Welcome to the fourth edition of the year – celebrating some reasonable British weather for once!
The principal matter ‘hitting’ the British Neurosurgical Community at present is the National Audit Project. This concept – measurement of outcomes – you may argue is long overdue; something the neurosurgical community should have embraced a long time ago perhaps, or even promoted and certainly been the prime motivator. Thus, there is perhaps a feeling this is a project we have been forced into to some degree over the years, however much it is now embraced.
It comes with warnings – unsurprisingly, there are problems with data accuracy. My own data revealed a death apparently due to CT scanning! Now whilst this is somewhat humorous and reasonably easily corrected, it does mean extra administrative work – notes have to be reviewed, the case understood as to what exactly was the actual problem and pathology. It also means looking at other instances to be certain that the same is not happening in other circumstances. Perhaps when this level of data inaccuracy is revealed, the NHS trusts could be persuaded to provide decent infrastructure to handle such data – that accepts a much greater responsibility for the accurate production of good data, rather than just leaving this with the consultant. Whilst it is understandable that this is left with the consultant – as he/she is the individual who will perforce have to ensure the accuracy else livelihood will be threatened it still does not seem an equitable situation. So a challenge is to reform the service so that trusts are motivated to get this correct.
There are other considerations – I have referred to some of these in previous editorials, and they remain important. I remain concerned by two areas. Firstly the use of surrogate rather than direct measures of quality of outcome, and thinking here in particular of length of stay. A second issue is that of population statistics. Measuring length of stay needs so many factors to be included in the case mix for it to be valid as a measure of quality. Some obvious ones are the total length of hospital stay – as opposed to simply the length of stay in the neurosciences unit, without including the time spent after ‘repatriation’; similarly early readmission after early discharge for an operative complication – such as, say, a post-procedural CSF leak – needs to be included in the length of stay! The situation with respect to population statistics is even more difficult. It has been recognised for a long time that in sub-arachnoid haemorrhage the ‘hospital’ statistics can be vastly improved by a highly selective admission policy – it might be regarded as similarly difficult, or even more so in other areas. Perhaps one could look at population-based operating rates – for example, lumbar discectomy rates per million of population!
Used well, the audit project could be excellent in terms of improving quality. If, however, it generates targets that are surrogates, then there is a real danger of us ending up with the same manipulations and gaming behaviour that we have all seen since waiting time targets were introduced.
Leaving politic aside, I hope as usual the mix of articles will be of interest to all, and not just those within the specific sub-specialities involved.