© 2013 Wichtig Editore - ISSN 1120-7000 Hip Int ( 2013 ; : 4) 343-344 23 343 Surgeon records in the public domain EDITORIAL DOI: 10.5301/hipint.5000078 The United Kingdom government has announced its intention to publish records of orthopaedic surgeons practicing in the country in relation to major joint arthroplasty. This follows collaboration between the British Orthopaedic Association and a previous government in the establishment of the National Joint Registry (NJR). Since its inception, the NJR has confirmed that hip and knee replacement are two of the most effective ways in which valuable NHS resources can be spent and two of the most consistently effective operations available. The public release of outcomes is established and accepted in parts of Scandinavia, but it is impossible in Australia, where the National Joint Registry is administered entirely by the Australian Orthopaedic Association. The assertion that public funding has provided the registry service and the public therefore has an entitlement to access results is perhaps disin- genuous, since the provision of medical services by the public sector is the default situation in the United Kingdom and parts of Scandinavia, whereas the private sector dominates the provision of heathcare in Australia, the United States, and in many other countries. It is very difficult and uncommon for a surgeon to practice independently in the United Kingdom, in contradistinction with most other professionals. The government in the UK therefore has a monopoly employer status and insists, on that basis, that results should be placed in the public domain. On 14 th March 2013 the Minister of Health in the UK was reported by the media as saying that that he intends to 'name and shame' surgeons who do not allow their results to be publicised. This may be pre-judging the outcome of this initia- tive -or demonstrating ‘prejudice’, in assuming that publicising data will be for the greater good and that shame should be associated with withholding data. It is not known if public dissemination of such information is likely to be a good thing, and ‘shame’ should not be attached to sincerely held beliefs in a democracy. At the time of the original discussions between the British Orthopaedic Association and the Department of Health in the UK in 2003 regarding the establishment of the National Joint Register, the DoH representatives indicated that there was 'no intention at this stage' to put results in the public domain. This assertion carried a degree of ambiguity. The current position of the UK government is that only mortality figures will be released. A cynic might query why a mid-term administration should seek to tackle this non-issue. There is strong evidence that mortality rates after joint replacement are consistently low and almost completely unrelated to the quality of surgery. Those patients who do succumb are far more likely to be the victims of social deprivation, poor medical health or care in a unit that is less than optimally equipped to undertake such work. In consequence mortality following joint arthroplasty is dependent on a range of factors almost all of which are beyond the control and unrelated to the expertise of the surgeon. Indeed, this journal has published standardised mortality ratios following hip replacement which indicate an enhanced likelihood of survival compared with the general population (1). Far more information is acquired from assessment of revision rates, which are also available in the NJR figures, and it may be anticipated that publication of this information is the next step in the process. However, publication of surgeon specific data may prove detrimental to the care provided through the NHS. As all surgeons know, the revision rate of an experienced and skilled hip surgeon with a complex arthroplasty practice may well be greater at five or 10 years than that of another surgeon in his or her department whose primary skills lie in other subspecialties and who generally only undertakes straightforward joint replacements. While great efforts have been made to correlate revision rates with pre- existing comorbidities and other confounding factors, the interpretation of results remains difficult even within a small group of surgeons within an academic department, and will be almost impossible for the public at large to understand. Risk stratification of the complexity of the case mix remains an unresolved challenge. Therefore, the apparent intention to produce ‘league tables’ will, in the public eye at least, create an impression of strati- fication from 'best to worst’ within each hospital and within each region which is likely to be unrepresentative and mis- leading. A further problem arises, at least within the UK, regarding the motives of the political parties. Reservations about public dissemination of information in this way are probably justifiable, and an extension of the information released to the public from mortality rates to revision rates (should this occur) may be a cause for concern.