Changing practice

BMJ 2004; 328 doi: (Published 29 January 2004) Cite this as: BMJ 2004;328:248
  1. Susan Mayor
  1. London

    A system of self regulation of surgery and anaesthesia in the United Kingdom has worked so well that the Department of Health is expanding its remit. Dr Peter Simpson, the man in charge, tells Susan Mayor the reasons why

    “If you want a system that requires clinicians to change their practice, it works best if it is clinically led,” believes Dr Peter Simpson, chairman of the newly expanded and renamed National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD). “This is the underlying reason why the inquiry has achieved major changes in surgical and anaesthesia practice over the past few years.” The organisation, originally the National Confidential Enquiry into Perioperative Deaths, recently changed its name to reflect a wider remit but kept the same initials (NCEPOD) to ensure continuity in the public mind.

    The inquiry was originally set up by surgeons and anaesthetists in 1982 to review surgical and anaesthetic practice in three regions of the United Kingdom. In 1988, it moved to a national level, supported by government funding. Its studies have ranged from measuring the percentage of patients dying within 30 days of surgery, to looking at deaths within a specific age range or from specific procedures. One of its studies that had particular impact was an investigation into patterns of operating within hospitals (Who operates when. The 1997 report of the national confidential enquiry into perioperative deaths. London: NCEPOD, 1997).

    Dr Simpson said: “NCEPOD's work is not seen by doctors as an outside audit imposed by official bodies.” Its work is run by a steering group whose members are nominated by the Royal Colleges (Surgery, Physicians, Anaesthetists, Obstetrics and Gynaecology, Pathology, Ophthalmology, General Practitioners, Radiologists, Faculty of Dental Surgeons, Faculty of Public Health) plus the Association of Surgeons and the Association of Anaesthetists. Several observers on the steering group also represent health managers, coroners, nursing, and the National Institute for Clinical Excellence (NICE), and there is one lay representative.

    “The issues that the inquiry decides to audit are based on discussion with clinicians,” he explained. Local volunteers (who are health professionals of any discipline) collect the relevant data from each hospital. These data go to coordinators (clinicians who are paid for their time) and are then compiled centrally. Committees of appropriate clinicians (nominated by medical colleges and associations) then reflect on the data and develop recommendations that are passed to the relevant professional bodies and to the NHS for consideration and implementation.

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    Dr Peter Simpson: “Doctors know that their work is being looked at by ordinary, practising clinicians, not by ‘the great and the good,’ who may be out of touch with day to day clinical practice”

    “Doctors know that their work is being looked at by ordinary, practising clinicians, not by ‘the great and the good,’ who may be out of touch with day to day clinical practice,” Dr Simpson says. “Local clinicians feel that they have ownership of the process, in that they can be involved as advisers, and consider that the work the inquiry undertakes is relevant to their clinical practice.”

    There is some evidence to indicate that its approach works. An independent review of the inquiry, carried out in 1998, found that 1700 of 2195 consultants responding said that NCEPOD had influenced their clinical practice in at least one way.

    “They considered that the greatest influence had been in the reduction of out of hours surgery, the completion of patients' clinical notes in greater detail, and the provision of a higher degree of supervision to locums,” Dr Simpson noted.

    “Another factor in the organisation's success has been that its work is based on anonymised data, with no attempt to link events with particular doctors,” said Dr Simpson, who is an anaesthetist at Frenchay Hospital, Bristol. “We support a blame-free approach as the best way of collecting the information needed to inform changes in practice.”

    NHS managers have also responded favourably to the inquiry's work. More than half the chief executives of NHS trusts who responded to the review thought that its work had achieved beneficial changes. Dr Simpson considers that this support from hospital managers is important. “For a recommendation to be implemented, it has to be supported by a trust or other body with influence,” he said.

    The watchdog also has teeth. All hospitals, both NHS and independent, in the areas covered by the inquiry—England, Wales, Northern Ireland, Guernsey, and Jersey—are required to provide data requested by the organisation. The General Medical Council has stated that taking part in inquiry audits is part of good medical practice, and the NHS requires trusts to take part in their confidential inquiries.

    What about the criticism that self regulation simply covers up problems to protect the members of the group? Dr Simpson acknowledges that the inquiry could be accused of being a “closed shop,” working to protect its members. However, he points out that the organisation's full time staff is made up entirely of non-clinicians. “Also, if anyone looks at the organisation's reports over the years, they will see that it has not been afraid of being critical of clinical colleagues when appropriate.”

    The government has acknowledged the value of the inquiry's work by expanding its remit to include medical patients and primary care. It will consider not only deaths but also near misses. The extended remit was agreed by NICE after a review of its work. As a result the organisation changed its name.

    “NCEPOD's biggest contribution has been in establishing an audit system that clinicians can work with and one that develops recommendations that change practice,” said Dr Simpson. He is particularly pleased with two outcomes of the inquiry's work over the past few years.

    ”First, so-called ‘CEPOD’ operating theatres—which are fully resourced to deal with emergency cases—were introduced after an audit showed that emergencies had an adverse effect on elective surgery lists, as cases had to be delayed until the evening, night, or weekend. Previously, the emergencies were left and were dealt with out of hours. These specially resourced emergency operating theatres have significantly reduced the number of out of hours operations that take place.

    ”Secondly the audit also led to greater supervision of junior staff, with more consultants working in hospitals out of hours.

    “NCEPOD's strength lies in auditing current practice, identifying factors with major impact on patient care, collecting information, and developing practical recommendations based on that information. Finally, it has been able to get the support of clinicians and NHS management to introduce these recommendations,” he concluded.

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