Health Check: 'A high death rate isn't always bad news'

To the Royal College of Surgeons for the launch of the first league table of heart-surgery death rates to name individual hospitals. This could be a good story, my colleagues and I thought as we arrived, meaning of course a bad one – a chance to finger the killer hospitals at the bottom of the ladder and stir up a bit of controversy about the "lottery" of care in the National Health Service.

Imagine our disappointment then when we were handed a press release, the top line of which read: "Adult cardiac surgical care is now as good as anywhere in the world." One colleague from a tabloid called her newsdesk to convey the gloomy news.

"I'm afraid it's a good-news story," she began, apologetically.

"Don't worry," came the automatic response. "It's not your fault."

It is fortunate for newspapers, but unfortunate for almost everyone else, that people prefer to read bad news to good. But when the news is surprising or unexpected, even good news can make the papers.

I thought this applied to the heart story. The fact that our death rate at 2.1 per cent was better than America's at 2.6 per cent struck me as remarkable, given the enormous disparity in resources between the two health systems.

Moreover, the tide of bad news about the NHS makes an island of good news sparkle all the more tantalisingly.

The Independent's newsdesk was unimpressed. What kind of headline would the story carry, they grouched. "Britain does well on heart surgery" is not a line to set the pulse racing. So we settled on a top line, followed by most newspapers as it happened, of doctors warning that high-risk patients might be turned away when league tables for individual surgeons are introduced, because of fears that a single extra death could affect their ranking.

Maybe we all missed a trick. The obvious thing to focus on was the hospital at the bottom of the league table, which turned out to be the Middlesex, part of University College Hospitals NHS trust in London, which had a death rate of 4.7 per cent, five times higher than the best-performing hospital, the Bristol Royal Infirmary.

We were persuaded at the press conference that the Middlesex had a high death rate because it admitted the highest-risk patients. "There is almost a case for congratulation rather than condemnation," one specialist said. Later, however, the chief executive of UCH issued a statement explaining that the hospital was upgrading its buildings and improving monitoring, and that the latest figures showed it had cut the death rate. So perhaps its performance was not as good as it should have been.

Death rates are difficult to interpret. And the task is not going to get easier when, from next year, we are able to compare death rates for individual surgeons, fulfilling a pledge made by the Government to make doctors more open and accountable to their patients.

Surgeons remain deeply unhappy at the prospect, arguing that modern medicine is a team effort and the success or failure of an operation depends not only on the skill of the surgeon but on the combined skills of the physicians, anaesthetists, intensive-care specialists and nurses who are all involved.

Dr Roger Boyle, the Government's national director for coronary heart disease, defended the plan while at the same time demonstrating from his own experience of dealing with his father's illness why individual death rates alone will be inadequate to help patients choose.

He said: "My father had two heart operations and he was first a high-risk and then a very high-risk patient. I knew the outcomes for all the heart surgeons in the area but I did not choose the one with the lowest mortality. I went to the surgeon who had most experience in dealing with my father's particular problem."

So, only someone in Boyle's position, or a heart surgeon, is likely to have access to the really meaningful information that will help a patient choose.

But will heart surgeons turn away high-risk patients once their individual death rates are published? The Royal College of Surgeons claims the US experience shows they will. Indeed, it says it is already happening in response to publication of named hospital death rates. Yet their own report shows that during the past decade, heart surgery is increasingly being carried out on older, sicker patients.

Some young heart surgeons may be deterred from taking on tricky cases. But others may think twice before undertaking what is termed "heroic" surgery but is too often merely foolhardy. As a breed, surgeons are not lacking in self-confidence. I doubt a league table will deter many from wielding their scalpels.