The leader of England’s surgeons has warned that the imminent publication of data about individual performance could destroy careers and harm patients if it is wrongly interpreted.
In his first interview on an issue that is causing considerable concern in the profession, Norman Williams, president of the Royal College of Surgeons, said they were facing “a watershed moment for us” with a degree of trepidation, amid concerns that the use of such data might deter surgeons from taking on risky cases.
“I want to ensure that we get the message out in a positive way and it is not destructive. It is not just a matter of trashing professional reputations and destroying the confidence of the public,” he said.
By the end of June, driven by NHS England, the first sets of outcomes data from 10 specialties – nine of which are surgeons (the others are cardiologists) – will be published online. Death rates will be counted in some specialties, but different measures – such as whether an operation has to be repeated or whether the patient is still in pain – will be used in others.
It is an exercise in transparency intended to drive up standards and better inform patients who put their lives in surgeons’ hands. Cardiac surgeons have been collecting individualised data for years and publishing their results, although not in an easily accessible place. But most other specialties are way behind.
Surgeons generally support the move, said Williams. “We have had a lot of positive responses from people saying, ‘We’re right behind this, we think it is the right way to go’.”
But there are anxieties as to how the information will be interpreted, especially if the data being collated is not completely accurate. Even those surgical specialties that do audit their performance may have gaps in their data.
That was what caused the recent drama at the children’s heart unit of the Leeds general infirmary. Because the full data had not been submitted to a central audit database, the death rate for children at Leeds looked dangerously high, leading NHS medical director Sir Bruce Keogh to intervene. Children’s heart surgery was suspended while a team investigated.
Williams said he thought most surgeons would consent to the publication of their data, which will be on the NHS Choices website. But worries about the quality of the data may make some refuse. Others argue that surgery is teamwork and one individual should not be held responsible for the outcome.
“It is a unique situation. I don’t think there is a country in the world that has done this or will be doing it in the future. It is a very brave move to even broach it,” said Williams.
“I have great admiration for my colleagues who are embracing it and working hard to get this data out, but it has got to be done in a very professional manner.”
What the data is likely to show is that most surgeons will perform to an acceptable standard but that some will be better and some will be worse than average.
“I would expect only a few true outliers – people who are not that good. I’d be very surprised if there were many,” said Williams. “We do have a pretty good training programme.”
When an outlier is identified, it will be important to understand why they appear to be getting worse results than others. “I might be an outlier,” he said.
Williams, a colorectal surgeon working in research before he became president, was doing “some pretty complicated bowel surgery” and remembers vividly the last operation he performed on a patient with Crohn’s disease.
“It took eight hours,” he said. “The patient was very high risk. If that patient had died or got some complication, nobody would have been surprised.”
That was why it was crucial that outcomes were risk-stratified, to account for the patients whose survival was in question, he added.
Surgeons must not be deterred from taking risky cases or trying new techniques, he said, warning that it was important “to protect the patient but nurture the innovator”.
There must be careful investigation of the reasons before it is assumed a surgeon is not good enough, he said. The few in cardiac surgery who had been judged to be genuine outliers, he added, “have often been near the end of their career and they have retired early. Whether they have been poor all their careers is impossible to find out”.
But auditing surgeons’ performance throughout their careers would ensure they would only get better, or know when to quit.
“This will get better and better and better and become second nature and it must drive up standards,” he said.
His biggest fear is that the media will pillory those who appear to be doing badly and surgeons’ reputations will be seriously damaged, which is bad for them and the public.
“The vast majority of patients do have a lot of confidence in their surgeons. If you are having major surgery, you need to have confidence. All the data suggest that most surgeons in this country are very competent,” he said.