Memorandum by the Royal College of Ophthalmologists
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)
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 www.rcophth.ac.uk
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
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
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
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 pathwaysincluding
failure mode analysisand 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
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
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
targetssuch 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
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
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
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
160 Patient Safety in Ophthalmology; Ophthalmic
Services Guidance'. The Royal College of Ophthalmologists.
London 2008-http://www.rcophth.ac.uk/standards/ophthalmicservices. Back