Select Committee on Health Written Evidence

Memorandum by the Patient Liaison Group: Royal College of Surgeons England (PS 26)


  The Patient Liaison Group at the Royal College of Surgeons works to bring patient concerns to the attention of the College and provide lay input and a patient perspective to numerous policy-making committees within the College.

  It is made up of 12 lay members and 6 surgeons. Most of the lay members are either patients or carers of a patient, they are volunteers who are non-medical and do not represent any organisation, their views are their own as individuals. The PLG therefore provides a collective view from individuals who bring a lay/patient perspective to their response. Our views are independent from those of the College; we make considered responses based on our patient experience and interest.


  We have tried to raise questions and highlight concerns around the questions you pose in this inquiry. Many of our concerns are about the possible implications of decisions taken at both national and local level, which may have unforeseen implications for the quality of patient care and safety.

  We have particular concerns about the impact of national policy, targets and Working Time Directive compliance on how care is delivered.

  At a time when the boundaries between health professionals are rapidly blurring, we feel that patients and the public need to be far better informed about who is delivering their care and how that care is delivered. They need to be told about changes made and reassured that those changes in service delivery are based on real clinical rationales, not driven by economics alone, and are not going to endanger the quality or safety of their care. Only if patients are well informed, and their views respected, will they have real confidence in the service. Patients should be able to provide their own assessment of patient safety issues based on a good understanding of how the service works, rather than having to rely on learning about it from press headlines.

  There may be many useful lessons that could be learned from the experience and training carried out in other high-risk industries such as the airlines and applied within surgery for example.

  There is a need to change the culture to one where reflection on practice is used to enhance learning and skills, rather than encourage "blame".

Q1.   What risks to patient safety are and to what extent they are avoidable

PLG Response to Q1:


  1.  Effective communications, between clinician and patient and clinician and colleagues is crucial for patient safety.

  2.  Poor English language skills, both verbal and written must be recognised as a possible risk to patient safety and clearly identified as an important skill to be assessed in the recruitment process for healthcare professionals.

  3.  Poor written skills are particularly high risk given the need for more handovers required within the Working time directive environment.

  4.  Reassurance that Trusts are taking real heed of this issue is needed particularly when recruiting doctors/nurses etc from the EU, as the GMC passes responsibility for language assessment etc to the employer or Trust.

  5.  Could useful parallels with the airline industry's approach to safety and training be drawn with surgery for example?

PLG Response to Q1:


  1.  The public's view of the health service is based to a large extent on their own direct experience, that of friends and family and what they read in the press.

  2.  It is important therefore that when actions are taken by the NHS to reassure patients that their safety is being considered, that these are evidence-based and not just knee-jerk reactions taken in response to public fears and press reports.

  3.  Patients value information and considered clinical argument in informing policy decisions.

Q2.   What the current effectiveness is of the following in ensuring patient safety

PLG response to Q2b:


    —  Whether adequate measurement and assessment is undertaken and acted upon.

  1.  There should be formal, constructive avenues that health professionals can follow in order to discuss constructively any incidents of their own poor personal practice, and concerns that they may have about the performance of colleagues.

  2.  A "blame culture" should become one that encourages continued professional development and learning.

  3.  There should be a ward sister or equivalent in overall charge and responsible for every hospital ward, ensuring that the highest standards of cleanliness are maintained. This person should be obvious to patients, so that they can approach him/her if they have queries during their stay.

  4.  Are cases of MRSA accurately recorded and acted upon?

  5.  Essential that there are incentives provided to ensure that Trusts encourage a culture where all adverse incidents are openly reported.

PLG response to Q2c:


  1.  Patients need to be far better informed about who is actually delivering their care, the training they receive, their assessment and supervision and how to recognise them in the hospital.

  2.  Patients need to be reassured that the rapid blurring of the roles of health professionals is not reducing the quality of patient care and safety.

PLG response to Q2c:


    —  The appropriateness of national targets

  National targets may inadvertently impact on patient safety and quality of patient care:

  For example, the desire to meet waiting times may lead to actions taken which could compromise patient safety:

    1.  Increased risk of hospital acquired infection rates as a result of bed occupancy rates being too high.

    2.  Beds being placed too close together, in order to maximise the number of patients treated.

    3.  Inadequate nursing care in monitoring patients and making sure that they actually eat nourishing food essential to their recovery, as a result of low nurse to patient ratios.

    4.  Poor cleaning regimes because patient throughput so high.

    5.  Fast throughput making less time for clinicians and nurses to follow adequate hand washing regimes.

    6.  Fast throughput reducing time available to "debrief" and learn from day to day practice.

    7.  Fast throughput and high patient: nurse ratios mean less opportunity for the "softer" skills of caring to be delivered and taught.

EWTD Compliance:

  8.  Compliance with the 48-hour restrictions could on its own determine long-term structural changes in service delivery by default, rather than changes being determined by the imperative to deliver the highest quality of patient safety and care.

  9.  Proposed solutions to the 48-hour restrictions must ensure that the benefits to patients of not being treated by an over tired doctor in training are not negated by rotas, that tick all the appropriate boxes but result in an inappropriate level/specialty of doctor being responsible for their hospital care.

  10.  Patients would not want to see the training of junior doctors compromised and training opportunities reduced, by the need for them to comply with the Working time directive.

PLG Response to Q2d:


    —  Healthcare Commission/ Care Quality Commission

  It would be useful to have indicators used by the Healthcare Commission/Care Quality Commission that reinforced the following:

  1.  Quality of training delivered, and training opportunities provided by the Trust (Determining future patient safety)

  2.  Implementation of lessons learned through incident reporting/patient complaints

  3.  Effective appraisals/revalidations carried out for clinicians

  4.  Details of remedial programmes in place for clinicians needing training.

PLG Response to Q2e:


  1.  Such useful procedures as the WHO checklist and "red flag" systems used in some operating theatres, should be encouraged and built into the training of junior doctors, thereby promoting best practice.

  2.  Training in team working for surgeons in theatre

  3.  Effective communication skills with both patients and colleagues

  4.  Training which includes sessions run by Trust Complaints Managers, Medico-legal experts and others who can provide case studies of those occasions when patient safety has been compromised. This would heighten the awareness of safety issues for trainee doctors, nurses and other health professionals.

  5.  Emphasis should be given to the need for doctors etc to reflect critically on their own practice.

  6.  Video recordings of operations in theatre could be used to emphasise safe practice. This has parallels with the use of black box technology on board aircraft whereby each flight is continuously monitored and, should an accident take place, activities around the time of the occurrence can be studied.

  7.  Perhaps some of the training methods used in the airlines could be adapted for use specifically for surgeons in theatre.

  8.  Examples could be drawn from other high-risk industries, and used as learning opportunities.

Q3.   What the NHS should do next regarding patient safety

PLG Response to Q3:

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

  1.  "WHO" has produced for theatre a surgeon's checklist, helping to improve safety during operations. This could be adopted in this country, or at least piloted.

  2.  "Red flag" systems are used by surgeons to flag up any potential problems such as having 2 patients with the same name on the day's list. Such useful procedures should be encouraged and built into the training of junior doctors, thereby promoting best practice.

  3.  Clinicians should perhaps be encouraged to visit and observe practice in their specialty at other Trusts, thereby gaining insights into how other Trusts carry out their work.

  4.  Specialist Associations and Royal Colleges provide an ideal route for spreading such good practice throughout their specialties and professions.

  5.  Regular updates could be part of CPD for clinicians.

PLG Response to Q3:

    —  How to ensure that learning is implemented

  1.  Via effective CPD programme that requires clinicians to show where they have implemented relevant learning.

  2.  Appropriate measurement and assessment (as described below) will provide quantifiable evidence of effective application of learning.

PLG Response to Q3:

    —  What should be measured and assessed: and what data should be published.

  1.  Adverse incidents should be reported and acted on by the Trust

  2.  Clinical Outcomes should be measured and used by the NHS to drive forward continually improving practice in all hospitals/units and should include such aspects as: Mortality rates vitally important as a minimum—they flag up danger signals/May help identify unsafe practice; Death rates however do not reflect variations in quality for all other outcomes; Quality also important for patients alongside the highest standards of safety; Infection rates; Post op complications; Revision work needed; Actual vs predicted length of stay in hospital; Impact of wait on outcome; Quality of patient experience; quality of life after discharge.

  3.  Great care should be taken in deciding what data is to be published, so that league tables don't emerge which could be misinterpreted by the public and lead to doctors avoiding high risk treatments and patients.

  4.  Vitally important however, for patients to know that any data collected and analysed, is being used to drive up standards of care in all hospitals and units, not just those where Patient Choice has highlighted concerns.

PLG Response to Q3:

    —  What incentives there should be to improve patient safety

  1.  Healthcare Commission/Care Quality Commission indicators met.

  2.  Patient safety ratings for Trusts in the area of Patient Choice

PLG Response to Q3:

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

  1.  The culture of the NHS must make it straightforward for patients to provide feedback on the quality and safety of their care, without fearing that it may rebound on them.

  2.  Patients must feel that their concerns will be listened to and responded to and that if appropriate, remedial action will follow. Patients should be told of actions that have resulted.

  3.  There must also be channels for patients to provide feedback on good practice that they have experienced.

  4.  Patients should feel able to talk to clinicians about the safety of their care, such as asking if the health professional has washed their hands since examining a previous patient.

  5.  Patients need to have more information about safety issues and the sort of questions they can ask a clinician when preparing to go into hospital.

  The Patient Liaison Group (PLG) of the Royal College of Surgeons of England is an independent body, which reports regularly to the College's Council. Comprising a majority of lay members (including its Chair), it provides a patient, carer, and public perspective across core College business. This submission represents the considered views of the PLG itself, and not necessarily those of the wider College or of its members.

September 2008

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