The Scottish Audit of Surgical Mortality (SASM) is unique in the United Kingdom. It is a voluntary process which identifies and peer-reviews all deaths which occur under the care of a surgeon, whether or not an operation has taken place within an NHS or private hospital in Scotland.

From its inception, its main role has been educational and feedback from its findings would lead to the improved care of future patients. Lessons from this educational process could be applied either through the actions of individual participating surgeons and anaesthetists or through the identification of more general improvements in the approach to the care of surgical patients. Correspondingly, feedback has been provided confidentially to individual participants and through reports applied to the service all over Scotland and to Health Boards, Trusts and Specialties. Recently, in the context of the heightening importance of clinical governance and raising professional standards, a role is being seen for information from the audit to contribute to these purposes. 

SASM was established as an amalgamation of several regional audits and is now funded by the Information and Statistics Division of the Common Services Agency Scotland, while Quality Improvement Scotland has contributed funding for pilot studies. The audit forms, completed by the relevant surgeon and, where appropriate, anaesthetist, undergo a peer review process involving an initial assessment. In some cases this may be followed by a case note review.

SASM produces annual Individual Consultant Reports, Hospital Reports, Specialty Reports and a Case Note Assessment Booklet. It co-operates with other national audits and has a Research Group whose remit is to promote the analysis of SASM data and to present these findings to the wider health community. SASM data will also be included in the forthcoming Surgical Profiles Report to be sent to each NHS Board.

In addition to the benefits derived from feedback to individual surgeons and anaesthetists, developments and changes that have been promoted by the findings from SASM include the development and implementation of guidelines, in collaboration with the Scottish Intercollegiate Guidelines Network, on peri-operative care and prophylaxis of deep venous thrombosis and pulmonary embolism. SASM reports have also reported increased service provision, for example for peri-operative high dependency and intensive therapy unit beds. These resulted from messages applied at a Scottish national level and have been welcomed. 

The inclusion of SASM data in the surgical profiles reports sent to NHS boards, along with other quality assurance data from NHSQIS, has the aim of assisting boards to improve patient care by identifying areas of improvement within current practice.  What now needs to be debated is the place of information arising from the audit in local clinical governance, for example at the level of the clinical team or individual practitioner. 

In the current year, consultant surgeons in certain specialties are receiving an individual annual report. This draws together the pattern of findings for patients designated to be under their care and places this in the context of other specialists at Board and national level. Such reports can be included in information that forms the basis of annual appraisal and it is anticipated that this will be the usual practice. The role of such information in revalidation/relicensing awaits the outcome of the consultation on the CMO in England’s review of Medical Regulation.  However, it has not been established or agreed if information arising out of the audit, for example in relation to the management of an individual patient or a pattern of findings in a series of patients, could prompt other further action.

The essence of the audit is its personally confidential nature. Nevertheless, there is a view that GMC guidelines and opinion provided in 2002 by the Central Legal Office place a duty on individual doctors taking part in the SASM process, as well as on the SASM board, to protect patient and public safety. This could oblige them to release data without the consent of a participant. In order to promote the debate required to resolve these tensions, a paper, “SASM’s Role in Clinical Governance” has been prepared and will be provided to participants and sponsors of the audit. The outcome of the debate should strengthen the role of the audit in the promotion of high quality professional specialist practice and quality of service to surgical patients throughout Scotland.

Thursday 24 August 2006.