Football yes, surgery noBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7349.1343 (Published 01 June 2002) Cite this as: BMJ 2002;324:1343
- Christopher Wigfield, specialist registrar in cardiothoracic surgery,
- Stephen C Clark, consultant cardiothoracic surgeon,
The main purpose of the football premiership is to provide entertainment. Competition is a source of excitement in sport, and league tables are essential tools to measure success. The prime target of cardiothoracic surgery is to restore health, often in life threatening circumstances. The process requires the application of highly technical and skilled surgery, anaesthesia, and intensive care by numerous professionals, to achieve a favourable outcome for the patient.
League tables will inevitably result in additional premature deaths
At first sight it may appear useful to introduce an element of competition as an incentive to improve performance. However, publishing league tables that claim to provide evidence of standards in health care can deceive the public, make patients anxious, and be scornful and demotivating for healthcare professionals.
Inferior premier league football clubs get relegated and replaced by new contenders every season. Sampling errors are virtually impossible and confidence intervals do not feature. No stratification of results is required and the ranking is the intrinsic reason for their existence.
However, surgeons placed at the bottom of a cardiothoracic surgical league table are not easily replaced if their performance is considered below par. By definition, half of all the cardiac surgeons in the United Kingdom will be of below average performance. The lowest ranking professionals may not receive a valid assessment of their patient caseload. The entire aspect of “teamwork” in NHS units is ignored and team shortcomings reflected in poor outcomes will be blamed on the individual cardiac surgeon. Although we frequently see premiership managers sacked unceremoniously for poor results, what fate will befall the surgeon?
The competitive ranking of cardiac surgeons' performance in daily newspaper supplements will hardly benefit patients. Instead, patients are likely to feel anxious as they perceive disparities between NHS regions. Furthermore, league tables, as recently published by Dr Foster (bmj.com/cgi/content/full/324/7336/552), adversely modify surgeons' attitudes. Clinical decision making will start to reflect surgeons' concerns over their position in the “premiership” tables. It is known that the highest risk patients have the most to gain from successful cardiac surgery—in the new era, will these patients get that chance?
A recent survey of all cardiac surgical consultants indicated that, if league tables were to be introduced, more than 90% would modify their practice to avoid high risk patients. This may reduce revascularisation rates at a time when the government is committed to increasing them and would lead to the deaths of more patients through lack of surgery rather than to the detection of any individual “high mortality” surgeon.
League tables could also undermine the future provision of surgical care. Already some consultant supervisors are reluctant to provide adequate training to the next generation. Because of their concern over the influence an adverse result may have on their league table position, some consultants are handling cases where there should be consultant supervised training. With good supervision, there should be no risk to the patient, but league tables have changed the consultant mindset. As a result, future consultant cardiac surgeons are likely to be considerably less experienced at the time of appointment than their predecessors.
The legendary football manager Bill Shankly once said: “Some people think football is a matter of life and death. I assure you, it's much more serious than that.” Likewise, surgical performance league tables, therefore, are not merely a measure of life and death—it's more serious than that. League tables will inevitably result in additional premature deaths, as hazardous operations will be denied or standard operations will be performed by less competent future consultant surgeons.
Despite increasing volumes and the worsening general health of the cardiac surgical patient population, overall mortality rates have steadily decreased in the 36 NHS trusts in the United Kingdom providing cardiac surgery. Such progress is a reflection of multifaceted improvements—in, for example, referral principles, medical therapeutics, anaesthetics, and postoperative intensive care.
When assessing the efficiency of health-care systems, complex performance indicators have superseded isolated mortality rates. The outcome of such sophisticated “systems” assessments differs markedly from convenient monocausal approaches. Control charts, for example, allow detailed analysis of adequacy of providers without comparative ranking.
We need refined tools to assess and display consultants' and their units' performances. It is in everyone's interest that fair and transparent outcome data is available to the public. Medical professional societies, legislative representatives, and the media must make concerted efforts if these are to succeed.