Background Information

In 2001 a public inquiry was held into the high number of babies’ deaths during heart surgery at Bristol Royal Infirmary.

The chairman, Professor Sir Ian Kennedy, recommended a relatively novel concept that results by clinical teams should be published to drive up the quality of care.

Cardiac surgeons in the UK began working on collecting this data relating to patients undergoing coronary artery bypass grafts.

Despite concern by many surgeons that the information would be misinterpreted by the media and the public, the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) went onto publish mortality rates for all NHS hospitals and about 80% of surgeons, and has continued to do so. The early evidence suggests that this has been good for these patients, improving quality. An analysis of more than 25,000 patients in the north west of England found mortality risk for heart bypass candidates has gone down, with no obvious ill effects.

The collection of data to improve care has been practised by doctors since Victorian times. It was Florence Nightingale who carried out one of the first clinical audits during the Crimean War in 1853-1855. There were high mortality rates among injured soldiers at the medical barracks in the hospital at Scutari. With her team, she introduced sanitary routines and hygienic standards of to the hospital and equipment, and also recorded the mortality rates among the patients. As conditions became cleaner, the mortality rates fell from 40% to 2%.

Data collection is now a core part of the quality improvement process for the NHS and allows hospitals, GPs and patients to know where their service is doing well and where there could be improvements.

In the UK, there are both national clinical audits, and audits that are carried out locally in a trust, hospital and GP practice or care home - anywhere health or social care is provided. They measure the effectiveness of care or an operation, against a set of agreed standards.

This enables the team or the doctor to see where their practice can be improved against given benchmarks, to take action, and then to re-measure and make further improvements.

There are now well established audits such as the National Joint Registry (NJR) which was set up by the British Orthopaedic Association 11 years ago to collect information on all hip, knee, ankle, elbow and shoulder replacement operations, and to monitor the performance of joint replacement implants. Greater public transparency and accountability has been a key policy under successive governments. Publishing outcomes data is a central part of this move, allowing patients more access to information about surgery outcomes and enabling them to have a more informed conversation with their surgeon about their care. The National Health Service Commissioning Board went on to commit to publishing mortality rates and other outcomes of surgery by summer 2013, of which the Royal College of Surgeons was very supportive.

The work was led by the Healthcare Quality Improvement Partnership (HQIP) under the auspices of NHS England’s Medical Director, Professor Sir Bruce Keogh. Professor Ben Bridgewater, a consultant cardiac surgeon at the University Hospital of South Manchester, was seconded to the HQIP to support its work. In 2013, surgeons across Britain became the first in the world to publish consultant outcomes data and lead the way in the NHS transparency agenda. A process that has now become an integral part of the profession.

As well as furnishing patients with a greater level of information, publication of the data has been used by surgeons, to better understand and improve their practice.

It also provides evidence and enables surgeons to make the case for improvement in facilities and support where necessary.

The Royal College of Surgeons of England supports the publication of the data, but believes it is vital that any analysis of surgeons who take on the higher risk patients (such as those with complex health needs like diabetes and respiratory problems) is fair and reflects the complexity of these conditions so as not deter surgeons from treating difficult cases for fear of being penalised. The process by which the data is analysed is constantly evolving and we welcome developments in the future to ensure that the data is always comprehensive, robust and reflective of the surgical professions work, and acts as a useful tool for both patients and surgeons.