Surgical audit in private practice

In his foreword to A First Class Service Quality in the New NHS, the Secretary of State for Health stated 'The National Institute for Clinical Excellence (NICE) will ensure authoritative national guidance is available for all health professionals on the latest drugs and technologies'. It is hoped that NICE will be able to monitor the results of surgery for a specific condition against the best and the average. However, this will only be achieved if all of us audit our results more closely. A paper on p. 582 records such an exercise. Mr Drew and colleagues describe how, when they audited the results of hernia repair as practised by one of the group, Mr Lee, recurrence rates were well below the national average but less good than those of specialist centres using different techniques. Mr Lee therefore changed his approach in the belief that the technique he used was inferior to others. The Department of Health will be delighted with this paper and certainly will not send in the Commission for Health Improvement (CHIMP) to check on Mr Lee, whose actions have embodied the ideals of clinical governance. Despite its merits, the paper has clear weaknesses as a work of science. Follow-up by telephone is less than ideal, and life-table analysis is no substitute for complete followup at 10 years. We are told nothing about the patients' occupations, whether they were all allowed to recommence work of whatever type at the same time, what sort of hernia types were encountered and whether or not the recurrences were all in one type, e.g. sliding hernias. Certainly the surgeon was standardized but what about the patient or the operating environment? There are so many variables there is no such thing as a standard patient (?a smoker; ?someone with chronic obstructive airways disease, ?someone with elastase deficiency) or a standard operation (time of day was the surgeon tired, was the suture material from the same batch, was the anaesthetic general or local?). The authors refer to Kingsnorth's prospective trial comparing the plication darn with the Shouldice repair and, in fact, there were more recurrences in the latter group despite the excellent results obtained at the Shouldice Clinic. On what grounds has Mr Lee chosen the Lichtenstein mesh repair? Some prospective trials have shown it to be no better in terms of recurrence rate than laparoscopic repair and with greater pain and a longer return to work. Perhaps because it is easier to teach, more easily reproducible, cheaper and can be done under local anaesthesia. But, in terms of clinical excellence, is this enough?