Is publishing surgeons’ mortality rates a good idea?
Will greater transparency lead to more informed decisions?
In 2014, the NHS for the first time published the individual mortality rates for consultant surgeons on a publicly available website. This step represented a milestone in transparency, which has not happened before in the United Kingdom or overseas. We consider the reasons behind the move, its effects, and possible implications for the future.
The MyNHS website breaks down individual consultants’ results, reflecting their competencies in specific operations. The scheme was devised by Bruce Keogh, the NHS medical director for England, who has placed great emphasis on transparency in healthcare to increase accountability and drive up standards. In 2007, he was involved in the establishment of the NHS Choices website, where patients can inform and educate themselves about their diagnosis, prognosis, and treatment options. The website aimed to deal with the balance of information that doctors have compared with that of their patients, to give patients the chance to make better informed decisions about their health and wellbeing.
The theory is that patients know their own needs and the effects that clinical options may have on their lifestyle better than a healthcare provider, so they should be central to decisions about their planned healthcare treatments.
Publishing surgical data is seen as another major step on this path to give patients more information to make informed choices about the healthcare they receive.
Not only will published data give patients better information, but Keogh hopes they will also help drive up standards. If mortality rates are published, he believes surgery will become more accountable. In a world where mistakes are publicly exposed, surgeons are less likely to do operations for which they have insufficient training or which they do not do often enough to maintain competence. In an interview with the Guardian Keogh said, “Anyone who does an intervention to somebody else has a professional and moral responsibility to be able to describe what they do and defend how well they do it.”
Why is there a need to improve accountability in surgery? The NHS has seen a recent decline in its satisfaction rating, dipping from the highest rating (in 2010) seen in years. The scandal of poor care standards at Mid Staffordshire NHS Foundation Trust, which dented the public’s confidence in the NHS, was attributed partly to lack of accountability. This move hopes to quell concerns over these events repeating themselves and pave the way for a safer future for our patients. Jeremy Hunt, secretary of state for health, said publishing surgeons’ mortality data was “a major step forward in restoring public confidence.” Politicians and NHS leaders hope that openness and transparency will improve standards of care, but is that really the case? Some surgeons disagree.
Peter McCollum, professor of vascular surgery at the University of Hull and Hull/York Medical School, is one of six surgeons who exercised their right to refuse publication. He told Student BMJ: “The principle of transparency is, of course, a good one but transparency in the context of outcome data must mean that the data itself is reliable, complete and relevant. Unfortunately the aortic aneurysm mortality data published at an individualised level fails on all three levels.”
McCollum said he opted out of publication of his data, against immense pressure, in the hope that journalists would ask him for his reasons. He said his concern is not with the principle of publishing information but that the figures would be misleading for patients.
He said that data for elective open aneurysm repairs and endovascular aneurysm repairs were combined to reach statistically significant conclusions. However, the expected mortality for these operations varies substantially, which makes the risk-adjustment ratio between the two harder to calculate. Publishing combined data would give patients a confused picture, meaning they might conclude that the safer endovascular operation was more risky than it actually is and the open operation safer. McCollum also argued that there are insufficient data to publish results for all operations.
Does mortality reflect quality?
Other critics see shortcomings in using mortality figures in isolation. John MacFie, president of the Federation of Surgical Specialty Associations, said: “The publication of individual surgeons’ performance data is crude and can be misleading, and does not include essential information such as duration of hospital stay and returns to theatre.”
He argued that mistakes are rarely attributable to surgical skill alone and could reflect wider failings of a department or institution. Angela Skull, consultant colorectal surgeon at St Richard’s Hospital in Chichester, said: “Very few of the deaths recorded in the mortality data will have occurred on the operating table. In my 40 years’ experience as a consultant orthopaedic surgeon I only witnessed four or five such deaths, and they were all critically ill patients who died while attempts were being made to save them. Surgical deaths occur nearly always as a result of postoperative complications and only a very few of these are due to poor surgical technique.” These surgeons point to the multifactorial nature of surgical success. Mortality can be due to a lack of cohesion within the team, the inexperience of an anaesthetist, or poor hygiene leading to infection. This is a criticism recognised by Keogh.
The future of surgery
Medical students who are considering surgery also have concerns about the move. Ross Munro, a second year medical student at Brighton and Sussex Medical School, said: “The decision to publish surgeons’ mortality rates has greatly decreased my enthusiasm for a surgical career. It troubles me that the lay public would be assessing their surgeon’s skills on mortality rates, which are not necessarily a sound measure of a surgeon’s ability. I feel that if data is viewed by the nation, it should represent all the factors which make up the complete surgeon.”
Training of junior doctors could also be affected by the move to publication of surgical mortality rates, although only the consultants’ data are published.
Daniel Gibbons, an intercalating student at Imperial College London, said: “I can see why surgeons would be hesitant. On the one hand it is meant to drive up standards, but on the other it doesn’t allow the junior doctors, who will make more mistakes whilst learning, to have that exposure to new cases that are necessary for skill development.”
A concern is that supervising consultants may be reluctant to allow aspiring surgeons a chance to practise their skills to achieve a higher standard, because any mistakes caused by inexperience could blot the consultants’ figures. However, the new policy could ensure better supervision and training of surgical trainees. The hospital and surgical teams will now have a bigger incentive to ensure trainee surgeons are not left to their own devices and receive more instruction and guidance from their institution and senior practitioners.
Patients who view mortality figures may choose not to have their operation performed by younger consultant surgeons, with fewer total operations to their name to average out their errors. The result may be that surgery training will stagnate and as older consultants retire, their replacements will be less practised and skilled.
Another fear is that surgeons will be less willing to do complex or risky operations because failure will damage their overall mortality ratings and expose them to public censure. This could stifle innovation and creativity in surgery and mean that patients with a higher risk of death in operations will not be offered the chance of treatment. The advancement of surgical science could be slowed or halted in the United Kingdom.
McCollum said the move to further transparency will further subspecialise the surgical workforce, moving practice towards fewer, larger specialist units. Surgeons may be cautious and stick to the operations where they have more experience, rather than covering a range of techniques and areas. We can already see the effects of this funnelling, with specialist centres attracting some of the best subspecialists, such as St George’s Trauma Centre and the National Hospital for Neurology and Neurosurgery.
McCollum argued that data should be collected from this specialised institutional level, not from individuals. He believed internal pressures to drive up standards would have the dual effect of producing sufficient data from which to make meaningful claims and boosting surgical successes.
The long term effects of the decision to publish the mortality rates of NHS surgeons will likely take time to emerge. However, NHS England should monitor the outcomes to pick up on potentially unintended consequences for the practice of surgery or surgical training.
Although publication in the interests of transparency and quality is a worthy goal, genuine questions remain about whether the data now being published are sufficiently meaningful or give a fair representation of the skills of the surgeon. It remains unpopular among many surgeons, who believe they have little option but to go along with the scheme. Perhaps more importantly, the data in their current form may be insufficient to help patients make truly informed decisions about their options for surgical treatment.Kiran Raja Eyre, second year medical student
1Brighton and Sussex Medical School, UK
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h852