Surgeons must be in a position to understand risk to patients so that they can overcome reluctance to take on high risk cases, writes Graham Copeland
Surgical risk is an area fraught with complexity and yet all too often in the NHS we end up taking the easy route by focusing on one or two indicators to assess risk.
However, it is becoming increasingly clear that this must change: the NHS needs to adopt more sophisticated ways of assessing surgical risk.
Over the last 25 years case mix complexity has risen. Until recently, surgeons had, over time, become predisposed to operate on more and more complex cases. This meant more patients would have had the chance of an operation when previously surgery was simply not an option.
However, recent reporting suggests there has been a reverse in the previous trend of surgeons taking on more difficult cases. Since the publication of unadjusted mortality rates, we have observed a fall of around 30 per cent in the complexity of cases surgeons are prepared to take on.
What if we go wrong
Certainly in some surgical disciplines, patients are now once again not being given the option of an operation in difficult circumstances, such as perforated diverticulitis, small and large bowel obstruction and blunt abdominal trauma. In a recent poll of heart surgeons it was revealed that at least one in three has refused to treat critically ill patients because they are worried it will affect their mortality ratings if things go wrong.
Surgeons refusing to operate have admitted they recommended a different treatment path to avoid the risk of adding another death to their score
The publication of unadjusted mortality rates has inevitably had an impact. Surgeons refusing to operate have admitted they recommended a different treatment path to avoid the risk of adding another death to their score.
Former president of the Royal College of Surgeons and senior clinical adviser to the secretary of state for health Sir Norman Williams recently spoke of a climate of fear amongst surgeons encouraging defensive medicine and a reluctance to take on high risk cases which might otherwise benefit from surgical intervention.
This is bad news for clinicians, for NHS trusts and above all for patients. Rather than publishing unadjusted mortality rates, we need more sensitive data to help surgeons understand their performance and how it can be improved.
As a surgeon, I firmly believed in being accountable for my practice, and I welcome the move to greater transparency. However, the true picture of quality within an organisation is not accurately captured using blunt mortality statistics which don’t genuinely adjust for clinical risk.
Getting an understanding
Surgeons should be in a position where they can assess their patients beforehand so that both patient and surgeon can understand the risk.
National and international benchmarking which standardises for risk can identify areas for concern but also highlight centres of excellence
The Francis report recommended that healthcare providers develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system. The solution is to ensure that measures of clinical quality take into account the case mix of patients treated, based on their individual circumstances. All of this is possible now.
Consultants and their teams can use this clinical audit analysis to identify areas of strength – and weakness, allowing them to analyse and improve their performance over time. Such improvements in clinical care will lead to lower mortality rates, but can also reduce complications and improve clinical teams’ assessment of, and responses to, surgical and medical risks. The natural corollary of this focus on quality is greater cost effectiveness and an improved patient experience.
Clinical audit data of this kind also helps medical directors to assess the performance of their staff – both doctors and nursing staff – across even the largest and most complicated organisations. National and international benchmarking which standardises for risk can identify areas for concern but also highlight centres of excellence.
This provides a greater level of confidence for responsible officers who must sign off the organisation as safe but also motivate the staff who deliver that care by celebrating the many things that they do well.
Graham Copeland is the former national director for Clinical Audit and an international authority on risk and quality in healthcare. He has advised government bodies around the world, as well as the WHO on this subject.