Why risk adjustment and assessing clinical performance against case-mix should be at the heart of the new consultant oversight framework

The CQC recently identified several areas where governance systems could be strengthened by operators, one of which was the oversight of consultants. It was announced at the end of last year that former NHS England National Medical Director Sir Bruce Keogh will lead on the creation of a new framework on how consultants are overseen in independent hospitals.


This issue is particularly pertinent in the wake of consultant Ian Paterson’s conviction and independent inquiry into his malpractice, which is due to announce its findings this summer. The new framework is part of the NHS response to this case and aims to foster a standardised approach to clinical governance in the private sector.


Previously, consultant oversight has relied on statistical tools and general proxy measures, such as death, readmission and complication rates. These fail to take into account the complexity of delivering care, including influential factors such as the individual conditions of the patients that consultants are treating and the nature of the operation proposed. In order to paint a true picture of clinical care quality, the risk profile of the patient and the surgery must be taken into account.


The CRAB Surgical Module uses a methodology for risk adjustment and assessing clinical performance against case-mix – both in relation to the physiology of the patient and the risk of the operation. The result of 30 years of research and development, it automates and enhances the POSSUM surgical audit methodology, originally published by Graham Copeland in 1991 and now in use around the world. As such, the Surgical Module represents a fair system for monitoring consultant activity.


An objective assessment of clinical quality and performance can be reached with a reliable evidence base. The referential data set on which the CRAB system is based has reached 65 million patient records spanning 46 countries, and it continues to grow by over 5 million records per year.


By adjusting comprehensively for clinical risk, this methodology supports consultants, institutions and patients. The system can enable hospitals to drill down from a poor-quality result all the way to individual case data, giving an accurate and detailed portrait of consultant performance. Equally it can demonstrate where excellent results are being achieved for high risk patients. In doing so it provides an assurance to the public of patient safety and a commitment to improving quality by reducing harm and variation and spreading best practice.


We believe this approach could form the basis of consultant oversight in the new Consultant Oversight Framework.

To find out more about the Surgical Module visit

  • 8 Apr, 2019
  • Kristian Low

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