Getting to the heart of the matter
26 January 2011
In recent years the extent of openness, transparency and accountability have become key issues for democracies across the world. In Britain, building on work by the previous administration, the coalition government has stressed the need to 'radically shake-up what transparency means in government'. This includes publishing the death rates of patients operated on by individual cardiac surgeons.
Reporting of hospital and surgeon death rates has been adopted in several countries in recent years, including the US. In Britain they have been published on the internet since 2008.The thinking behind this is that disclosure of such information will lead to improvements in the quality of care, make doctors more accountable, and help patients choose their doctors. However, some frontline doctors have resisted disclosure of mortality rates because it could encourage colleagues to avoid treating clinically difficult patients. Some also claim that death rates obscure other measures of their performance, that the quality of information is poor and that disclosure threatens their freedom to practice.
In a research project for the ESRC Public Services Programme, co-funded by the General Medical Council (the regulatory body for doctors), Dr Mark Exworthy, Professor Jonathan Gabe and Dr Glenn Smith from Royal Holloway-University of London, and Ian Rees Jones from Bangor University, explored the impact of disclosure of death rates on cardiac surgeons. In 2009, they undertook an in-depth study at the micro level of a surgical unit, the meso level of the hospital in which the unit was based and the local Primary Care Trust, and the macro level of the regulatory environment. The research explored the connections between clinical professionals, managers and regulators.
At the micro level, the researchers found differences of opinion among the surgeons about the consequences of disclosing their individual death rates. While trainee surgeons accepted the reporting of death rates, there was some resistance from senior surgeons who saw it as a threat to their autonomy. All surgeons recognised that disclosure was changing trainees' experiences and reducing opportunities to operate on high-risk patients. And as published death rates for named surgeons also include juniors working under their supervision, such surgeons were more likely to operate on high-risk patients themselves so as to avoid a negative impact of the published death rate.
At the meso level, hospital managers did not use the information about death rates to manage surgeons. They approached these issues cautiously, working with local clinical leaders. However, they could see the benefit of publishing low mortality rates to attract patients. Primary Care Trusts were not using this information when they commissioned acute medical services.
At the macro level, policymakers and professional bodies were enthusiastic about publishing death rates; the Care Quality Commission (regulator) and Society for Cardio-thoracic Surgeons (surgeons’ professional body) have co-sponsored a heart surgery website to report surgeons' death rates. Given the lack of enthusiasm from some senior surgeons, divisions may become apparent in the future between the surgical leaders and rank-and-file surgeons.
It is significant that research from the US and Britain suggests that patients do not use reported death rates to inform their decisions. Death rates for British cardiac surgery are currently below two percent of operations, suggesting that most patients survive surgery. Hence, work is now directed towards other measures such as quality of life, which are reported by patients. Equally, as reporting remains voluntary, a quarter of surgeons do not release their death rates for publication. Little is known about this group who do not disclose.
Reporting the performance of public services is likely to accelerate and broaden in scope. But while reporting brings important benefits, it is not a magic bullet for the problems of health services.
From the ESRC magazine Britain in 2011