Professor Sir Bruce Keogh, National Medical Director
The NHS, the BBC, the police, the banks and even Parliament have all suffered significant reputational damage from recent scandals leading to an erosion of public trust in some of the most cherished British institutions. Greater transparency, rather than secrecy, offers the better solution to restoring trust
The NHS belongs to all of us. I believe that everyone offering services in our NHS has a duty to be able to describe those services and define how good they are. This applies to individuals and organisations. It is the essence of professionalism. If you can’t define how well you are delivering a service, should you be offering it? Our NHS has more comprehensive data than any other national healthcare system, yet several recent events have demonstrated that it is not used effectively either to inform the public, improve services or to spot problems early. This has been a missed opportunity.
In 1977, heart surgeons in the UK were the first in the world to measure institutional and national surgical results, but institutional results were not shared with the public and weren’t always given proper attention by the hospitals. If they had been, some deaths of children in Bristol in the 1990s might have been prevented and an expensive 3 year public enquiry avoided. But they weren’t. Heart surgeons responded by publishing hospital results in 1998 and individual surgeons’ results in 2006. It wasn’t universally popular. Surgeons worried that that they would be penalised in league tables for taking on high risk cases, that unfair comparisons would be made and that some authorities would take inappropriate action as a result. These issues remain a risk, but publication of results has undoubtedly focussed the minds of heart surgeons in this country who now demonstrably offer among the best results in the world.
Over the next week six other specialties will join the cardiac surgeons and publish their results at an individual doctor level. Three others will follow soon after. This is a big step, not just for the surgeons and cardiologists, but also for the profession and the NHS. This has not been attempted anywhere else in the world, and it illustrates the vision and responsible leadership of the Royal College of Surgeons and surgical specialty societies.
There have been some strange challenges en route. The Data Protection Act dictates that surgeons give their permission to publish their results. In the end all but a handful of surgeons have agreed. We have named those who haven’t and given them the opportunity to explain why. This is an important part of an evolving debate around data quality and the ability of statistical methods to take account of differing patient populations operated on by different surgeons, some of whom have highly specialist practices relating to rare or complicated conditions. For some it is simply fear of the unknown. For others there is a genuine objection to the principle of attributing surgical results to an individual when those results are dependent on effective teamwork between surgeon, anaesthetist, theatre and ward nurses and physiotherapists. In my mind I think the patient enters the agreement for surgery with the surgeon and someone has to be accountable for the team’s outcomes.
The Office of National Statistics interpretation of the Statistics and Registration Service Act (2007) is that where the numbers of deaths are 0,1 or 2 for any surgeon, there is a risk that the identity of the dead person could be deduced if taken together with other public information. My concern is that excluding surgeons with low mortality rates would be counterproductive to restoring trust because it would shift the emphasis from reassurance and promoting excellence to a focus on presumed poor practice. The cardiac surgeons have been publishing excellent results with many surgeons having 0,1 or 2 deaths since 2006. We concluded that the legal duty for NHS England to promote quality and its commitment to transparency as a driver for quality was in the greater public interest.
Publishing this sort of data will raise some inconvenient truths. Where there is a clear relationship between the number of operations and results should occasional practitioners of some operations stop doing them and hand the patient over to more experienced colleagues? Could this lead to significant reorganisation of some specialist services? Whatever the answers it is clear that the best way to pursue quality and improve outcomes is to follow the data.
But what data? When death is a rare outcome there are other, often better, measures of a quality of service: length of stay in hospital, readmission rate, patient satisfaction, to name a few. In our NHS we define quality as including effective outcomes, safe care and a decent experience. There are different measures for all three. Earlier this month South Manchester University Trust took the step of publishing activity, outcomes and patient ratings of all consultants in one specialty, with others to follow. They have set the standard that others must follow and try to beat.
So we have started a professionally led journey towards greater transparency which will drive up quality and I hope will lead to greater confidence and trust in our NHS.