Government commits to public repository of consultant details “in principle”

Dear Editors

It is interesting to note the government response to the independent national inquiry, launched in 2017 and published in 2020, following the malpractice of rogue surgeon Ian Paterson (ref 1), is to accept a recommendation (from the Inquiry) to create "a public repository of consultants’ practice details that sets out their practising privileges and key performance data, including how many times they have performed a particular procedure and how recently" (ref 2).

I am not sure if the industry observers sees the irony of this recommendation which would not necessarily suggest it can prevent another malpractice like Dr Paterson.

Several assertion had been made in the Inquiry document, the following extract probably best illustrates this:

"In some cases, the treatment Paterson provided was not accepted practice, including the so-called cleavage sparing mastectomy (CSM). Patients had incomplete mastectomies without realising it. Paterson also failed on some occasions to complete full diagnostic tests. In other cases, surgical treatments and diagnostic tests were entirely unnecessary, and performed without any clinical justification. We also heard accounts of patients having repeated surgeries and tests. In other cases, Paterson performed surgical procedures for which he was not qualified and was sometimes explicitly restricted from undertaking"

Throughout the document and also various BMJ articles (ref 1, 3-5), it was pointed out that Dr Paterson was not "qualified" to do certain surgical procedures he had performed; it was also suggested that there were concerns about his professional competence and conduct. I am uncertain how and to whom Dr Paterson would have demonstrate he is qualified to perform certain procedures, and also who or which national authority would be able to confer a health professional to be "qualified" to perform procedures in a officially gazetted list, and whether doing a procedure not on this list meant he was not officially "qualified" to do it. This would even be more contentious for procedures that is not "mainstream" or commonly seen in all hospitals; but it does not necessarily mean uncommon procedures (and hence not often reported) is inappropriate either.

It needs to be clear that competency to do a procedure is not equivalent to being "qualified" to do this procedure. I do not have access to the court proceedings that convicted Dr Paterson but I noted that none of the authors in the references below suggested that Dr Paterson was not competent (or incompetent) to perform those breast surgery operation he was being investigated for.

Hence the issue of "practising privileges" or scope of practice may be hard to determine since trying to be prescriptive and specific in what a healthcare professional can be very hard to do. Note that practising privileges of a doctor in a healthcare facility is not just limited by what the doctor can do, but also what services the facility have to support the doctor and the patient; and therefore a public repository of practising privileges based on each facility may very well unfairly portray the limited practice of a doctor who works in smaller hospitals. Furthermore having defined practising privileges does not imply that the practitioner was not competent to perform procedure not mentioned in the practising privileges

The crux of allegations against Dr Paterson appears to be him performing inappropriate or "unnecessary breast surgery operations", thereby intentionally wounding patients. In the proposed public repository of consultants’ practice details that uses key performance data which includes how many times they have performed a particular procedure and how recently, Dr Paterson would not have been flagged since he appears to have been overservicing and therefore the performance indicators would reflect higher volume of various procedures and recency of practice with respect to these operations.

In fact, such a repository will "reward" a surgeon who performed a limited range of procedures in large volume on low-risk patients with little co-morbidities. Any surgeon taking on patients with significant medical conditions and performing less-common and more complex operations (often with higher risk of complication), even if clinically indicated and likely to improve quality of life (of the patient, not the surgeon), will risk being flagged or identified by ill-informed assessors for review. Even if these performance indicators are risk-adjusted for patient comorbidities, the higher likelihood of complications in medically complex patients cannot be adequately mitigated as compared to younger healthy patients. Therefore it will be inevitable that such repository can result in deliberate (or unintended) gaming from skewed surgeon practice and patient clientele, both in private practice and to some extent, certain smaller NHS trusts.

If this does happen, this public repository will simply be another white elephant to creates middle management jobs and paperwork, but does nothing to prevent mediocrity or overservicing, and will only accelerate the increasing public distrust of the UK's health system.

References:
1. James G. Report of the independent inquiry into the issues raised by Paterson. Feb 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploa....
2. Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson. www.gov.uk/government/publications/government-response-to-the-independen....
3. https://www.bmj.com/content/368/bmj.m560
4. https://doi.org/10.1136/bmj.m465
5. https://www.rcseng.ac.uk/-/media/files/rcs/news-and-events/media-centre/...