A health culture lacking in audit process and outcomes

Prof John Browne says 'it's a scandal' that information and data about survival rates and quality issues are not available to the public here as they are in the UK, writes MICHELLE McDONAGH

WHAT IS the best hospital in Ireland to get a knee replacement? What surgeon has the best survival rate for coronary artery bypass operations? And in what part of the country is a patient most likely to be offered reconstruction after breast cancer surgery?

Although members of the public in Northern Ireland and throughout the UK can readily access equivalent information through the NHS, this information is not available to patients in the Republic. This, according to health services researcher Prof John Browne, is a scandal and what’s even more scandalous, he says, is that the information is all there.

“It is now possible to check the post-operative survival rates for individual surgeons performing cardiac surgery at NHS hospitals in Northern Ireland, for example. If somebody is going for a coronary bypass in the North, they can go to a website, get the name of all the surgeons who do this work, find out how many operations each surgeon does each year and how many patients die within 30 days after surgery. It’s a scandal that patients undergoing a similar operation in Cork or Dublin cannot find out the survival rates here.”

Browne from the Department of Epidemiology and Public Health at University College Cork, points out that in recent years, a range of excellent information sources about quality within the NHS have been made available to the public. He believes that citizens of the Republic should have access to equivalent information.

He hopes to kick-start a programme of research by convincing a range of patient, clinician and State stakeholders to participate in national and international comparative audits.

“These audits will produce information that not only allows individual providers to benchmark themselves against national and international peers, but it will also produce the type of evidence that the Irish health service needs to improve quality in the future,” he explains.

Having trained in Trinity College and worked in Ireland before spending 10 years working on quality improvement within the NHS in the UK, Browne has considerable experience of the health systems of both countries.

He highlights the importance of not waiting for the next scandal or disaster before demanding high quality data on healthcare activity and outcomes and points out that prospectively collected data would have prevented some of the worst excesses of rogue doctors like Harold Shipman.

“Maybe if this kind of data was out there and published, Michael Neary might have been moved aside or encouraged to take early retirement from the Lourdes hospital after the first year,” he suggests.

Browne moved to the UK in the wake of the 1998 Bristol scandal which led to two doctors being struck off and a third banned from operating on children. More than 90 infants and children are believed to have died unnecessarily at Bristol Royal Infirmary where the death rate for children undergoing serious heart surgery was found to be twice the national average.

“It was a watershed moment in the NHS. People realised that very serious quality care errors were occurring at the serious end of the scale, ie patients were dying. Just a routine statistical analysis would have shown excess mortality among children at Bristol. There was a lot of anecdotal evidence and GPs were in the know, they weren’t referring patients to Bristol and there was a culture of cover-up.”

Shortly after his move to the UK, Browne was given the task by the Royal College of Surgeons of England of setting up a national clinical audit in various areas including breast cancer surgery, hip and knee replacements and hernia operations.

Other colleges in the UK were doing similar audits in other areas such as stroke and heart attack.

An audit system, explains Browne, must have three elements – structure, process and outcome. While the Health Information and Quality Authority (Hiqa) carry out a hygiene audit of structures, ie buildings, kitchens and theatres each year, Browne says the problem in Ireland is that there is no culture of audit process and outcomes.

“The HSE and Hiqa are trying to introduce process-type audits like the myocardial infarction audit in the UK so that when a patient arrives in an AE department, they will get the drugs they need within a certain time period.

“Every year, these figures would be published so if a hospital is not doing its job, they can find out and hopefully improve the following year – it’s a cycle of improvement. The HSE and Hiqa are trying to get this off the ground in a small number of areas, but it doesn’t seem organised, is optional and happening in a very haphazard way at the moment.”

Why this information is not already available in Ireland is an interesting question, says Browne.

“Some might make the case that there is clinician resistance on the basis of fear, but Irish clinicians publish cases all the time in the international literature so there would not be a massive fear that all hospitals in Ireland would be exposed as providing dreadful care. I think it’s down to apathy and poor leadership. The Irish Hospital Consultants Association [IHCA], to me, has not provided any real strong leadership on this matter and there’s a big issue to be addressed here.”

There is another argument that publishing outcomes could result in defensive medicine whereby surgeons will operate only on low-risk patients, but Browne says the results from the UK show that there has been no increase in defensive medicine. In fact, there have been all sorts of population-wide beneficial effects including, most importantly, a decrease in post-operative mortality, he explains.

“If you were to ask the average orthopaedic surgeon what his/her revision rate was, they would not know how many patients came back within a 10-year period. This is another area where the HSE is floundering around. They’ve been talking about setting up a national joint registry which they have in the UK for seven or eight years, so that they have data on every knee or hip replacement that has taken place and the outcome.”

It’s exactly this type of research that Browne is now trying to kick-start in the Republic so that a patient going for a hip replacement, for example, can make their decision not based on infection risk but on the least pain and best function after surgery.

“I would encourage individual hospitals to collect data. There are lots of people who work for the HSE whose time would be better spent in hospitals helping surgeons to collect data rather than in offices, so I don’t think it’s a matter of a shortage of staff. There’s no point in waiting around for IT systems with bells and whistles on which the UK spent millions on; paper and routine direct entry are far the best for this kind of work most of the time.”

Responding to Browne’s ideas, assistant secretary general of the IHCA, Donal Duffy, points out that Ireland is a much smaller country than the UK.

“Consultants in Ireland get referrals by and large from GPs who know them very well. I’m not sure you would achieve the same level of result as in the UK for a similar level of investment,” he says.