Select Committee on Health Written Evidence

Memorandum by Dr Jeffrey C McILwain (PS 02)



    —  Role of human error and poor clinical judgement. Human error and clinical judgement are synonymous. A "poor" judgement is influenced as much by the professional's poor judgement as the presentation by the patient. If the patient leads the clinician down the wrong path in the history, within limited NHS time resources the clinician has little time to correct this. Humans do not fit mathematical modelling except at the macro level ie populations, not individuals.

    —  Systems failures. There are only three things that can go wrong in life:—humans, systems and equipment. The first designs and controls the latter two, therefore all systems failures are human at source. System design can work if the system is tested to an extreme. This is a standard engineering principle. If one component fails then the whole system may fail eg `O' ring test failure in the Challenger space shuttle disaster. After extreme testing then monitoring has to take place. Further, is the issue of standardisation. The Great Western Railway, as an example of standardisation, greatly brought forward safety and production by standardising and interchanging parts. There are no tested nor standardised safety systems within the NHS except within purchased equipment.

    —  How far clinical practice can be risk-free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare. Clinical practice never has, and never will be, "risk free". Industries such as the petrochemical, rail or air industries have shown that despite improvements and "lessons learned" there are still risks either apparent and unsolvable or latent.

    —  The role of public perceptions of risk in determining NHS policy. Perception is a frailty built upon notions or opinion not fact. No fact = no science. No science = no measurable commodity.


a.   local and regional NHS bodies, and other organisations providing NHS services (including primary and community care, and mental health services)

    —  How far the Boards of NHS bodies have established a safety culture. There may be a will, but there is not a way. For 17 years the NHS has been focused upon targets and change, mainly financial. The notion of safety has been at the behest of clinical professionals, not lay dominated Trust Boards. The obsession with financial targets means that clinical and managerial staff are focused upon required results not safety. There are only 24 hours in a day and if finance (and its consequential targets) takes up most of this time then there is little or no time for safety as a secondary measure.

b.   systems for incident reporting, risk management and safety improvement

    —  Whether adequate measurement and assessment is undertaken and acted upon. The current system is based upon the risk matrix which is at the heart of the problem. This is a grid that places severity and frequency on different axes. However, whilst severity may have some general notion of what it is, it is maimed in definition by emotive words such as "catastrophic". Death is death, but an event listed as catastrophic means, to a lay person, a true catastrophe. Yet a death may be an actual predictable or expected consequence or outcome. The record though of the incident is "catastrophic". However, and much worse, is the portion of the matrix that uses probability of recurrence ie "likelihood". Likelihood is as scientifically effective as placing a wet finger in the air to determine wind direction. The likelihood of something recurring is future tense and speculative. If one trips and falls down the stairs what is the likelihood of this recurring? Answer, unknown or unlikely. But, if one's slippers are worn, or one is dizzy, the likelihood goes up, although you may not think so yourself. So two unscientific parameters immeasurable are used to determine the risk values that an organisation needs to risk profile a case scenario. So the data is wrong and so any drawn conclusions are wrong. So, any consequent action is wrong.

    —  The impact of the changing public-private mix in provision. Public and private institutions have a) differing end points to their defined needs and so b) differing pathways to follow. If kept separate then they can co-exist. However, if a patient goes from public to private and back to public ownership though contract or failure of the private sector then the patient may suffer further harm due to a lack of continuity.

c.   national policy

    —  The appropriateness of the objectives set out in national policy statements, including Safety First and High Quality Care for All, and what progress has been made in meeting them. Nice words but nothing systematically to underpin them—no local nor national expert panels.

    —  Whether past spending on patient safety has been sufficient and cost effective, and what future spending should be. It has been well noted that 10% of anything that can go wrong will go wrong. It therefore follows that 10% of budgets must be allocated to safety issues and management at every level of the NHS from top to shop floor. Spending has not, to date, been efficient or effective.

    —  The appropriateness of national targets. Inappropriate. You cannot measure something unless it is measurable and such measurability must reflect the need to be measured ie be appropriate to its consequence.

d.   the National Patient Safety Agency and other bodies, including:

    —Healthcare Commission / Care Quality Commission. NPSA: for its cost since inception it has not evidenced the fact that it has been directly responsible for saving one life nor preventing a death. No annual data flow comes from NPSA despite its assiduous collection of data.

    —NHS Litigation Authority. A remote organisation aimed to reduce costs, not prevent harm.

e. education for health professionals. No Royal College devotes the 10% required to direct patient safety issues. They presume that if the teaching and training is correct then nothing untoward will happen. This Nelson mentality ("I see no ships") displays a grave error of awareness and commitment at best and a reckless disregard for the nature of safety at worst. There are no Collegiate Professors of Clinical Risk Management / Patient Safety.


    —Whether the measures taken to improve patient safety are supported by adequate evidence regarding their clinical effectiveness and cost effectiveness. Effectiveness whether clinical or cost should reflect the principle of doing the right thing. However, the "right thing" remains undetermined and so efficiency (doing the thing right) dominates, even if one is doing the wrong thing. The evidence is lacking at many levels of safety issues as many such issues remain unidentified and so not available for analysis.

    —  How to determine best practice and ensure it is spread throughout the whole NHS. This remains contentious as "best" remains subjective and objective. Objectivity would include many weighted strands such as outcomes as well as morbidity, as well as environment etc. One has to declare what best practice is and then at least the NPSA might sufficiently distribute it. However the NPSA seems to choose easy media-friendly targets to attain rather than real world difficult and complex issues to tackle. A co-ordinated strategy through the many UK universities along a strategic line for each University would create an environment and culture of safety and accrue solid evidenced data.

    —  How to ensure that learning is implemented. As above via Universities, Royal Colleges and NPSA.

    —  What should be measured and assessed; and what data should be published. An interesting issue is when incidents occur—usually day time when most activity takes place, not at night or weekend. There is much temporal data to be extracted. Thereafter the time honed risk management tool of Identify, Analyse and Control should be invoked—again a standard well known throughout non-clinical industries. All data must be published to permit external assay and analysis.

    —  What incentives there should be to improve patient safety. Removal of non-clinical targets and diverting the costs to implement those targets, and political targets, into a safety budget set for each organisation.

    —  How patients and the public can be involved in ensuring that services are safe. Without knowledge of the above they cannot participate other than to give a notional account of a perception. In this case as the saying goes "one man's meat is another man's poison". However, skilled patients and here I mean ex-clinicians and retired clinicians who are patients who can straddle both camps are an untapped source of knowledge and experience. Lay people can have a role, however it remains personally driven, perceptive in nature and unscientific.

Dr Jeffrey C McILwain MB BCh BAO MD FRCS

Consultant, Clinical Risk Management,

St Helens & Knowsley Teaching Hospitals NHS Trust

July 2008

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