- GIRFT report into general surgery says NHS can save £164m a year by reducing unwarranted variation
- Report says cancer targets and performance measures may reduce quality of care
- “Staggering” variation uncovered in procurement of surgical equipment
A senior clinician leading a national drive against unwarranted variation in the NHS says cancer targets and surgeon mortality rates are “politically derived measures” that may reduce care quality.
The Getting It Right First Time report by consultant surgeon John Abercrombie recommended a review of national cancer targets following the creation of a new pathway for patients with colorectal cancer.
The report said current waiting targets ‘do not help improve our service’
The report into general surgery, published today, said shortening lengths of stay for patients, slashing procurement costs and introducing consultants at the hospital “front door” to reduce emergency admissions could save £164m a year.
Mr Abercrombie, GIRFT’s clinical lead for general surgery, criticised data measuring surgeon-specific mortality rates rather than lives saved, or how quickly cancer patients had operations rather than which treatments were successful.
Mr Abercrombie wrote: “These politically derived measures are not clinically driven or motivated; they do not help improve our service or our skills nor do they lead to better outcomes for patients.
“They may even have adverse consequences by inducing surgeons to adopt risk averse behaviour.”
The “tight timescales” set out in two week, 31 day and 62 day national cancer targets “may inadvertently result in reducing the quality of care patients receive”, the report said.
The standards meant little time was afforded to tackling risks causing significant negative impacts on outcomes, such as smoking or poorly controlled diabetes, before surgery.
It said delaying surgery in most cases would not impact on survival as colorectal cancer progresses slowly, allowing patients with urgent, but not cancerous, conditions to be prioritised.
Funded by the Department of Health and overseen by NHS Improvement, the £60m GIRFT programme analyses data including hospital episode statistics, mortality data and patient surveys.
Detailed reports are produced for trust management and clinicians to compare performance against peers and national averages ahead of discussions with GIRFT clinical leads to reduce unwarranted variation.
General surgery is the first of 34 specialties to report since programme chair Professor Tim Briggs’s pilot into orthopaedic surgery in 2012.
It found significant variation in pathways, activity, mortality and readmission rates, procurement and data collection after visiting 50 hospitals. It makes 20 recommendations to reduce variation, improve quality and increase value.
Data showed 90 day mortality following major resection for colorectal cancer varied from zero to 10 per cent, with wide variation between trusts despite them carrying out similar volumes of activity.
The report said considering wound infection rates and readmissions as well as mortality would allow a broader assessment of surgical performance. This data is routinely collected in the US with surgeons accountable to their hospitals and insurers.
The report said surgeon-specific mortality data created a “clear perverse incentive” to avoid operating on very high risk patients, to improve performance. “Worryingly, there are some indications that this is happening,” it added.
It said data from the national bowel cancer audit showed the number of patients undergoing major resection for colorectal cancer fell from 17,099 in 2012 to 15,005 in 2015.
The report found some hospitals undertake more than 22,000 general surgery procedures a year. Others carry out fewer than 4,000, undertaking more complex procedures “only a handful of times”.
Low volumes of activity are viewed as “not conducive to high quality outcomes”, which could affect higher risk operations.
The GIRFT team found surgeons were treating patients with the same conditions differently, even in the same hospital, because of the absence of defined pathways or data showing success of a procedure or alternative treatment.
The report also found “staggering” variation in procurement after trusts submitted prices paid for common surgical instruments and consumables. The difference was “so startling”, trusts were asked to double check information submitted to the GIRFT team.
GIRFT’s timeline is for NHS England and NHS Improvement to agree national policy proposals supporting its recommendations by October, with consultation taking place “if needed” ahead of agreement over a final implementation date.
- Seven regional hubs will start working with trusts to implement changes by the autumn.
- NHSI’s objective is for GIRFT implementation in general surgery to be complete by April 2019.
- Mr Abercrombie told HSJ: “If you don’t push hard, things take much longer, but we do recognise we are turning around a very large structure and there will inevitably be inertia in the system.
- “We think putting in timescales and pushing hard on the levers is the right way to go.”
- The 20 recommendations
- Improve coding of emergency general surgical activity.
- Introduce national policy levers to ensure hospitals complete national audits to levels approaching 100 per cent.
- Improve quality of routine data collection.
- Enhance national audit programmes by recording patients with a relevant diagnosis, not just those undergoing surgical procedure.
- Design and progress implementation of an optimum care pathway for colorectal patients, reviewing national cancer targets in light of evidence.
- Instigate pricing transparency in procurement.
- Review national options for consolidation of procurement.
- Identify centres of good procurement performance.
- Require reversible risk factors to be addressed prior to non-urgent procedures.
- Define optimal care pathways in national guidance to be implemented locally where not already described. Implement those which are defined.
- Adopt “zero tolerance” of known avoidable surgical complications.
- Strengthen morbidity and mortality meetings by expanding the current focus on deaths and major complications.
- Improve understanding of causes of litigation, taking action to reduce common errors.
- Make available and require at appraisal surgeon level intelligence on activity and outcomes.
- Identify best performing teams and enable others to visit as part of continuing professional development.
- Conduct a national review assessing the NHS model of clinical autonomy against international comparators to reduce unwarranted variation in clinical practice.
- Require routine collection of data on operation duration to establish measurable benchmarks for different procedures.
- Undertake a capacity planning study to enable theatre capacity to be principally organised around emergency care.
- Provide consultant delivered emergency general surgery in each trust.
- A consultant lead for emergency general surgery to be identified in every trust, with time allocated in job plans.
HSJ asked the Department of Health for a response to the “politically derived measures” described in the report. It released a prepared statement from health secretary Jeremy Hunt that said: “We want to build the safest, highest quality healthcare system in the world – and by reducing variation we can improve care and eliminate waste at the same time.
“As this excellent work led by Professor Tim Briggs shows, some hospitals are already working smarter with their money to save time and get better outcomes – but there’s more to be done and I hope to see hospitals across England replicate this work.”