For decades, the consultant was king, unchallenged and unchallengeable. However, British surgeons will soon operate under unprecedented transparency following the introduction of rules that will tell their patients more about them than ever before.
From next month, patients preparing for operations under 4,000 surgeons working in 10 different specialities – nine of them surgical – will be able to see data about their consultant’s performance levels and how they compare to their peers.
And, the information-gathering exercise will not stop outside the hospital as soon as the patient leaves after an operation. It will continue to track future mortality rates, their length of stay in hospitals, how many developed complications, or needed to be operated upon again.
Records could be questioned
Understandably, the changes are making some people nervous, fearful that their records could be questioned or, worse, misunderstood by the public, particularly with the help of sensationalist reporting by the press.
One of those who has led the changes, Prof Norman Williams, the president of the Royal College of Surgeons, told The Irish Times: "We really do see this as a watershed moment for the profession – it is all about transparency."
The figures cannot be produced as a simple league table, as that would not fairly reflect the breadth of cases dealt with by surgeons, since some deal more with older, sicker patients, or those who have had operations repeatedly in the past.
Some fear that transparency could make surgeons more reluctant to take on riskier cases, fearful that they could be in danger of being stigmatised in the court of public opinion if their successful operation figures start to fall.
However, Prof Williams points to cardiac surgery, which was rocked to its foundations in the 1990s by the Bristol Royal Infirmary’s controversy, where babies died because surgeons were poorly led and not up to the task.
Mortality rates
Since 2005, information about the mortality rates recorded by hospitals' cardiac surgery units and, just as crucially, by individual surgeons has been published following recommendations from the Bristol inquiry.
The change, if an uncomfortable one for many, has improved standards all round, he said, adding that fears that it would make them chary of more difficult cases were not borne out: “Standards are going up and up.”
Saying that, they were “pleading” with the press to report responsibly, he said.
“I suppose the profession is concerned about individual people being wrongly stigmatised. We think that if a surgeon is performing at a truly low level – which we think there are very few [of] in this country, actually – we feel they should be helped to get up to a standard that is really excellent.
"What we don't want to see is people being stigmatised for the wrong reasons – which is why we want to explain that someone can appear to be an outlier when they're not at all," he went on.
Changed landscape
For Martyn Porter, the president of the British Orthopaedic Association, the landscape has been changed utterly by the Mid-Staffordshire Foundation crisis, where hundreds, if not thousands, of patients died because of poor care.
“This is a very important paradigm shift in healthcare. If you look at 10 years ago there were cases of individual surgeons who had poor practices and there were a lot of harmed patients who had suffered.
“By using audit you detect problems at a much earlier stage. I think it was inevitable that after Mid Staffs that people would ask questions.
“ I think there is a certain lack of confidence in the system, I think this is a way of re-establishing confidence,” he said.
Information about orthopaedic surgery – about numbers, if not individual surgeons – has been gathered and published by the National Joint Register for 10 years, a register that is now the largest in the world, with 1.3 million operations recorded, said Mr Porter.
Indicating that sometimes the issue is not with the surgeon, but with the tools, Mr Porter said the register played an important role in highlighting the problems that existed with the ASR metal-on-metal hip transplant.
Understandably, not everything will be revealed by the first set of figures to come in July, though the numbers will become more comprehensive as the years go by: "Some of the data is mature, some is not," said Prof Williams.
Unit closures
However, the statistics may in time encourage the closure of smaller hospital surgery units, he acknowledged, since surgeons who are carrying out small numbers of operations may be at risk of looking worse than the average.
Backing major units, Prof Williams said the argument was a simple one in urban areas. The closure of London’s “30 plus” stroke units to just eight over recent years, a move unpopular when it began, has seen mortality figures fall drastically.
“There is no getting away from it, if you want a better result as a patient, you are better off in a bigger unit that is doing these things day in, day out. There is no argument about it,” he said.
