Q: Tim, you’ve been in post about three years now, which is a very similar timeframe to when we relaunched NCIP to consultant surgeons. Do you have any reflections about how you’ve seen NCIP grow during your time and what this might mean for surgeons?

Tim Mitchell, immediate past President of the Royal College of Surgeons of England:

The first thing is it’s critical that surgeons should be recording their activity. And not just their activity but the outcomes of their activity. And so NCIP is a fantastic resource to allow them to do that.

Clearly over the last three years it’s grown. It’s become more widely available to more specialties and the data it provides has improved. And the key now really is to ensure that it’s more widely used by surgeons and embedded in processes. For individual surgeons, it gives them an opportunity to have easy access to their data and some outcome measures, which is not easily available for most people through their own hospital administration systems. So, I think that’s a major positive; that helps to support the appraisal process.

Surgeons should be naturally inquisitive about their outcomes in any event. And increasingly, patients are pushing for that. Patients want to know, “how many of this particular procedure have you done and what are your outcomes?” So, I think at a whole range of levels it’s important.

Professor Sir Norman Williams, Chair NCIP:

I’m delighted to say that we’ve now got nearly 50% out of 10,500 consultants using NCIP, and the percentage of Medical Directors looking at their data is really quite high, at 70%. I think that really says a lot for the profession and the value of it.

Tim Mitchell:

And that’s likely therefore to represent a tipping point where if you’ve got 50% of consultants using it, 70% of medical directors using it, then it starts to become the norm.

Norman Williams:

Business as usual.

Tim Mitchell:

So, if there’s an expectation within a hospital, therefore these types of data will be presented at morbidity and mortality meetings, that they will be seen on surgeons’ appraisals, then it becomes part of everyday practice, which is where you want to get to.

Norman Williams:

You bring up a really important point actually, because we’ve got one trust in the country where usage rate is at 86%, and the next is about 83%. And I think what they’ve done is they’ve embedded it into their systems.

So, it’s not just saying to consultants, use it for appraisal, it’s saying please use it in M&Ms and audit meetings. In that particular trust, in the urology unit, they were not doing many day cases for male bladder outflow obstruction, and they were one of the lowest in the country. They were able to look at their own data, see what needed to be done, persuaded management that they could do better and got new instrumentation. And suddenly, over a couple of years, their day cases went sky high, right up to about 75%. And that was really impressive.

It’s that old adage, isn’t it? You can’t improve what you don’t measure.

When I first started doing this, I was quite surprised that we could track every readmission no matter where it occurred in England. And when we first started going to trusts and speaking to consultants, some of them had no idea that their patients had been readmitted elsewhere. And they were very grateful to know actually: why was that patient admitted, and was it related to the operation or not?

Because the readmissions weren’t all related to the operation; that’s important for people to know. Everybody knows patients can be readmitted for various other reasons. But if it is related to the procedure, I think most consultants want to know that and why and, “what might I do better next time to prevent it from happening?”

Tim Mitchell:

Considering tonsillectomy, for example, of which I have done many. It wouldn’t be unusual to perform a tonsillectomy on a university student who happens to be at a nearby university. They then go to recuperate where their family lives, which could be at the other end of the country, and then they might be admitted to the local hospital with a tonsil bleed that therefore the operating surgeon would know nothing about.

Q: One of the roles NCIP has is for leadership and oversight, so medical directors, responsible officers and clinical leads can see data for consultants in their jurisdiction. Why do you think that’s important within trusts?

Tim Mitchell:

Talking to medical directors, for example, it’s interesting how little they may know about what’s actually happening within their hospital. So, this is an opportunity for them to have access to data about the consultant body in their hospital. And unfortunately, we continue to hear of high-profile instances where things have gone wrong.

So, whilst NCIP can provide very useful information to the individual clinician, it can also be used as a check by the medical director to make sure that they’ve got a handle on what’s happening within their own institution.

Norman Williams:

Absolutely. I would also say that most outliers that we see aren’t outliers because of a problem with their skill or patient management. Often the reason is the data is not as accurate as we would like. So, the first thing we always say when we see a data deviation, is please check the data.

And even when that’s right, there are often very easy explanations. For instance, somebody pointed out an outlier in a colorectal unit, which is my specialty. They were doing only 12 cases in a three-year period, and all of these patients ended up with stomas, which was a bit strange. But when we looked at it, they were doing very complicated cases, pelvic exenterations, and it was quite understandable. So, they weren’t outliers at all. They were doing a very, very important job because they were a referral centre. So, I think that’s really important that we stress that. We’re not looking, and we don’t routinely look for outliers, but sometimes they are pointed out.

Tim Mitchell:

Yes, it’s very easy to focus on the high profile, bad cases. But the response, as you’ve suggested, has to be proportionate and used as a flag to say, well, okay, there’s something here that needs further investigation rather than there’s going to be punitive action.

This is actually a way of confirming that surgeons’ outcomes are within the acceptable range. And we should also accept that there is a range of outcomes. And just because people are in the bottom half, as it were, doesn’t necessarily mean that their outcomes aren’t acceptable.

Norman Williams:

Of course, it depends on the actual individual patient they’re operating on, and the risks. What we do provide, is an indication of a consultant’s practice in relationship to comorbidity and demographics. Particularly if they’re in a poorer area where health outcomes are not going to be great because of co-morbidity, we can provide context to their practice, which I think is helpful. 

Q: What would you say to any surgeons that question the accuracy of NCIP data?

Norman Williams:

What we always say is that at the end of the day, the data is yours. and you have a responsibility to ensure that it’s okay. Certainly, if I’m having an appraisal, I want to be sure that my data is accurate. However, we do appreciate that it’s sometimes difficult in an organisation, particularly around attribution.

We’ve got better at it and when consultants raise this issue with us, we will try and help them because we can go back to the trust and find out why the attribution wasn’t accurate and help correct it. And in most cases, the people who are responsible for the accuracy of the data have been very keen to engage. And of course we have a data quality guide.

Q: Are there any other ways you’d like to see NCIP develop in the future?

Tim Mitchell:

Well, I think making it available to all surgeons. There’s a wide range of specialties now. You’ve touched on making the data more reliable. I think then it’s about it becoming embedded in practice.

And to some degree, it’s the profession taking ownership, and engaging with NCIP is part and parcel of that. And then individual surgeons can report back, as you’ve suggested, that it’s not doing this for me or there’s a particular issue here. Can you address that? It then becomes increasingly reliable and increasingly valuable.

Norman Williams:

We’ve got an implementation guide for trusts, for to how to implement NCIP. There are various examples of how different trusts have embedded it and it’s a really good document.

Going forward, I think I’d be interested, particularly now that you’re going on from here, to be the chair of the Academy of Medical Royal Colleges, in your views because one part of our strategy is to expand it, first of all, to the interventional medical specialties like gastroenterology, pain management, etc, and then further afield.

It’s probably going to be more challenging, but when I’ve spoken to physicians, there seems to be an appetite for it.

Tim Mitchell:

I think as a matter of principle that would be a good thing to do. I think it has to be done in consultation with the profession so they understand what the process is about and they can feed back what their requirements are and make sure that you are collecting appropriate data.

Norman Williams:

I agree with you 100% and it’s the way we’ve always done it. We’ve always worked hand in glove with the specialty associations, and the colleges: “what outcomes do you think your specialty has?” You can’t do it without engaging, and we would never do that.

Tim Mitchell:

And you’ve got to get buy-in from the specialty, not only to set it up, but then to make sure it’s adopted.

Norman Williams:

And you have to have that trust, there’s no question.

One thing is, we’ve developed a champions network. And what we’d really like is champions in each trust, in each specialty, who will go out there and encourage their colleagues to use NCIP.

We’re very keen on utilising the data, not just for individual consultants or for governance issues, but also for tracking innovative procedures. Because I don’t believe that that’s been done too well.

We’ve got various specialties that are now starting to look at innovative procedures, particularly robotics, because it’s being used in all sorts of different specialties and they’re providing real life experience. And I think that’s really helpful for the NHS: what’s effective, what the problems may be, because they are always teething problems in any innovative procedure. So, I think that’s going to be a very, very great use of the data.

Tim Mitchell:

I think robotics, is a good example of that, and it’s absolutely key that there’s an evidence base for what we do.

Q: Do you have any final advice for RCS members about how they can get the most out of NCIP?

Tim Mitchell:

First of all, engage with the process. If you have concerns about the data, check it yourself, make sure you’re happy with what’s being collected. And then encourage your colleagues to use it, so that it can actually add benefit to what’s going on within the department. Maybe you can talk to your medical director about what their view is. And I think the direction of travel is very clear. This is going to become more widely used and the profession needs to own this and to be part of it.

Get started

NCIP is part of NHS England’s Getting It Right First Time (GIRFT) programme.

• Surgical consultants in the 13 specialties currently in NCIP can login at: https://ncip.model.nhs.uk/
• For your NCIP password, support for improving data quality, or if you’d like to join our NCIP Champions Network, email ncip@nhs.net
• Read the NCIP Implementation Guide
• Read the NCIP Data Quality Guide 
• Read more about NCIP