Advice for Medical Directors

The introduction of mandatory publication of consultant outcomes for surgical specialties by NHS England has focused more attention on surgical results. In keeping with the other specialties publishing consultant level outcome data cardiac surgery are conducting analysis at 2 levels alert and alarm with worse and better than expected risk adjusted survival respectively.

The alarm is a 99.8% confidence interval deviation from expected and will be published on NHS choices with results worse than expected. This finding is unlikely to be due to chance alone.

Alert is a 95% confidence interval deviation from expected and will be published on NHS choices as ‘as expected’. There is a reasonable probability that results may be abnormal at this level due to chance alone, but it is flagged up to surgeons and their hospitals to enable further investigations and understanding to take place as necessary, to help prevent a future alarm.

In addition to defining survival rates that are worse than expected, we have been asked by NHS England to identify and publish results for units and surgeons that are better than expected – again at 99.8% (which will be published) and 95% (which are for internal notification only). There are no 99.8% surgeon outliers at high survival rates for the 2011-2014 analysis.

The SCTS in conjunction with NICOR (the audit provider) will write to the medical director of all hospitals and surgeons that are identified as having results that differ from expected at 99.8% limits and to those below expected at 95%.

By the time any data is published it should have been validated by the units themselves. All hospitals should ensure that they have the appropriate resource and infrastructure to do so, and SCTS is aware that HQIP and NHS England have written to Trusts about this in the past.

It is recognised that the data processes and risk adjustment algorithms are complex. Should a Medical Director or his representative need to have detailed discussions about this we would suggest contacting Anthony Bradley a.j.bradley@ucl.ac.uk in the first instance.

Any results that are significantly better or worse than expected will be published and are likely to attract some media attention. If the Trust should wish to coordinate communication strategies we would suggest they contact HQIP and SCTS – James Thornton <James.Thornton@hqip.org.uk>
By the time results are published we would expect that the organization would have a good understanding of why survival rates are not as expected. We have given specific advice to surgeons on looking into mortality rates in our document advice for surgeons.

The experience of SCTS from the IRM is that results which are worse than expected are often related to organisational issues, team-working or behavioral factors rather than surgical skills. We understand that these issues may be challenging to define and resolve. SCTS strongly recommends that any survival alarm, for either hospital or surgeon, should lead to an invited review from the college of surgeons, unless the reasons for the divergence are already clearly understood and have been resolved.

SCTS recognises that risk adjusted survival rates are only one aspect by which surgeons’ performance may be judged. There are many others including incident reporting, the results of M and M discussions, coroners inquest reports and investigations, MSF and patient experience measurement. SCST would encourage all aspects related to surgeon performance to be considered in the round. SCST understands that the modern regulatory landscape involves discussion with regulators (CQC and the GMC) and is aware that HQIP have written to all medical directors involved in consultant outcomes publication about these issues.