Select Committee on Health Written Evidence

Memorandum by the Royal College of Ophthalmologists (PS 23)



  This Memorandum from the Royal College of Ophthalmologists (the College) is in response to a new Inquiry into "Patient Safety". Much of this Memorandum is a distillation of the College's Patient Safety in Ophthalmology guidance (2008)[160] which appears on the College's website.

    —  Section 1 of this Memorandum provides an overview on issues currently pertinent to patient safety and quality in ophthalmology.

    —  Section 2 provides responses to the discussion points announced in the Select Committee's Press Notice of 17th July 2008 in advance of this Inquiry into Patient Safety.

  The College considers that, while positive progress has been made in relation to patient safety, there is room for improvement but that this cannot be achieved through the current performance management framework. Professional leadership and engagement are needed to make changes which embed a safety and quality culture across the NHS.


1.   Quality and Standards in Ophthalmology

  1.1.1  Healthcare quality and safety and clinical governance are intimately interlinked. Standards of practice for ophthalmic care are available in guidelines from the Royal College of Ophthalmologists, the National Institute for Health and Clinical Excellence, and in position papers from the College's Professional Standards Committee. The position papers are published as Ophthalmic Services Guidance and are regularly updated and made available on the College's website

  1.1.2  The maintenance of standards in ophthalmology is dependent on adequate staffing levels, proper facilities, appropriate managerial support and the commitment of individual ophthalmologists. The quality of ophthalmic care for NHS patients has improved in recent years with new technologies, care pathway modernisation, improved investment in the NHS and shorter patient referral to treatment waiting times. Strict attention to detail and careful consideration of the patient pathway, including risk assessment and vigilance, is needed to maintain and to enhance ophthalmic patient care and to maintain patient safety.

1.2  Risk and Error in Ophthalmology Care

  1.2.1  Despite the above high standards, errors, incidents and complications will happen in all healthcare settings and sometimes recur. Such events often provide a rich opportunity for learning, if properly considered and this learning may reduce the risk of similar events recurring.

  1.2.2  Under reporting of patient safety incidents, especially under reporting by medical staff, is commonplace, and clinicians need to be helped to overcome their reluctance in incident reporting. Clinicians and organisations reporting higher numbers of patient safety incidents may have a better developed patient safety and importantly learning culture and this should be fostered nationally.

  1.2.3  The Royal College of Ophthalmologists has provided guidance on clinical governance in ophthalmology in general and specifically on the reporting and analysis of ophthalmic patient safety incidents.

1.3  Safety in Ophthalmic Practice; Role of the College

  1.3.1  The Charter of the Royal College of Ophthalmologists states that the College should "maintain proper standards in the practice of ophthalmology for the benefit of the public." Accordingly the College places great emphasis on patient safety and best clinical practice as educational features and competencies for ophthalmologists and recognises both as core features of good ophthalmic service provision.

  1.3.2  While the College is not a regulator it does have a continuing interest in the integrity and reputation of its membership. Developing an understanding of the principles of patient safety features heavily in the College's training Curriculum for ophthalmic trainees. Patient safety aspects of ophthalmic care are featured in all relevant College Guidelines

  1.3.3  The College welcomes many of the recommendations in relation to a new quest for quality as outlined in High quality care for all: NHS Next Stage Review. (Dept of Health 2008). Investment in staffing; training in patient safety and service improvement techniques; appropriate equipment (including clinical audit and outcomes tools) and ophthalmic facilities provision, and development of a safety culture with clinical leadership and patient involvement, are in our view the key elements to modern safe and high quality ophthalmic care. Planning for patient safety and quality is required at individual patient and clinician levels, at local commissioning levels and at national policy levels. It is vital that clinical input and engagement occurs wherever policy change is envisaged.

  1.3.4  In practical terms, the College is able to provide specialist advice in the following ways:

    —  External Clinical Advice Teams (ECAT) at the request of healthcare organisations where ophthalmology services are experiencing problems which may present a threat to patient safety;

    —  Through its website, publications and educational events, the College aims to disseminate good practice and innovations which improve patient safety;

    —   The College liaises with the NPSA, MHRA, NCAS, the Healthcare Commission, the Department of Health, and other organisations, in addressing safety incidents, in both NHS and independent healthcare, if the College is made aware of such concerns;

    —  The College works with Agencies, such as the NPSA on producing guidance, such as the Correct Site Surgery Alert, and with the MHRA on ophthalmic medication or device Alerts which are later released to the NHS. A web portal to facilitate ophthalmic device incident reporting is now live.

1.4  Leadership in Patient Safety

  1.4.1  The College considers that further improvements in clinical quality and patient safety are more likely to come about through strong clinical involvement in the planning of day to day care and in training than from further legislation and central regulation. Senior doctors who shape a culture of clinical quality improvement and patient safety by personal example have a powerful and lasting effect on the members of their clinical teams and, via their training activity, on the next generation.

  1.4.2  As governance and patient safety within some areas has been problematic, the College encourages ophthalmologists to highlight concerns to the College, while also complying with statutory and regulatory requirements, so that lessons can be shared and may be brought to wider attention, if required.

1.5  Advancing Quality and Patient Safety in Ophthalmology

  1.5.1  The College welcomes Quality Improvement Reports in ophthalmology. Ophthalmologists and eyecare teams are encouraged to submit such reports as abstracts for presentation at the College's Annual Scientific Congress or as memoranda or reports to the College's Quality and Safety Sub-Committee or for peer reviewed publication. Where appropriate these will be brought to widespread attention.

  1.5.2  Help from the College is available to ophthalmologists seeking to improve the quality and safety of ophthalmic care and to those seeking to highlight or publicise such matters or achievements. Currently most of this activity is unfunded and provided pro bono.


  What follows is a response from the College to the topics proposed in the Select Committee's Press Notice. For ease of reference the Select Committee's questions are presented in italics and the College reply is in regular font.

2.1  What the risks to patient safety are and to what extent they are avoidable, including

  2.1.1  Role of human error and poor clinical judgement. Human activity, judgement and error -including clinical judgement- are interlinked. The role of human factors and of team resource training in patient (and in aviation and other critical areas) safety is well recognised in the literature. Although human error and lapses in clinical judgement do occur, well functioning, stable clinical teams with good handover procedures provide a powerful defence against error and failure.

  2.1.2  The College is concerned that, in many hospitals, long established clinical teams are under threat or have broken up or been subject to re-configuration thus losing their ethos of team-working. Furthermore little in the way of team-working training or team resource training occurs in the NHS at present.

2.2  Systems failures.

  2.2.1  Because systems and equipment are designed and controlled by people, systems failures are human failures at root causation. Well established systems can fail but are often also tested over time and modified without failures. Hasty and ill-considered changes to parts of systems can however disrupt performance and affect safety adversely.

  2.2.2  The College is concerned that, in the zeal to reform and improve systems, insufficient attention is given to the evaluation of such changes and the need to test changes on a limited scale before wider implementation. Without this care, the introduction of untested changes may themselves result in new threats and unintended consequences to patient safety. Thus, systems designed to achieve tight access targets may unwittingly create pressure to compromise patient safety; systems intended to facilitate the direct booking of hospital appointments may introduce risk by breaking the link between the referring and receiving clinician by creating pressure to compromise patient safety by distorting clinical priorities.

  2.2.3  In relation to the "18weeks" target return patients with chronic and often blinding eye diseases are being displaced by new patients, some of whom have only minor visual problems in comparison. This is compounded by "new to follow up patient" ratio targets to satisfy commissioners, for whatever reasons. Thus managerial priority is being achieved to the detriment of clinical priority.

  2.2.4  The College considers that the emphasis given to performance management targets and constant organisational change may themselves be regarded as systems failure. It is regrettable that patient safety has not been emphasised as a key NHS organisational value during recent changes.

2.3  How far clinical practice can be risk-free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare? With expert input clinical systems can be designed to minimise or control risk.

  Careful consideration of patient pathways—including failure mode analysis—and technology advances are of merit in this regard. However clinical practice never has, and never will be, "risk free". Industries such as rail or air transport have shown that despite technical improvements and "lessons learned" there are still risks either apparent and unsolvable or latent. Furthermore as much of the NHS is running at full capacity -with wards and clinics full to overflowing- there is little precaution or safety headroom to cope with surges in demand (so called "winter pressures" or variations in capacity (eg staff shortages or sickness). Adequate headroom and back up is a key precautionary principle of other safety conscious endeavours and is lacking in the NHS.

2.4  The role of public perceptions of risk in determining NHS policy.

  Public perception and short term media attention is undoubtedly a factor in determining all public policy and strategy, not least healthcare policy. However the complexities of patient safety and of clinical risk are not communicated sufficiently clearly, maturely or objectively to the public. Ultimately historical analysis may be more potent than contemporary perception of the need for policy changes in response to alleged public concerns.

2.5  The current effectiveness of the following in ensuring patient safety:

  2.5.1  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.

  2.5.2  Since the publication of an Organisation with a Memory (Department of Health, 2000) the NHS has made better efforts to improve and or ensure patient safety. However, for many years before that report and most importantly ever since then, NHS organisations have perpetuated a performance management and target culture, rather than a safety culture.

  2.5.3  Constant organisational changes within the NHS lead to leadership fatigue and act as a disincentive to local innovation. Chronic unrelenting financial pressure on NHS organisations inevitably cascades downwards and has resulted in financial austerity in front-line clinical services and all-too-often, a "make-do" culture in the clinical workforce at the sharp end. These pressures on organisations, which are mostly output or outcome related, frequently trump any other culture in such organisations. While improvement in access and good financial stewardship of public money are worthy enough cultures in themselves they should not be allowed to compromise safety

  2.5.4  The College has concerns that not enough has been done to retain the ideas in an Organisation with a Memory and that time and effort is still needed to ensure that new NHS organisations understand and can foster a culture focused on patient safety.

2.6  Systems for incident reporting, risk management and safety improvement. Whether adequate measurement and assessment is undertaken and acted upon?

  All NHS organisations and independent sector providers have some patient safety incident reporting system. Slips, trips and falls remain the commonest source of patient safety incidents reported across the NHS. Most reporting is undertaken by non medical staff. The College has given advice on which clinical incidents in ophthalmology should be reported and analysed and on how to do so in order to improve ophthalmic risk management.

2.7  The impact of the changing public-private mix in provision.

  Patient safety standards and monitoring should be the same in public and private institutions. The College has long argued to see standards in Independent Sector Treatment Centres (ISTCs) improve. We provided evidence with regard to the impact of ophthalmic ISTCs to the Health Select Committee's Inquiry into this matter in 2006 and were uplifted by the Committee's conclusions and many of the resultant recommendations made in the Healthcare Commission's later report on that topic. We now see some evidence that certain ISTC providers are taking patient safety and clinical governance more seriously than previously.

  The College remains concerned about the impact of the "additionality" rules in Wave 1 ISTCs as we have found that the visiting overseas clinicians have differing training and attitudes to patient safety than do those trained in or familiar with NHS settings. It is self evident that the financial impact of ISTCs and other clinical outsourcing on the provision of comprehensive local NHS care in the NHS Hospital Eye Service will impinge on emergency and specialised tertiary ophthalmic clinical services and thus impact adversely on patient safety.

2.8  National policy

  2.8.1  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?

  These recent policy directions refreshing patient safety at conceptual levels are welcomed. What are now needed are the resources and clinical leadership to put these thoughts into action. The patient safety mindset and memory is present, it now needs limbs. Otherwise it is all talk and no action.

2.8.2  Whether past spending on patient safety has been sufficient and cost effective, and what future spending should be?

  It is estimated that approximately 10% of healthcare episodes and interventions are compromised in some way by clinical errors, 50% of which are preventable. It is thus argued that 10% of resources should be allocated to patient safety or quality matters. To date this has not occurred. Payment is by activity regardless of quality. Investment in clinical leadership of patient safety and quality has been lacking and may be a worthwhile development which might re-energise clinical engagement in these areas.

2.8.3  The appropriateness of national targets.

  It is difficult to envisage national targets for safety that would be meaningful or appropriate. With all national targets—such as 4 hour waits in Accident and Emergency Departments- come perverse incentives and consequences and the possibility for gaming. The College has suggested certain metrics for developing quality ophthalmic practice to the Chief Medical Officer, the Department and Healthcare Commission, such as the monitoring of post operative eye infections. These will require funding and must be considered as developmental. However we remain concerned about new waves of targets (including targets about quality metrics) being imposed without appropriate clinical evaluation or consideration of their impact on non-targeted care.

2.8.4  The National Patient Safety Agency and other bodies, including Healthcare Commission / Care Quality Commission.

  Colleges have worked with the NPSA since its inception and Clinical Specialty Advisors (CSA) in several key areas including in ophthalmology were appointed. Sadly all such CSA posts at the NPSA ended in 2006 due to financial pressures at the NPSA just at a point in time when the NRLS data was coming on stream. At present there are circa 2 million patient safety incident reports on the NPSA's database (the NRLS) from which little has been extracted that has had implications for care. All of these are possibly potent windows on the system. More work could be done on extracting specialty specific data from that resource if funding was made available and if the quality of data on the NRLS was improved upon by better reporting. More effort needs to be made at local organisations to learn from incidents when incidents are reported. All too often little occurs.

2.8.5  NHS Litigation Authority.

  We are unaware of efforts made by the NHSLA to prevent harm or improve safety relevant to ophthalmic care. If such efforts have been made they have not been highlighted or widely publicised. We are aware of a considerable amount of training being mandated in local organisations across the NHS as a result of a need to comply with NHSLA (former CNST) requirements.

2.8.6  Education for health professionals.

  We are aware that certain medical schools have incorporated patient safety training into their curriculum. The College's Curriculum for Specialist Training emphasises patient safety for ophthalmic trainees as do College Guidelines. We are dubious about the value and educational merit of much of the current enforced "mandatory training" at Trusts save it being a box-ticking requirement for the NHS Litigation Authority.

2.9  What the NHS should do next regarding patient safety?

2.9.1  Whether the measures taken to improve patient safety are supported by adequate evidence regarding their clinical effectiveness and cost effectiveness?

  The College supports many of the measures taken to date and now planned or envisaged in Lord Darzi's report to improve quality of care for all. There is evidence that investment in quality improvement often leads to improvement in quality. There is evidence that improvement in patient safety saves lives and healthcare costs. Publications in journals, such as in Quality and Safety in Healthcare, dedicated to publicising international endeavours in such fields are often compelling. The College encourages such endeavours and would welcome "pump priming" investment in objective analysis in such fields of translational and applied research.

2.9.2  How to determine best practice and ensure it is spread throughout the whole NHS.

  The College provides carefully considered direction on best practice in ophthalmic care. Such material is evidence based and is frequently updated in College Guidelines and in guidance from the Professional Standards Committee. Where possible all such material contains guidance on patient safety as relevant to the topic under consideration. Careful consideration of clinical outcomes introduced into NHS practice might well improve quality and might also inform revalidation.

2.9.3  How to ensure that learning is implemented.

  Reports from NHS agencies and others following patient safety incidents should be publicised (but in an anonymous format) and discussed in a mature professional manner by healthcare organisations and relevant clinicians with an aim to seek local and wider implementation of lessons learned. Evidence of such endeavours might form a part of the appraisal of consultants and the accreditation of clinical services.

  Investment will be needed for this vision to mature and for evidence of its implementation to be robust. Royal Colleges could have such roles in partnerships with NHS national agencies or Strategic Health Authorities subject to funding. Thus it might be possible to consider the state of patient safety in ophthalmology in East Anglia or the state of safety in vascular surgery in Greater Manchester for example. Thus there needs to be investment in leadership networks in ophthalmology at regional levels. Such networks should combine clinical and management leadership.

2.9.4  What should be measured and assessed; and what data should be published?

  All data in relation to both patient safety and patient outcomes should be published to permit external comparison and analysis. Such data may be subject to freedom of information requests where not published. Publication of individual clinician/ practitioner outcomes is misleading unless it can be adjusted appropriately for complexity and level of pre-intervention risk or casemix, but we support publication of appropriate clinical outcomes from large specialty specific or even procedure specific electronic datasets, such as a national cataract dataset. Such tools are available and have been successfully piloted in a large cataract dataset analysis but are not in widespread use.

2.10  What incentives there should be to improve patient safety?

    —  Investment in: appropriate tools (such as an electronic cataract surgical care dataset) and the staffing to use such tools; along with recognition of professional leadership, including the appointment of clinical leaders in patient safety in each specialty in each NHS organisation or region; and the removal of non-clinical targets would be worthwhile incentives to regain the patient safety agenda.

    —  The role of College external advice teams could be extended into the accreditation of specialist services in partnership with the Care Quality Commission although this will require a formal contractual framework which provides "back-fill" to the employers of clinicians engaged in such work. Currently, nearly all such activity (though it is for "the greater good of the NHS") requires staff to take special professional leave and is dependent on the goodwill of employers. It is rarely recognised in consultant job plans.

    —  We agree with Lord Darzi that organisations and individuals should be rewarded for tangible improvements in patient safety and we believe that this should allow a reduction in the burden of performance targets not directly related to patient safety and quality of care. Reinvestment of the saved transactional costs into patient safety and quality of care and in awards to recognise such endeavours would provide further powerful incentives.

    —  There should be an incentive for Connecting for Health to speed up work on the adoption of clinical datasets into workable clinical information systems. Today's acorns might thus grow into tomorrow's oaks.

2.11  How patients and the public can be involved in ensuring that services are safe.

    —  We welcome the role of patient satisfaction monitoring and health outcomes, including patient reported health outcomes, into the NHS. Such tools, along with robust clinical outcomes analysis, are of merit in the qualitative triangulation of services. However satisfaction with services may not always equate with outcomes and vice versa. The input of skilled patients and patient representative organisations as a means of patient involvement is welcomed.

    —  Lay people also have a role in patient safety and it is important that lay governors and non-executive directors remain on NHS Boards and that their voices are heard. It is important to ensure that lay representatives consistently reflect the opinions and needs of communities they represent and that they are strong enough and well-enough informed to challenge Executive Boards when there is a danger of clinical quality or patient safety being subjugated to competing imperatives.

    —  All patients, all clinical staff and all lay people are members of the public and will have views and opinions which should be captured and taken seriously. It is not sufficient that public opinion should be the preserve of politicians and NHS organisations should be encouraged to seek the opinions of the public at large without needing political directives.

September 2008

160   Patient Safety in Ophthalmology; Ophthalmic Services Guidance'. The Royal College of Ophthalmologists. London 2008- Back

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