Extending NHS Transparency
Mortality rates for individual cardiac surgeons were first published in the UK following a request under the Freedom of Information Act by the Guardian Newspaper in 2005 (1). The event was described at the time as a glimpse into the secret garden of medical self-regulation. The current publication of results of individual clinicians practising bariatric surgery, orthopedics, interventional cardiology, vascular surgery and thyroid/endocrine surgery opens that door more widely. There has never been a more important time for the medical profession to be seen to be regulating itself effectively following events in Mid Staffs and elsewhere in the NHS, and the wider erosion of trust in a number of the great British institutions following the scandals over MPs expenses, regulation of the banks, and governance of the BBC.
Publication of these results is a major event in the history of the NHS and the medical profession (2,3). For the first time since medicine has been practiced, a patient who needs any of the treatments included in these audits can find information about how many procedures each consultant has performed along with an indication of the outcomes. This development should surely be welcomed by all. It has been a long time coming. The original call for the results to be published came from the Bristol Public Inquiry in 2001 (4); that recommendation was repeated in Robert Francis’ report into Mid Staffs earlier this year (5). Cardiac surgeons began working towards reliable and meaningful outcomes in the early half of the last decade (6). Last December NHS England tasked the Healthcare Quality Improvement Partnership to manage the process for the 9 other specialties to publish their data. These audits will need further refinement in the years ahead but at least a start has been made.
Much of the media coverage of these events has focused on ‘league tables’ and patient choice, and questioned whether published data will support this. Actually, the key benefit is more that publication, by its very existence, is already forcing improvements in data quality and the structure of the audits to make them ‘fit for purpose’. It is pushing the professional societies responsible for the audits to set clear standards of clinical performance. It has driven a process of outlier identification and management. As a result the data will be vital in supporting effective clinical governance and quality improvement in future. This last point is probably the most important for patients overall because we know from cardiac surgery that the improvements can be marked, with an overall reduction in risk-adjusted mortality rates in the UK to 1/3rd of those which were seen only a decade ago (7). The data generated by the audits will feed professional revalidation for doctors to give a robust evidence-base for their right to continue to practise (8). Publishing the data should act to maintain public trust in the profession, and will help the media and others to hold organization’s and individual’s to account by ensuring that the quality of care is actively and appropriately monitored and that action is taken when required. Some might think that all of these things already happen throughout British medicine, but evidence, such as that from Mid Staffs, suggest that things can still go badly wrong. Publishing data is about improving and assuring quality, demonstrating professionalism and thereby earning public trust.
Examination of the data presented this week shows that there is more work to do. There are still concerns about data quality, but experience from cardiac surgery suggests that it is only publication of the data that improves this. Despite some of these audits being ‘mandatory’ we know that not all units and surgeons submit to the national registers, and it is hoped that publication will expose this and drive compliance. The measure used so far has been predominantly mortality, but this is low for most specialties and there will be a challenge to develop more appropriate metrics, which are discriminating between providers to facilitate better governance and choice. Risk adjustment methodology needs to improve. Local data collection needs to be supported by appropriate personnel and information technology solutions, and analyses must move towards real time. Finally the mode of presentation is not consistent across the audits; none of them are perfect and there needs to be some standardization and formal testing . However now we are ‘across the Rubicon’ with respect to transparency and these issues should be relatively straightforward to resolve.
Alongside outcomes, patient experience data – a complementary measure of quality – is beginning to be used to measure the extent to which individual doctors meet their patients’ expectations, in terms of their attitudes and the ability to communicate, as described in the GMC’s Good Medical Practice (9). Indeed one Trust in Manchester (UHSM) has recently started to publish both clinical outcomes and patient experience data for individual consultants (10).
An important consequence of publishing results in this is way is that it encourages professional groups responsible for collecting, analyzing and disseminating the data, to look at things from the patients’ rather than the profession’s perspective. For patients, it does not make sense to place data in the public domain without putting that data in the context, of the relevant disease process and its treatments. Cardiac surgery and a number of the other audits are moving from data reports written primarily for doctors to embrace a wider patient orientation (11)
Overall, the last few weeks have seen a massive step forward in NHS transparency. Things are not yet perfect, but we are now well placed to move forwards.
1. The Guardian Newspaper. Wednesday 16 March 2005. URL: http://society.guardian.co.uk/nhsperformance/story/0,,1439210,00.html [Accessed 2nd January 2013].
3. Everyone counts; planning for patients 2013/2014. NHS Commissioning Board, 2012. URL: http://www.commissioningboard.nhs.uk/files/2012/12/everyonecounts-planning.pdf [Accessed 2nd January 2013].
4. Learning from Bristol: the report of the public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. URL: http://www.bristol-inquiry.org.uk/ [Accessed 2nd January 2013].
5. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://www.midstaffspublicinquiry.com/report
6. Bridgewater B, Keogh B. Surgical “league tables”: ischaemic heart disease. Heart. 2008 Jul;94(7):936-42. doi: 10.1136/hrt.2008.143602.
9. General Medical Council. Good Medical Practice. London, GMC,2013.