TITLEATFITTLEER MID STAFFSWhy the dedicated professionalism of the Hospital, and a long history of other reportsUK cardiac surgeons offers the best way detailing poor care from across the NHS, theof ensuring a consistently high standard public are right to be concerned for patientsof medical practice across all specialities needing medical and nursing care.in future As has been amply demonstrated in this book, theSir Donald Irvine, Former President of the GMC, recent story of adult UK cardiac surgery shows that surgery of consistently high quality can beChairman, Picker Institute Europe achieved and sustained over time across a whole specialty. This is a very significant achievement, When we with implications extending across the NHS. become ill, if our problem The critical factor is that, both as individuals and requires through the SCTS, the cardiac surgeons decided surgery – that they must take prime responsibility for setting especially and ensuring the standards of clinical practice and cardiac care in their specialty. They see this responsibility surgery - as the core element of their ethical duty to the we want public and to their patients, the right thing to do, to be seen the very essence of their professionalism. After all,promptly by a surgeon who has a reputation for the consultant members of SCTS are the nationalproviding first class technical care, who we know experts in cardiac surgery; if not they, to whomachieves consistently good results, and who can could patients, employers, and regulators turn?relate to us in a way that forges our trust. Aswell as excellent surgery, we want the overall The acceptance of this responsibility to the publicexperience of care, from cardiologists, nurses, by a membership organisation caused somereceptionists, radiographers and the many others internal stresses and strains because, for somewho may become involved in looking after us, to members, it was a new and very significant change.be exemplary from beginning to end. However, clear-sighted leadership has prevailed.Throughout the history of modern medicine there The foundation method was the establishmenthave always been patients who have had such of the National Adult Cardiac Surgery Audit,experience, but others have not. So, a big question which describes the patient mortality ratestoday for the medical and nursing professions, of every NHS cardiac surgeon and surgicaland the managers of the NHS, is whether a state team doing every individual operation onof consistent ‘goodness’ can be achieved across every patient in the NHS. The surgeons haveall specialties and settings for all patients, all of found that surgeon-specific degree of datathe time. With disasters like Mid-Staffordshire HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 51
granularity to be essential. They have also set best place. Third, SCTS has shown that, over time,the bar high, to reflect the optimal standard of the results of UK surgery are getting steadilypractice achievable under normal operational better and even safer mainly because frequentcircumstances. They have embraced complete feedback has resulted in the fine-tuning oftransparency through the publication of their surgical performance. This is incremental qualityresults on the SCTS website. At the same time, improvement as it should be. And lastly, becausethe SCTS has developed a sophisticated method the improvements in surgery have reduced thefor continuously monitoring the results so that time spent in hospital, the money saved appearsunexpected departures from the prevailing to have more than covered the costs of operatingstandard can be quickly spotted, investigated the monitoring system. The overall result isand attended to before patients or surgeons fantastic. Everybody wins – patients, healththemselves are exposed to further risk. They professionals, NHS and taxpayers.have managed to do this whilst still makingit possible for surgeons to carry out risky Looking ahead, the SCTS has also describedoperations on patients who have chosen surgery what it is now doing to make sure that patientsbecause they know their patients would have get great care as well as excellent surgery. Inno chance of life without it. For patients and addition to technical surgical performance, theysurgeons this element of professional discretion are now thinking in terms of the totality of theis vital, and must be protected. patients’ experience of care from the moment patients enter their service. This means theAnd what do the results tell us? First, the nursing care, the outpatient experience, and allstandard of adult cardiac surgery is uniformly the ways in which the patient’s journey can behigh. Of course there is some variation as one made as good as possible. Hence, for example,would expect in a difficult field demanding the involvement of some SCTS members with thegreat skill and professional judgment, but it is Picker Institute’s work to develop tools to providesmall. For the British public these results are evidence of the patient’s experience of individualwelcome news. They mean that any NHS patient surgeons, particularly of their attitudes and theirundergoing cardiac surgery can be assured of the communication and interpersonal skills. Thesecompetence of the surgeon – the SCTS through instruments should therefore tell us how well aits system of monitoring and the continuous named surgeon is meeting the generic standardsprofessional development of surgeons has seen to set out in the GMC’s ethical code – Good Medicalthat. The second point is that the overall results Practice -particularly those that focus on theof UK cardiac surgery put the UK at the top of the importance of the doctor-patient relationship.international league table. So, patients havingcardiac surgery in the NHS know they are in the52 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS
The SCTS intends that the patient’s chosen no need for the plethora of organisations withsurgeon will be there to take a personal interest in commissioning and performance managementthe progress of their case. Patients will know that responsibilities”3.they can turn to their consultant, someone whomthey know they can trust, if they or their relatives So the question now is how to extend thehave wider concerns about the quality of nursing approach to professionalism and quality taken byand general care. the cardiac surgeons to all other disciplines of the UK medical profession.This new, deeply ethical professionalism in thepractice of cardiac surgery, rooted in professional Implications for Medicine and the NHSconscience, is the much-needed alternative to theprevailing culture of target-driven managerialism In cardiac surgery, we are fortunate that a workingrife in too many parts of the NHS. Robert Francis, model of exemplary care where many of thein his letter introducing his report to the Secretary things the government and NHS want to do, andof State for Health, described in the NHS an the public are hoping for, are already there, tried…”insidious, negative culture involving a tolerance and tested, and up and running. Some examplesof poor standards and a disengagement from of the wider implications are given below.managerial and leadership responsibilities”.Significantly, he added in the report that….”if all 3. Report of Mid Staffordshire NHS Foundation Trust Public Inquiry.professional staff complied at all times with the Volume1. Analysis of evidence and lessons learned (part1). London;ethics of their professions there would have been Stationary Office, 2013 HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 53
1. Professionalism 3. Royal Colleges and Specialist SocietiesI put this first, deliberately, because it is about Several specialist societies are looking anewculture and values which, for better or worse, at their responsibility for clinical standards andultimately inform all performance. We have seen the measurement of performance against thosethat the UK cardiac surgeons have embraced a standards. The British Cardiovascular Society,professional ethos and mindset which puts the which is the expert professional body for UKneeds of the patient before all else. They therefore cardiology, is a good example of a Society which issee personal and collective responsibility for now travelling the same road. They are publishingperformance as basic, regard the observance of a statement – Professionalism and Transparency:optimal standards of performance, ethics and What Makes a Good Cardiologist? – jointly withservice as a matter of professional obligation and sister societies in Australia, New Zealand, and theconscience, and are committed to accountability to US - on clinical and professional standards.patients, colleagues and public through completetransparency about the results of the effectiveness The Royal Colleges and Faculties are primarilyand experience of all aspects of care. about professional standards, which is why they qualify as registered charities. They areThis holistic view of professionalism linked all membership organisations. Now, all faceinextricably to quality is still uncommon in the the same challenge managed so successfullyhealth professions today, yet is exactly what by the cardiac surgeons. Together, they have apatients want. All other medical specialties, wonderful opportunity to transform the face ofgeneral practice and the nursing profession British medicine. They do need to recognise thatshould now adopt it. institutional inertia on this fundamental matter is no longer credible or acceptable.2. DataNHS England4 has recently publishedan important statement of intent aboutquality, choice and the centrality of data andtransparency in the future NHS. In particular,mortality rates for several surgical specialtiesand interventional cardiology are to be analysedand published by individual clinician, a directconsequence of experience in cardiac surgery.Feedback on patient experience is to assume ahigh order of priority.4. http//www.commissioningboard.nhs.uk/everyonecounts/54 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS
4. General Medical Council the robust instrument for assuring the public ofThe GMC controls the registration, licensing the quality of British doctoring that its authorsand specialist certification of UK doctors. GMC originally intended it to be.registration and licensure are meant to givepatients and employers a guarantee of the 5. NHS Hospital Governancequalities of a doctor in whom they can place Last but not least, there is the impact on hospitaltheir trust. The SCTS initiative impacts on these clinical governance. The SCTS clinical outcomesprocesses in two main ways. initiative, to be reinforced by revalidation, a CQC fully focused on quality and the plans forFirst, the clinical standards set for cardiac NHS Commissioning, should put much neededsurgeons by the SCTS complement the generic pressure on NHS trust boards to manageprofessional standards set by the GMC in Good quality more effectively in the future across allMedical Practice, the latest edition of which has clinical services. It is interesting that hospitalsjust been published5. in Western Europe and North America which achieve outstanding results have boards whichSecond, on revalidation, SCTS intends that the share the following characteristics; they take fullsupporting evidence cardiac surgeons submit responsibility for the performance and reputationfor their annual appraisal will be as objective as of their institution; they put the needs of patientspossible, containing outcome data, evidence that absolutely first; they demand excellence; theytheir knowledge is up to the mark, evidence of support staff who want to achieve excellence; theypatients’ experience with their particular surgeon, are intolerant of poor or mediocre performance;and confirmation that their ethical conduct and they have good comparative data giving anaccords with the generic standards in Good up to date picture of how well they are doing. ThisMedical Practice. It is anticipated that evidence of basically is how the SCTS has approached itscompetence and performance will be published, responsibilities. NHS management has much toso that anyone should be able to see the basis on learn from their example.which appraisers and Responsible Officers aremaking revalidation decisions. All this will bring And finallymuch needed objectivity and transparency to theprocess of revalidation. The SCTS is thus setting At a time when there is so much gloomy newsa standard of evidence for revalidation that, I about the NHS, the UK cardiac surgeons havebelieve, the GMC should insist become the norm shown us that there is a clear way ahead that isacross British medicine as soon as possible. Then effective, affordable and just what patients want.revalidation has an excellent chance of becoming That is reason enough to be thankful for their initiative, leadership and good example.5. General Medical Council. Good Medical Practice, 5th edition.London; GMC, 2013 HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 55
CONTACT INFORMATIONRebecca CosgriffNational Adult Cardiac Surgery Audit Project ManagerEmail: [email protected] Floor170 Tottenham Court RoadLondonW1T 7HABen BridgewaterNational Adult Cardiac Surgery Audit Clinical LeadEmail: [email protected] the SCTS by emailing: [email protected] // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS
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