Select Committee on Health Written Evidence

Memorandum by Graham Tanner (PS 33)



  1.  Twenty-two Patient for Patient Safety Champions for England & Wales were appointed in May 2008 in accordance with Recommendation 13 of Safety First. Patient Champions whilst working in collaboration with healthcare bodies in England & Wales are also aligned to the World Alliance for Patient Safety. The projects aim being to improve patient safety in various areas of healthcare provision. This submission is compiled on the basis of discussion with a large number of patients and may not necessarily be the view of the Patient Champion project corporately.

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

  2.  Patients recognize that there are inherent risks in all forms of invasive surgery and medical treatment. There are obviously higher risks associated with the development of new techniques and therapies but these have to be weighed against benefits accruing to the patient. Few of the advancements in surgical procedures and therapeutic treatment which prolong people's lives would have taken place if the risks involved had not been confronted by surgeons, patients their families and carers. The involvement of patients and their carers is therefore vital to future research and development of medical procedures.

  3.  There are two great risks (outside of invasive surgery) facing patients in acute, primary and social care settings. These arise from infection some of which display increased antimicrobial resistance together with restrictions on availability of life prolonging medications.

  4.  Contemporary antibiotics are becoming increasingly ineffective against a large number of bacteria and in some instances even the strongest antibiotics are becoming ineffective. There has been a view that some of the more infamous infections were restricted to acute care and mainly confined to elderly patients. Statistics released by the Health Protection Agency (HPA) are beginning to dispel these views. At least 25% of Clostridium Difficile emanates from settings other than acute care and MRSA is becoming more prevalent in the community particularly amongst the younger generations. The mortality rate associated with infections which have developed resistance and produce virulent toxins has increased markedly over the last two years.

  5.  The World Alliance for Patient Safety has recognized the growing threat from antimicrobial resistance and the rise in increased treatment failures. The risk of untreatable infectious diseases increases the threat of transmission of these virulent pathogens and this could endanger the collective health of large sections of populations. Research demonstrates that resistance to antimicrobial therapy is contributing to national and international increases in infectious disease mortality. The World Alliance is therefore working towards a Third Global Challenge centred on antimicrobial resistance.

  6.  It is recognized that the best method of preventing transmission of these diseases is the cleansing of hands. The National Patient Safety Agency is conducting the "cleanyourhands" campaign in acute trusts with limited pilots being extended to primary and social care providers. The campaign in acute care has made a vast contribution to the reduction in MRSA bacteraemias but although the necessity to cleanse soiled hands with soap and water is emphasized in the campaign materials there is still confusion amongst healthcare professionals as to when hand gels are appropriate.

  7.  Some healthcare professionals are becoming so concerned about the confusion that currently exist there are suggestions that the hand gel stations should be removed. This in itself will not resolve the problems; it may actually promote the transmission of infection. The NPSA needs to reinforce its campaign but place greater emphasis on the necessity to use soap and water to cleanse hands when soiled and where diarrhea is involved. Extension to the primary care and social care sectors also needs to be undertaken as a matter of urgency if patient safety is to be truly improved. In order to achieve this objective there needs to reconsideration of the funding allocated to the project. Healthcare associated infections incur costs in excess of £2 billion per annum and savings made from reduced infection levels would more than compensate for increased expenditure.

  8.  The increasing severity of healthcare associated infections can be demonstrated by examining the mortality statistics for Clostridium Difficile and MRSA over the last 4/5 years. The annual mortality rate for Clostridium Difficile has increased from 5.02% in 2004 to 16.52% in 2007 based upon statistics from the ONS and HPA. MRSA mortality has increased from 12.57% in 2003 to approx. 33% by 2007. Whilst some of these increases may be a result of improved reporting it is also apparent that the rapid development of virulent toxic strains of the diseases is a primary factor. It has also been said that these are diseases mainly relating to hospitalized elderly patients with already compromised immune systems. The HPA statistics from April 2007 show a different picture. Approx 23% of Clostridium Difficile cases in each quarter are consistently reported as emanating from establishments other than acute trusts. There are therefore problems in the community, possibly arising in the social care sector, which places a wider number of patients at risk than previously thought. It is also evident that approx 25% of Clostridium Difficile cases relate to the 2-64 year age group, again providing for a much wider risk to public health.

  9.  The benefits of mandatory surveillance have been clearly demonstrated by the introduction of measures designed to reduce specific healthcare infections and improve patient safety. This mandatory surveillance now needs to be extended to other infections and areas of infection. There are other bacteria of equal (if not greater) severity than MRSA and Clostridium Difficile. Staphylococcus Aureus infections are not limited to MRSA and Methicillin Sensitive Staphylococcus Aureus (MSSA), 8500 cases per annum, can be as equally devastating to patients, Klebsiella which can result in pneumonias exceeds 6000 cases per annum, Escherichia Coli (E.Coli), which is rapidly developing a virulent resistant strain, is in excess of 22000 cases per annum. Blood stream infections account for around 6.2% of healthcare associated infections (BMA 2006) whilst Surgical Site Infections (SSI) is 10.7% of the total yet there is no mandatory surveillance of the incidence. People who have compromised immune systems and receive regular therapy for renal and malignant disease are at higher risk of contracting a healthcare associated infection. Women who undergo cesarean section are also vulnerable to urinary tract and other infection. These groups account for large sectors of the population yet there is no mandatory surveillance to identify the incidence of infection. The introduction of which could lead to improved patient safety.

  10.  Whilst requests for consideration of extension of mandatory surveillance and increased patient safety go unheeded by Ministers some NHS Trusts have recognized the escalating problem and are funding pilot schemes in an attempt to arrest the situation. These local fundings, however, will soon expire and patients will continue to suffer until Ministers recognize the reality of the situation and make adequate funds available for enhanced surveillance. The problems relating to healthcare associated infections can be overcome but only if the extent of the problem is factually identified and remedial evidence based action taken to redress the issue.

  11.  Many elderly patients who are admitted to hospital display signs of under nourishment on admission. This obviously impedes their chances of successful treatment and places them at greater risk of contracting a healthcare associated infection. The availability of nourishment within the hospital can also be restricted due to the diet offered, constrained mealtimes which do not allow patients to complete their meals and/or lack of assistance with feeding. This is an area which requires much greater consideration and one which will require intense thought given the increasing age profile of the population.

  12.  The other great threat to patient safety is the restriction on availability of life prolonging medication. Some patients require expensive medication to counteract malignant disease in particular. In some instances the medication is available in a neighbouring Primary Care Trust but not available in the patients own trust (the post code lottery). Such treatment is, however, available in other European countries and via the internet.

  13.  Patients who are desperate for life prolonging treatment are obviously tempted to purchase the necessary medication form other sources including the internet. This involves self administration of medication without adequate supervision possibly with serious adverse consequences. Lack of supervision of administration of medication can also be life threatening to people with learning difficulties and those within mental health programmes.

  14.  Many people have, for varying reasons, to take a range of medications with prescribed frequency and dosage. It is essential to the short and long term health of these patients that there is clear labeling and instruction and that the size of print is such that people with impaired vision can easily decipher what is required. The side—effects of medication should also be explained to patients at time of prescription either by the General Practitioner or the Pharmacist responsible for dispensing. Combinations of medications, particularly where these have been obtained via the internet can be extremely dangerous and this area needs careful consideration.

Q2.   What is the current effectiveness of the following etc.

  15.  The majority of the Recommendations contained within Safety First have to some degree been implemented. Recommendation 12 of Safety First relates to NHS Trusts adopting an honest and open approach with patients particularly when errors occur. This is not an easy route and progress in this area is extremely slow. Many healthcare workers receive little or no training in skills of communicating with patients. Many are unprepared for the trauma of emotional reaction to adverse events; others fear aggressive confrontation when news is imparted and some are cautious of possible recriminations, disciplinary action and possible litigation. Legislation approved by Parliament in recent years includes mandatory provisions for openness with patients. The Health Act 2006 and the Code of Practice on Prevention & Control of Healthcare Associated Infections (Duty 5) requires that NHS Trusts provide information on HCAI to patients and public. Unfortunately many NHS Trusts are still not compliant with this duty. This places patient safety at risk and also potentially exposes other members of the community at risk of transmission of disease.

  16.  The World Alliance for Patient Safety promotes "Open Disclosure" which the UK Government as a member of the World Health Organization is also committed. The European Union Strategy on Patient Safety to be published possibly November 2008 contains reference to honesty and openness with compassionate communication of information. There is a school of thought that suggests that specific mandatory provision, with sanctions, should be applied to "Being Open." It would, however, be more beneficial if Parliamentarians ensured that the proposed NHS Constitution contained explicit provision for patients (their families and/or carers) to be informed of all information regarding their treatment, including adverse events.

  17.  Patient safety needs to be re-embedded into the ethos of the NHS at all levels. Each NHS Trust and those required to register as healthcare and/or social care providers in accordance with the Health & Social Care Act 2008 should ensure that their quality standards include patient safety. A situation must not be allowed to further develop whereby patient safety is a "bolt-on" to service provision and pursuit of financial advantage. If Patient Choice is to be a reality then there has to be transparency in respect of patient safety and those establishments which a re negligent in this regard can be judged by patients and public.

Q3.   What the NHS should do next regarding patient safety

  18.  There is an urgent need to learn lessons from adverse events and to develop systems and procedures which avoid repetition. The Healthcare Commission received over 8000 complaints relating to patient safety (in one form or another). The adoption of new technology should allow identification of trends in adverse events, analysis of errors and promote an ability to learn from the patient experience. Coroners' reports, observations and recommendations, public inquiries reports and recommendations could all be used to enhance patient safety. The NPSA has a data base of over 4.2 million incidents (not all properly recorded) which again can be a useful source of examining the patient experience and perception of the health service. The NPSA and NICE produce many useful guidelines on different approaches to improving patient safety, unfortunately guidelines are rarely implemented and often ignored. It would be hoped that the newly created Care Quality Commission will place patient safety at the top of its agenda when assessing healthcare and social care providers and any necessary remedial action will be enforced with punitive measures where necessary.

  19.  It is impossible to eliminate all errors and adverse events but they can be minimised. When an error occurs there must be openness with the patient, family and carers and support provided. The physical and. psychological consequences of adverse events and their short and long term implications need to established and discussed with the patient. Similarly healthcare workers traumatized by the serious consequence of error/adverse event must be provided with support. The National Clinical Assessment Service could be a source of such support for doctors and the newly created Practitioner Health Programme (PHP) could be of assistance to doctors (and dentists) in the London area

  20.  All 60 million inhabitants of the UK are to some degree users (or potential users) of the NHS and many are reliant upon the services provided. Patients expect to receive safe treatment in a clean and as far as possible an infection free environment. They understand that there are risks attached to all forms of medical treatment and that some areas of society are more vulnerable to risk than others. Patients do, however, become frustrated and angry when there appears to be blatant disregard for patient safety and there is a denial of an adverse event and/or error. The NHS Redress Act (2006) contained many of the remedies sought by patients,—apology, explanation of error and details of actions to prevent reoccurrence. Prolonged delay in enacting this legislation has led many patients to use litigation to obtain explanation and reason of adverse events and error. Government should move swiftly to rectify its own error in not supporting openness and honesty within our NHS system.

  21.  There is a need to review the present system relating to allocation of drugs by Primary care Trusts and to introduce a consistent system of prescription which also has a transparent and consistent appeals procedure where accessibility of clinically appropriate drugs is denied.

  22.  Patients also need to be involved in research and development of treatments and systems which could improve patient safety. Whilst there have been some recent improvements in patient involvement this is not generally understood by patients and public and more transparency is required. Calls for proposals for research projects should stipulate that patient/patient organizations must be involved in all stages of research in order to ensure that research meets public need and is not just an academic exercise to promote individuals and/or organizations.

Graham Tanner

Patients for Patients Safety Champion

England & Wales

September 2008

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