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21 April 2011: Society of Cardiothoracic Surgery

  • Last modified date:
    25 May 2011

Check against delivery

Good afternoon everyone. At the risk of seeming contrary on what’s traditionally the first day of spring, may I start by harking back to mid-winter.

Because I want to begin by paying tribute to the vital and life-saving work that many of you did in delivering the specialist ECMO care during the Swine Flu outbreak.

It is a striking achievement that, under such tremendous pressure, you managed to achieve survival rates that were as good as the very best specialised centres in the United States.

I’d particularly like to mention Richard Firmin, who led the process from Leicester.

The successful mobilisation of limited resources through cooperation and collaboration demonstrates what I want to talk about today.

That is – the power that’s unleashed by professional groups working together as a community.

By sharing information, combining resources, harvesting collective know-how and expertise to support patients.

It’s something this Society has been demonstrating for many years now.

Whether it’s in respect of survival rates in cardiac surgery or resection rates in lung cancer, the Society’s work follows a simple logic.

Be open – and you improve safety.

Communicate – and you reassure.

Share knowledge – and you improve performance.

The value of information

A couple of centuries ago, the Duke of Wellington famously said ‘Publish and be damned’.

Well, in recent years, you’ve proved the opposite: ‘Publish and be praised’.

It is a motto I’ve held to throughout the seven years I’ve spent covering the health brief – and it’s now a clear motif in our modernisation plans.

The conviction that through better information, stronger clinical auditing and a greater willingness to self-assess on the outcomes achieved, we can unlock higher clinical standards.

A belief, frankly, that an open NHS is a safer NHS – and also, by definition, a more trusted NHS and a more empowering NHS.

Because by putting information into the public domain, we give patients more control and more meaningful choice over how they’re treated.

That’s why one of the first speeches I gave after getting this job was on the subject of outcomes and the information revolution.

I want to make this a top order issue for the NHS, because I believe clinical auditing is such a powerful driver for clinical excellence.

It does invite people to look at and compare their performance based on clinical parameters not tickbox rules and regulations.

And it’s vital for improving accountability and public trust, which is something your report today quite rightly points out.

Cardiothoracic success

Over the last five years, cardio-thoracic surgeons have broken new ground in using outcome measurements to drive up clinical standards in the UK.

You’ve shown that opening up your data and demonstrating variation in standards isn’t an admission of weakness, but a sign of strength.

And the result is the steep improvements seen in cardiac care.

Of uniformly high standards in mortality rates across all specialist cardiac centres in England.

Of better survival rates than ever for older people undergoing heart surgery.

Of quality improvements achieving real savings in bed days for procedures.

According to today’s report, £5 million was saved on bed days for coronary artery bypass operations alone, set against an outlay of £1.5 million for clinical audits.

Good quality information is also identifying the gaps – the areas for improvement across the system.

We know there’s significant variation in waiting times for non-elective cardiac surgery.

This is unacceptable for emergency cases, where delay can make a huge difference to a patient’s experience of care and the cost of the service.

It gives the NHS a clear warning sign that this needs to be addressed.

Thoracic surgery too is heading in the same direction.

Some important work has been done to develop the risk models necessary for full clinical outcome reporting.

From the data we do have, we know there is still significant variation in resection rates for lung cancer patients.

It varies from under 5 per cent in some areas, to more than 25 per cent in others.

It also varies by age. The proportion of patients who undergo surgery for lung cancer drops off after the age of 50 and virtually flat-lines once you reach 80.

There may be good clinical grounds for this – but this information gives us cause to ask questions and find answers.

And proper analysis based on outcomes will give us either the confidence that the right decisions are being made – or cause for action and redress if they’re not.

An 'Open Source' NHS

That’s why my message today is quite simple: where you lead, the rest of the NHS must follow.

In the past, and in too many areas today, we still have a ‘closed circuit’ NHS, where clinicians hold information close to their chest.

And yet you only have to look at how the world is changing around us to question that logic.

Look at the huge potential opened up by new technology.

Look at the exponential rise of the internet as an influence over people’s lives.

And look at how open source standards and protocols have pushed the boundaries in IT and mobile telecommunications.

They’ve pushed boundaries precisely because they’ve allowed experts to develop and improve a product together, through a free exchange of ideas.

We need to apply the lessons of openness and transparency in health.

If you like, we need an “open source” NHS as far as information is concerned.

A health service that’s more transparent, more digitally adept and more willing to share knowledge across professional groups and with the public.

That’s what I really mean by an information revolution: a free exchange of ideas, information and data to drive improvement and expand choice for the patient.

Cardio-thoracic surgeons are pioneering it.

Clinical audits must be at the heart of it.

Funding for Clinical Audits

That’s why in July’s White Paper, we said that we would extend national audits to more conditions and a wider range of interventions.

Over the next year, we’ll make another £1.2 million available for up to four new national clinical audits.

The National Clinical Audit Advisory Group, chaired by Professor Nick Black, will lead on advising us on which areas these audits will focus on.

But we want topics that align well with the Outcomes Framework and have NICE Quality Standards in place.

Because in essence, the clinical audit provides the missing piece in the jigsaw.

The Outcomes Framework show us what we’re looking to achieve …

The Quality Standard shows how we do it – what a high quality service looks like …

And the Clinical Audit gives us the detail and the benchmarking necessary to achieve it …

Information for the public

This is vital for continuous professional improvement on the one hand.

And, of course, it can also help us to give the public the information they need about their treatment.

So we need to make this data accessible to the public. To make it something they can use to assess and shape decisions about their care

I think the public portal that the Society has set up is excellent in this regard – a true pioneer of the kind of patient-friendly information I want to see across the NHS.

I know there is still work to do on the long term funding of the portal – discussions about where it’s hosted, how it can form part of a more unified access point and so on. 

But that should not detract from the achievements so far – and neither should they prevent the cardiothoracic community pushing further ahead.

Building for the future

I think you have some firm foundations to build on.

Funding for the Adult Cardiac Surgical Database is guaranteed for the next three years, and we are continuing to support national clinical leads who will help with the collection and analysis of audit data.

Longer term, funding for clinical audits will be up to the NHS Commissioning Board to determine, but the path of our reforms means it’s likely to be a clear priority for commissioners.

For instance, the data from the audits are vital for delivering outcomes in the Operating Framework, and I also expect audits will be used to revalidate consultants.

So it’s no flight of fancy to suggest that all providers in the future will be required to have robust clinical audit systems in place as a condition of contracting for NHS services.

Quite simply, without them, how else could a commissioner be certain they’re targeting their resources effectively?

How can they be sure that taxpayer’s money is being used to achieve the very best outcomes for patients?

It won’t happen overnight, but over time I want the whole NHS waking up to what you and others have already recognised – that good information and good analysis isn’t an add-on, but an essential component of a high quality service.

Outcomes are one of these key purposes of reform. 

A focus on patients, with shared decision-making is another.

The third purpose is empowered professionals.

So, for me, the leadership which you have given and continue to provide is instrumental to the achievement of continuously improving healthcare in a modernised NHS.

Conclusion

In concluding let me say this.

I know it’s uncomfortable to be the vanguard. I know the progress you’ve made is hard-fought. I know it occasionally ruffles feathers.

But don’t let internal resistance put you off.

I’m giving you a very clear green light as far as this Government is concerned: we absolutely want to see these sort of approaches applied and expanded across the NHS.

Since I started off with the Iron Duke, let me end with the Iron Lady.

Margaret Thatcher once said: “You may have to fight a battle more than once to win it.”

As far as opening up the NHS, extending information and applying greater scrutiny to clinical outcomes goes, this is a battle worth fighting.

And based on what I see coming out of this Society and its membership, it’s a battle you’re winning and I hope will continue to win.

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