Select Committee on Health Written Evidence


APPENDIX 4

Memorandum by Miss Zoe Penn (MS 9)

SUMMARY

  Training of health professionals is predicated on an agreed schedule of care and procedures to enable professionals to work to an agreed standard that should be evidenced based and up to date. Although locally agreed multidisciplinary guidelines remain the gold standard, in practise these have been slow to develop and prove a heavy burden to maintain and update on a continuous basis. The Chelsea and Westminster hospital have a comprehensive set of guidelines that are produced locally by a multidisciplinary team and we propose that these should be made available on a national basis for local units to take on and customise and that the Chelsea and Westminster should be provided with the monies to enable continuous updating in line with current evidence and nationally produced protocols.

AUTHOR

  This memorandum is submitted by Miss Zoe Penn, Consultant Obstetrician at the Chelsea and Westminster Hospital and Honorary Senior Lecturer at the Imperial College School of Medicine, London (020 8846 7902; e mail: zoe.penn@chelwest.nhs.uk). Although she is submitting this memorandum as an individual the work was undertaken by a multidisciplinary team at the above hospital. She has submitted evidence on the use of guidelines to the Deaprtment of Health in 2001 as a part of "Organisation with a Memory". The electronic format of the guidelines was enabled with monies from the NHS litigation Authority and "Datix": an electronic database and search facility developed by Capsticks Solicitors.

MEMORANDUM

  1.  Training of health professionals to provide the best advice and care for pregnant women needs a secure evidence based guidelines. Without guidelines there is no agreed standard and so no remedy for substandard clinical care, no explanation for variations in clinical practise and no defence against litigation. Any organisation that puts adverse incident reporting at the head of its priorities for improving clinical care for mothers and babies is committed to a future of special enquiries and the allocation of blame to beleaguered professionals, already overwhelmed by clinical duties, the tide of clinical information and national initiatives, as well as the unwelcome attentions of the press every time something goes wrong. Guidelines should be the first step in training: the gold standard is established by reference to the best evidence, this will help women understand the care they can receive, achieve continuity of care, make professionals feel supported and secure in their practice and give us an audit tool to assess standards of care and log and understand adverse incidents.

  2.  Without gold standards of clinical practice it becomes impossible to perform clinical audit, since there is no standard against it which to assess actual clinical care. Without gold standards of clinical practise, laid down in guidelines, it is impossible to fully inform women about what they should expect from their maternity care. Without gold standards of clinical care it is impossible to judge whether variations in practise are acceptable or whether adverse incidents are due to system failure, failures of education or defects in clinical knowledge. Without gold standards of clinical practise it is impossible for clinical staff to feel secure that they are practising optimally for the well being of mothers and babies in their care and, additionally to feel protected by their clinical colleagues. Without clinical guidelines all adverse incident reporting is like erecting a wooden wall against the incoming tide of litigation.

  3.  Guidelines should be available with ease, and a computer system ensures that the guidelines are all available at every clinical station. Guidelines should be locally developed and kept up to date: we contend that without strong central direction and given the current manpower crisis in the NHS this will be impossible for local maternity units. Our guidelines have been developed over six years and only now are they nearing completion and have been enthusiastically embraced by all clinical groups within the maternity unit. Other NHS maternity units will not have the time or resources to undertake this kind of massive investment of time and money.

  4.  However, our guideline system will need to be locally customised with the names of local professionals or phone numbers and taking into account the local physical constraints and manpower arrangements. As such, local consultation measures will have to take place. Local consultation ensures that the local professionals will feel some ownership of the guideline and will raise awareness of the guideline. Guidelines should also be practical and useful to clinicians, often practising in a system that is pushed for time and resources: our guidelines have been used for a number of years in actual clinical practise, they have been redrafted to take into account the views of our professional groups and to be succinct and practical in their approach.

  5.  We propose that the Maternity Clinical Guidelines, in use at the Chelsea and Westminster Hospital for the last six years, are used as a national template for maternity clinical guidelines. These guidelines have been in continuous evolution for the last six years and have been developed by a multidisciplinary team, including midwives, obstetricians, obstetric anaesthetists, pharmacists, obstetric physicians, clinical risk manager, haematologists, biochemists and many other stakeholder professional groups. They have been subject to wide consultation and have been used in clinical practise over a number of years.

  6.  The special features of this programme are that it is practical and proven in clinical care, evidence based and fully references, developed by a multidisciplinary team, up to date and provide a "gold standard" against which actual clinical practise may be audited. Risk management and logging of adverse incidents have also been initiated against the standard of these guidelines. Clinical guidelines are formulated, where possible, alongside the production of a patient information leaflet than conforms to the latest guideline.

  7.  The team at the Chelsea and Westminster Hospital comprises an obstetrician, two midwifery managers, the Director of Midwifery services, supervisors of midwives, Specialist Registrars in Training, obstetric anaesthetists, obstetric physicians and various other co-opted clinicians who are experienced in the drafting and launching of clinical guidelines and are committed to their long term support, to ensure that they are up to date with the latest evidence.

  8.  The other unique feature of the Maternity Clinical Guidelines at the Chelsea and Westminster Hospital is that they are available electronically. The computer based system was developed in collaboration with Datix Information Systems. It is based on a Lotus Notes system. This provides an electronic version of the Guidelines at every computer station in the hospital: labour ward, antenatal clinic, antenatal and postnatal wards and obstetric ultrasound departments. The guidelines can be printed by the clinician and placed in the patients' notes. This enables consistent bedside care, but also a contemporaneous record of "gold standard" management of the future. Up to date patient information leaflets can also be provided at every clinical station. Where requested, the woman can also be provided with a copy of the clinical guideline so that they know what the plan of action for their pregnancy or problem will be.

  9.  The system administrator can continuously update the guidelines to ensure that any new research data or national initiative can be incorporated as soon as it appears. The system administrator can also archive old guidelines so that a record of best practise, at that date, is always available. This will be of particular importance for the purposes of litigation and claims management.

  10.  The Datix Maternity System is also interactive so that all professional users can have a dialogue with the system administrator and so contribute to improving the system and the redrafting process. This ensures the involvement of all stakeholder professional groups and also increased the ownership of the guidelines by local professionals. The "start up screen" alerts the user to the initiation of new guidelines or the presence of new versions of guidelines to ensure that users are always aware of changes in practise as they occur.

  11.  The electronic version of this system is easily adaptable to any hospital and the site specific information can be easily stripped out so that the subscribing hospitals can customise their own guidelines, using the template, with the minimum effort.

RECOMMENDATIONS

  12.  The Chelsea and Westminster Hospital Guidelines group proposes that they run a group that will be responsible for the drafting of guidelines to keep them up to date and fully compliant with the latest research data.

  13.  They will also provide each client maternity unit with redrafted guidelines and information sheets for women, within a short time of new clinical information becoming available. They will respond to enquiries from all subscribing maternity units.

  14.  We must emphasise that these "guidelines" are not "protocols", they are intended to facilitate good clinical care and not to constrain thoughtful and individualised practise: "guidelines" guide care whereas "protocols" mandate care that may or may not be optimal for an individual woman. We would intend subscribing maternity units to use the national guidelines as an evidence based framework and we would provide a practical "how-to" guide upon which to develop their own local practice.


 
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