Sir, I am baffled by the report that Sir Bruce Keogh will require surgeons’ death rates to be published (News, Nov 17). He is a serious surgeon with a track record of good sense. Why is something so extraordinary going out under his name? Anyone who has worked in the NHS knows that avoidable postoperative complications are more related to nursing care than anything else, and that surgeons have little control over that. Clearly a correct diagnosis has to be made, and the correct operation offered and performed by the surgeon. Once the last stitch is in, it’s over to nurses and physios to ensure success. Death rates will reflect the success of the team working together, not the skill of the surgeon. - Alastair Lack – Coombe Bissett, Wilts
This letter appeared in the pages of The Times almost exactly a year ago. Although it was not written by a cardiac surgeon, it represented an articulation of the reaction of many members of the profession to the news that the Society for Cardiothoracic Surgery had decided to place surgeon-specific mortality data in the public domain. On the one hand, there was the suggestion that this would serve as a performance measurement tool for the surgical community, and enable patients to make judgements about where they had the best chance of getting a favourable outcome if they needed cardiac surgery, and on the other was the contention that viewing results exclusively as a reflection of the competence of individual surgeons is essentially simplistic and ignores a multitude of other factors that may or may not contribute to a patient’s prognosis.
The publication of this data will, said surgeons, achieve exactly the opposite of what is intended in terms of the identification and promotion of quality of care by actively encouraging risk-averse behaviour, whereby the most challenging cases will be shunned by surgeons who are fearful that information regarding morbidity and mortality that are the result of circumstances outside their immediate control will impact upon their professional profiles.
So who is right and who is wrong on this matter? At this year’s Congress in Newcastle, Mr Sam Nashef addressed the issue with expert eloquence, dealing specifically with risk stratification and the interpretation of mortality statistics. When I put it to him that results are not infrequently affected by events seemingly unrelated to individual surgical performance, such as displaced tracheostomy tubes or problems with Swan-Ganz catheters, he conceded that these possibilities do exist, but maintained that the consultant surgeon, as ultimate team leader, must bear overall responsibility for both the prevention of such complications and for their sequelae if they do occur, regardless of their being ostensibly external to his or her sphere of influence.
While some of us may believe that Mr Nashef’s magnanimous stance on this is admirable, I would be surprised if it is a position that is universally adopted by all of his colleagues. On the contrary, it would seem intuitive to assume that the assertion in the second paragraph of the letter above is more likely to be the majority view. Indeed, in my own unit, it is rare for surgeons, cardiologists and anaesthetists to discuss a case postoperatively at one of our monthly review meetings and conclude that any unfavourable outcome is primarily attributable to individual surgical performance. Having said that, one should not be blind to the reality that it is almost certainly not coincidental that the argument that highlights the significance of collective clinical responsibility is being wheeled out at a time when surgeons are finding themselves increasingly under the spotlight. Although it would clearly be uncharitable to tar everyone with the same brush, I am sure that we all know more than one cardiac surgeon who would have been grievously offended ten years ago by the suggestion that the contribution of the nursing and physiotherapy teams is on a par with that of the surgeon, particularly when things go well. To put it in a nutshell, you can’t have it both ways, guys.However, notwithstanding all of this, if we were to make the broad assumption that both good and bad outcomes in cardiac surgery are generally the result of varying levels of contribution from every component of the multidisciplinary team, where does the role of the perfusionist feature in the grand scale of things? We should not forget that on more than one occasion our profession’s representations to the Department of Health during the interminable struggle for statutory regulation have been underpinned by the assertion that “cardiopulmonary bypass is the single most invasive procedure in existence in medicine today.” While it is true that modern perfusion systems are associated with extraordinary levels of safety (older members, please compare with what we used in the 1980s), it is also indisputable that there are bypasses and there are bypasses: we all know when we have been responsible for or have witnessed best practice, and equally, quite the opposite. The surgeon must necessarily prevail as the dominant force throughout a patient’s surgical pathway, but the importance of the input from other teams, perhaps most notably anaesthetic and perfusion, must never be underestimated.
So where does all this leave us when it comes to publication of mortality data? For many, an analogy is to be found in the way things were thirty-odd years ago when the idea of identity cards for members of the public was being mooted – if you haven’t got anything to hide, why would you have a problem with it? Others continue to see it as having the potential to apportion blame unfairly in terms of the quality of surgical outcomes, and identify it as a factor that is likely to act as a deterrent for junior doctors when they come to make career decisions about which surgical specialty to pursue. Like a lot of these things, the extent to which the idea continues to be prioritised within the Department of Health’s in-tray may be dependent merely upon the identity of who is responsible for formulating policy such as this at any given time – after all, it is not inconceivable that the aspiration to achieve a seven-day working week across the NHS, for example, may be modified or abandoned altogether for no other reason than a change of political party in this country over the next few years. Perhaps the most that cardiac surgeons can hope for at present, or at least while Professor Sir Bruce sees mortality data publication as the way forward, is that the identification of high quality performance is the most common of the several outcomes that this tool has the potential to achieve.