The British Association of Dermatologists (BAD) welcomes Fiona Godlee’s challenge to ourselves (and others) published in the BMJ on the 7th July. We are grateful for the opportunity to proclaim our longstanding commitment to the improvement of clinical standards in dermatology: one of our several aims being to provide ourselves and our patients, the public, with credible and useful performance indicators to assist both individual patient choice and the deliberations of commissioners.

The cardiothoracic surgeons trail-blazed this agenda around success and safety issues by making their individual mortality data publicly available allowing outcomes to be compared. Mortality is a very easily assessed end-point and the ideal target standard is easily set at 0%. Setting targets and measuring performance outcomes in medical specialties such as dermatology and in the special setting of dermatological surgery for skin cancer are more challenging propositions. This is specifically acknowledged by Tim Kelsey (as quoted by Aniket Tevare in the BMJ) and probably one reason why BAD discussions with Dr Foster as early as 2004 failed to bear fruit. It is also important to remember that outpatient activity is not routinely measured by the NHS yet this is where most dermatology (hundreds of thousands of episodes per annum) takes place. Basal cell carcinoma epidemiology and clinical interventional statistics are not collected and collated even at the most basic level yet it is estimated that there are over 100,000 cases per annum. However, all dermatologists belong to skin cancer Multi-disciplinary Teams (MDTs) and all MDTs will have been peer reviewed against the high standards delineated by the Improving Outcomes Guidance (2006). The public is entitled to know that an individual MDT has met those standards. But comparing MDTs is going one step further. How might MDTS be compared? Who should do that? Are such comparisons useful? Is it not sufficient to know that standards have been certified as met? Another challenge is that posed by Any Quailified Providers where there is evidence that existing standards are not being met, let alone outcome measures being compared.

Notwithstanding the above obstacles, difficulties and reservations, for fifteen years the BAD (an organisation funded by the subscriptions and activities of British Dermatologists for the betterment of the practice and teaching and research of dermatology with no significant income from public funds) has led the field, nationally and internationally, in producing guidelines (some multidisciplinary eg for melanoma) for the diagnosis and management of skin conditions based on the best available evidence. These have embedded within them standards and targets that individual departments have used for audits since they first appeared. The BAD is committed to producing national audits based on these guidelines and to publish the results of the findings to highlight areas for improvement.

In parallel, within dermatology, and again led by the UK, painstaking work has been done to validate disease-specific quality of life assessment and skin disease severity scoring tools. These are used to measure outcomes (PASI + DLQI in psoriasis; EASI or SCORAD in atopic eczema; acne disability index) and are used by NICE. Also the BAD has set up and financially supported BADBIR (Biologics Interventions Register), which has become the largest register of dermatology patients on biologic and systemic agents in Europe. It can be interrogated for outcomes and complications of treatment and can be used for research and to compare centres.

Anticipating refinements in guideline development, standard setting and outcome measures and the laudable appetite of the public and purchasing/commissioning managers for robust informatics, the BAD conceived a Minimum Data Set Project five or six years ago, and identified it as a strategic priority in 2008. It has been developed by our Health Informatics Sub-committee to be a rolling programme of data collection involving all UK departments but a stumbling block to data collection appears to be NHS IT systems.

Attention switched to the qualitative element of the project, driven by the commissioning agenda and last year the BAD led a multi-stakeholder group to deliver ‘Quality Standards for Dermatology’. This authoritative paper provides clear, evidence-based information about what constitutes high quality care and defines key performance indicators. This document (attached) is readily accessible and now hosted on the Primary Care Commissioning Team website. Further specialised standards are being produced to continue the scope of these generic ones and will be available shortly.

The BAD aspires to facilitate the comparison of audit and performance data between departments and teams but it is vital to ensure that these comparisons are like-with-like. Whilst completeness of excision of skin tumours, for example, is relatively easy to compare, mortality outcomes are harder to generate. And for the very large numbers of inflammatory skin conditions that we diagnose and manage the challenges are even more vexing, but as our record testifies we are not shying away from these challenges.

To summarise, our strategic thinking over the last twenty years has been that in order to compare the performance of individuals and teams and hospitals and countries, then it needs to be defined what outcomes are important, what constitutes good quality care and finally at what level standards should be set. These standards and outcomes need to be evenly applied to Any Qualified Provider (and there is evidence already that this is not happening). Next, systems need to be in place to capture and to analyse and to report the findings in the most beneficial and least pejorative way. Finally, suitable remediation mechanisms will need to be available for the 'sub-optimal' performers. All this will require significant national public funding.

Nonetheless, we believe that Fiona Godlee is right to suggest that the clinical leadership for this sort of work might best be provided by Specialist Societies and Associations and we believe our track record and strategic vision is second to no one in this regard. However, government, management, commissioners, patients, Pharma, Insurers and new Alternative Providers all have roles to play, as do leading medical journals. Thank you again for throwing down the gauntlet.

Yours sincerely

Chris Bunker, President and
Jan McLelland, Hon Secretary

British Association of Dermatologists

Competing interests: None declared

Patient Safety and Public Reporting.

Papers in this week’s BMJ imply that public reporting improves patient safety, at least for an adverse event (AE) like CABG mortality.1 While public reporting is undoubtedly vital, what is the evidence that it makes hospitals safer? If the outcome of interest was the efficacy of a new drug, a trial would include the best currently available drug for comparison. Has it been practicable anywhere to randomize hospitals to public reporting/no public reporting?

In fact the evidence that public reporting improves safety seems, at best, to be highly tenuous.2,3 Indeed there is evidence that much current quality improvement effort is of limited value.4 Yet there are learning curves. With time, people can learn how to do things better and technology improves. Conversely, the unfortunate effect of making doubtful inferences from publicly reported data has recently been highlighted by Playford and his colleagues.5

How then can we promote safety? Although counting AEs and public reporting are vital, it is not possible to achieve safety by studying the results of unsafe practices alone. Adopting a safe system is the only possible way to be really safe. To achieve this it is necessary to have a clear understanding of the interacting agents that result in safe emergent behaviour in the complex system that is the modern hospital. To understand the agents and their interactions that contribute to safe emergent behaviour we must learn to use the tools for understanding complex systems such as agent-based modelling.6

References.
1. Godlee F. Measure your team’s performance, and publish the results. BMJ 2012;344:e4590.
2. Fung C, Lim Y, Mattke S, Damberg C and Shekelle P. Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine 2008;148:111-123.
3. http://www.ama-assn-org/amednews/m/2012/03/19/gl10319.htm
4. Landrigan C, Parry G, Bones C, et al. Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine 2010;363:2124-2134.
5. Playford G, McDougall D and McLaws M-L. Problematic linkage of publicly disclosed hand hygiene compliance and health care-associated Staphylococcus aureus bacteraemia rates. Medical Journal of Australia 2012;197:29-30.
6. Galea S, Riddle M and Kaplan G. Causal thinking and complex system approaches in epidemiology. International Journal of Epidemiology 2009;39:97-106.

Competing interests: None declared

We agree with Fiona Godlee that transparency in audit and outcome data is extremely important. This College, and other professional bodies, have shown leadership in this work emphasising the strength of our commitment.

The results of the national audit of the acute care of stroke patients (run by The Royal College of Physicians on behalf of the Intercollegiate Stroke Working Party) are freely available online (1). Members of the public, clinicians, commissioners and Trust managers can easily access them and compare how their local stroke team are performing against national standards and other providers. The most recent report covers the care of almost 9,000 patients treated between January and April 2012.

The National Sentinel Stroke Audit has published its results at Trust level on the internet since 2006 and last year we compiled individual reports for every Member of Parliament with results for their constituency. We are taking similar approaches with other national audits.

We agree with Tim Kelsey; most doctors support increased public reporting, (2) but they want reassurance that measures accurately and fairly represent the quality or care they deliver. Measuring the quality of care in those with chronic conditions or with complex medical problems is not as straightforward as in some other conditions, but it can be done. It is likely to require a suite of measures, including clinical outcomes, but also using patient-reported measures. After all, poor communication and poor experience of care (not concerns about clinical care) underlie most patient dissatisfaction and most complaints about doctors (3,4).

Unfortunately, Patient Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) are not well developed for most medical conditions, although we are using some of our ongoing clinical audit programmes to test and develop these.

The RCP’s Future Hospital Commission, due to report in early 2013, has a work-stream devoted to Data for Improvement, which will address the issues of measuring, understanding, reporting and improving the quality of care for medical patients. Integral to this work will be the issue of public reporting of quality metrics. How do we make them meaningful? What support do people require to interpret the data?

We shall be seeking contributions from any professional, academic or commercial organisation with an interest in this area, and have already had informal discussions with many of them. We would be delighted if the editor of the BMJ would consider joining us.

Kevin Stewart, Clinical Director, Clinical Effectiveness & Evaluation Unit

Varo Kirthi, Clinical Fellow to the President

Linda Patterson, Clinical Vice-President
Royal College of Physicians, London

References

1.http://www.rcplondon.ac.uk/sites/default/files/sinap-public-results-quarter-4-january-march-2012_0.xls).

2.http://www.bmj.com/content/345/bmj.e4464

3.http://www.kingsfund.org.uk/publications/continuity_of_care.html

4.National Clinical Assessment Service (http://www.ncas.nhs.uk/publications/)

Competing interests: None declared

"What are you doing?", is the challenge. It's a familiar one to electroconvulsive therapy practitioners, delivering a controversial therapy for severe depression, which, despite its unfairly negative media image, is one of the more effective treatments in modern medicine.

It has clearly gone unnoticed, but in Scotland, detailed national statistics on the use of ECT for each and every clinic are published each year, in the public domain (see www.sean.org.uk).

The reports summarise data that have been collected via an electronic care pathway installed in all ECT treatment clinics in Scotland. Data are collected on every aspect of patient care relating to ECT; presented in sections relating to patient characteristics, legal status, diagnosis, details of interventions, clinical outcomes, adverse events, and self-reported patient experience. Each year, a summary table is available to enable comparison of clinic activity with the previous year. The data is regularly presented to clinicians, patients and their carers at open meetings. The work informs a continuous cycle of accreditation visits to each clinic. Standards are high and outcomes are excellent.

I'd urge readers to take a look at the site. There is a model here that others might consider worthy of emulation.

Competing interests: Member of the Scottish Electroconvulsive Accreditation Network