes of their surgeons. Ironically, because of pooling of waiting lists, many patients do not know who is operating on them until the night before.  Consent forms used in the NHS state that there is no guarantee who the operating surgeon will be.
The points raised by this piece are very strong and evidence based. It is a shame that the authors let themselves down by suggesting that facilities in NHS institutions were poor, which they're not and by also suggesting that surgeon reporting was dissuading junior doctors from joining the speciality,a statement which again is not evidence based - as Professor Bridgewater suggests in his subsequent piece, entry to CT surgery training remains very competitive.
The second article is written by Professor Ben Bridgewater, a cardiac surgeon from Manchester who with Professor Sir Bruce Keogh (current NHS medical director) was responsible for the current system of outcome reporting we have today in cardiac surgery.  He now works for HQIP, as the head of Consultant Outcomes Programme.  Professor Bridgewater makes the usual arguments that in modern healthcare, it is impossible to argue that patients are not entitled to know the outcomes of the clinicians they are being treated by. He also reminds us that reporting of outcomes of individual doctors is now part of the constitution of NHS England. He claims, as he has done on previous occasions, that outcome reporting of surgeons' outcomes has led to an improvement in the results of heart operations in the UK resulting in British heart surgeons having the best outcomes in the world. I have always felt that the claim that reporting of SSMD (Surgeon Specific Mortality Data) improves outcomes is disingenuous  - cardiac surgery outcomes have, ever since the first heart operation was performed, been improving in the UK and elsewhere where SSMD are not reported. The same applies for other branches of surgery whose SSMD are not reported.
As a consultant cardiac surgeon of 17 years and a strong advocate of patient involvement in their healthcare, I understand and empathise with points made in both articles. Publication of SSMD is here to stay. Crucial and avoidable mistakes have clearly been made in the anarchic way the SSMD publication programme has been rolled out, especially in my specialty. I know this having lived through the whole sorry saga over the past 15 years. I hope that these mistakes are not repeated in other specialties because at the end of the day what surgery in general does not need are unhappy disenfranchised surgeons and patients being denied treatment.