Partha Kar

Transparency has to be based on good data

Joseph Pulitzer once said: “There is not a crime, there is not a dodge, there is not a trick, there is not a swindle, there is not a vice which does not live by secrecy.”

That’s been the mantra which has been at the core of the NHS’s latest effort at transparency. It’s at the heart of what Sir Bruce Keogh, NHS medical director, stands for, and part of the effort to shake off the damning Francis report and Morecambe Bay scandal.

Now I know Sir Bruce – I have met him – and I think his passion to improve the NHS is indeed something to be inspired by. There is no questioning his desire to create transparency but one thing I have learnt is that if you want to use data to support performance management and drive up standards, then you have to battle past a treacle of cynicism, and mistrust of NHS data.

Because if you show data which is then exposed as wrong, you have not only lost face, but also the troops. You have lost their trust that the data you produce is meaningful, that it is about patient care and not just ticking some boxes. So when the vascular surgery data came out, I did indeed feel emboldened to believe that perhaps, just perhaps, the powers that be had indeed got it right.

And then I opened the Telegraph. Sensationalised was the fact that a certain surgeon from our local trust had the highest mortality rate in aortic aneurysm repair. Nearly a third of his patients had died…shock and horror…how do we allow such poor surgeons to operate?

This doctor hadn’t done such surgeries since 2010/2011- and is a specialist in carotid endarterectomy. His mortality rate there? A mere 0%. The Vascular Society made amendments to their document later in the day – but by then the damage was done. Collateral damage, said some. Part of the learning process said others. It’s always easy to be philosophical when your own name isn’t being dragged through the mud, isn’t it?

Moving away from the individuals, let’s look at it in a scientific way. Here is a quote from the document concerned: “Often information about the severity of disease is added to a risk adjustment model but a minority of patient records in the dataset were missing this information for one or two variables and, to avoid dropping these patients from our analysis, we did not use these variables for risk adjustment.”

Seriously? So, no account of severity of illness? No account of quality of pre and post op care? No account of coexistent morbidity? You now account a death directly to a consultant… the other members of the team don’t matter anymore? Even for the surgeons who have performed ‘well’, where’s the recognition for the team around them? The anaesthetist, the nurse, the physiotherapist, the GP – all of whom factor in the 30-day post operative recovery?

Let me give you a personal example. How do you measure me as a doctor? Our local amputation rate was poor in 2010, so does that mean I am to blame as the departmental lead? What is the responsibility of the nurse specialist, practice nurse, and GP, all of whom are involved in the patient’s diabetes care? No responsibility given to public health – who still can’t get a grip on smoking which is known to make amputations worse?

Anyhow, let’s assume that makes me a bad doctor. Now how about patient feedback? A patient kindly nominated me and I won an award for hospital doctor of the year…so now am I a good doctor?

The reality is that medicine is complex and you cannot just take a marker out of thin air and fix it to a consultant saying all of the process is a cross for him or her to bear. If you want to measure and have transparency, then do so for the team. Measure the outcome of a vascular team. Measure how they perform together. It is a crying shame that the evangelists are quick to quote Formula 1 racing and airlines as models to emulate – but forget to stay away from individuals rather than team while estimating performance.

Jenson Button may be a fabulous driver, but what is he without the right team and car? He struggles to qualify. I was there at Silverstone and no one called him a poor driver.

My worry? It switches off people from learning and using data to improve patient care. Cynicism sets in. Gaming begins. To get your mortality rates down, don’t touch any patients with a higher risk. Here’s some simple but scary maths. Ten patients have complicated problems; if a skilled surgeon operates on them maybe five survive. His mortality rate? 50% ergo BAD surgeon.

Walk away from them all? Mortality rate 0% ergo GOOD surgeon. Who loses? Those five patients and their family who could have survived due to the daring and risk taken by the surgeon concerned.

Be very careful what you wish for in the name of transparency. A lot of things are at stake here. Reputations; morale; the ethos of teams and above all, patient care. I am a big believer in transparency but do so properly, not to satisfy any diktats or tick a box.

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