Intended for healthcare professionals

Reviews Press

Why doctors' outcomes should be published in the press

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7526.1210 (Published 17 November 2005) Cite this as: BMJ 2005;331:1210
  1. Ben Bridgewater (ben.bridgewater{at}smuht.nwest.nhs.uk), consultant cardiac surgeon
  1. South Manchester University Hospitals Trust

    I recently gave a talk in a debate at a UK regional meeting of vascular surgeons, proposing the motion that “vascular surgeons' mortality data should be published in the press.” The initial request came through for a “light hearted” presentation for five to 10 minutes at the end of the day.

    Before the meeting I suggested that the publication of named clinician outcome data was one of the biggest things to happen to cardiac surgery over the past 20 years and that it would inevitably happen to vascular surgery. I also said that the subject was not light hearted and would merit more time in the programme. The debate went ahead as initially planned, and an eminent vascular surgeon was invited to the meeting to oppose the motion.

    I based my talk around the fictitious premise that my 78 year old father had recently been diagnosed as having an abdominal aortic aneurysm, and now required urgent surgery. I used the example to demonstrate the paucity of data available to patients and their carers undergoing this type of major surgery.

    There is insufficient data available from hospital websites, professional organisations, or the Healthcare Commission to demonstrate that there is satisfactory clinical governance in place to assure the quality of major vascular surgery in the United Kingdom. There is no identifiable mortality or other outcome performance data accessible to enable people to choose a safe surgeon or hospital.


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    Not naming and shaming: the Guardian published named surgeons mortality rates in March

    It is accepted that there are different models for dissemination of health outcomes data: the professionally oriented model, the public accountability model, and the market oriented model (Dying to Know: Public Release of Information about Quality of Healthcare. Nuffield Trust and Rand, 2000). The lack of available data for patients, coupled with the fact that more than half the vascular surgeons in the UK currently do not contribute to the national vascular audit database (http://www.vascularsociety.org.uk/), suggests, I argued, that the professionally oriented model is failing, and the public accountability model is desperately needed.

    Cardiac surgery in the UK has a long history of data collection, but it has only been recently that comparative outcome data has become available to the profession and the public. The agenda has been driven by the Dr Foster organisation (http://www.drfoster.co.uk/), which published an analysis of comparative hospital performance for coronary artery bypass graft mortality as long ago as 2000. I, among others, was critical of this at the time (BMJ 2002;324: 542).

    The Guardian newspaper used the Freedom of Information Act to publish named surgeons' mortality on 16 March 2005. Contrary to most doctors' expectations the journalists at the Guardian, and their counterparts who covered the story in the local media, used the data responsibly, presenting the dominant message that the data were reassuring and accountability was beneficial to patients, rather than looking to “name and shame” badly performing individuals.

    These repeated, media-led initiatives have stimulated the “professionally oriented” model for public disclosure (BMJ 2005;330: 506-10). However, without the involvement of the press it seems unlikely that named surgeon outcomes for cardiac surgery would now be in the public domain, despite the recommendation from the Bristol Royal Infirmary inquiry into paediatric cardiac surgery deaths that patients should have access “to the relative performance of the trust… and the consultant units within the trust” (http://www.bristol-inquiry.org.uk/).

    There are major benefits that have arisen from cardiac surgery data collection, which are far beyond publishing named surgeon mortality data. Patients and their carers now have access to a large resource of information to reassure and support them through major surgery. Most cardiac surgical units have thought long and hard about what information patients need, and how best to get it to them. The websites that most cardiac surgical units have now developed are impressive, with readily available data demonstrating to patients that their surgeon's outcomes are satisfactory, as well as giving a variety of other useful information. The cardiac surgical community now benefits from the comprehensive and accurate data for a range of purposes, including academic and managerial initiatives.

    The information available to vascular surgical patients, however, is inadequate. It is also of interest that the mortality for non-ruptured abdominal aortic aneurysm surgery is 7.2% (http://www.vascularsociety.org.uk/), which gives far more room for improvement than the 1.4% mortality for elective coronary artery surgery (according to Keogh and Kinsman's Fifth National Adult Cardiac Surgical Database Report 2003); and yet it is cardiac surgery that has been subject to the closest scrutiny. The information available for patients undergoing orthopaedic surgery, upper gastrointestinal surgery, interventional cardiology procedures, and pretty much every other area of medicine also lags significantly behind cardiac surgery, despite the far-reaching recommendations from the Bristol Royal Infirmary inquiry.

    I finished my talk to the vascular surgeons by showing a fictitious letter to “all the vascular surgical units in the country” requesting named surgeon mortality data for elective abdominal aortic aneurysm repair under the Freedom of Information Act. This letter was almost identical to the request that all cardiac surgical units received from the Guardian newspaper earlier this year. I then explained that I was only joking (to try to comply with the “light hearted” requirement for my talk) but suggested that only when this happened would quality be demonstrated and patient oriented information develop.

    Despite these arguments, the motion for public accountability of vascular surgeons' results was not carried by this particular audience. Whether this was because of the brilliance of the opposing speaker, or the entrenched attitudes of the medical profession, I do not know. However, despite the obvious benefits from the cardiac surgery experience, it does seem that it is again going to be up to the media to drive public accountability.

    Footnotes

    • Competing interests BB is a member of the steering group of the northwest quality improvement programme in cardiac interventions, and a Society of Cardiothoracic Surgeons of GB and Ireland representative on the tripartite group (SCTS, Department of Health, and Healthcare Commission), steering national cardiac surgical audit.