The NHS Choices website has published death rates for four types of surgery at NHS hospitals in England. Claire Reynolds explains how this could affect performance management

The government's move to publish mortality rates for some types of surgery has been welcomed in many quarters as giving patients an opportunity to choose to be treated where their lives are least at risk. Others are not so sure and believe publication could cause complex problems.

For health service managers, a major issue is, of course, performance management. Hospitals are already identifying and dealing with poor performance, but some think publication of death rates will result in more doctors being performance managed.

The published figures will (for the time being) give results for hospitals, not individual surgeons, so a highly performing surgeon could find his or her personal reputation "tarnished" by poorly performing colleagues.

Career progress

This could affect their ability to get a promotion or change jobs. As individual performance is also to be monitored (although not, for the time being, published), surgeons wanting a move will perhaps make known their own personal figures or even be asked for them. This could have confidentiality implications and it is uncertain how organisations could confirm the truth of what a job applicant said.

Even where there is no obvious performance issue, publishing mortality rates could result in redundancies. Patients might be reluctant to be treated at a hospital with higher mortality rates than other hospitals. Fewer patients means less work.

Publication and monitoring of a hospital's figures could also affect the particularly sensitive matter of pay. Sir Bruce Keogh is reported as saying: "Once outcome measures are sufficiently robust, the figures, including survival rates, could feed into appraisals, revalidation, service line reporting and clinical excellence awards."

Financial ramifications

It is not only individual pay that may be affected. Hospitals' incomes are likely to be directly affected. When results are published, patients will choose their hospital not just on the basis of waiting times, but also quality of care. Those hospitals that seem to deliver a better standard of care will attract more patients.

For health service managers, this is likely to herald a renewed and more intense focus on performance management. When this is based on death rates, it is likely to be time consuming, difficult and contentious. As the Royal College of Surgeons has said, bad outcomes could be due to factors other than the quality of patient care, such as a bad run or case mix or even bad data.

Also, as any surgeon being performance managed is likely to point out, surgical ability is only part of the story when death rates are being considered. A recently published report by the National Confidential Enquiry into Patient Outcome and Death found that better systems reduced mortality rates among those having coronary bypass grafts. Poor organisation, communication and teamwork adversely affected quality of care for two-thirds of patients.

Greater transparency

Currently, death rates are only published for four major surgical procedures, but the drive to improve NHS outcome measures and to move towards greater transparency in all branches of medicine will inevitably lead to more statistics being published.

How are outcomes to be measured? Simply being alive at the end of a procedure is (to say the least) very important, but what about mobility and quality of life? It will be harder to measure these outcomes in a meaningful way, but it seems that one will have to be found. Sir Bruce Keogh has made it clear that there is no turning back.