Select Committee on Health Written Evidence


Memorandum by the British Medical Association (PS 62)

PATIENT SAFETY

The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 139,000.

EXECUTIVE SUMMARY

    —  The risks associated with clinical practice will always be present to some extent however they can be minimised by ensuring adequate training and supervision.

    —  A consultant-based system can improve patient safety and health outcomes; many specialties would benefit from focussed consultant expansion.

    —  System failures are by far the most common cause of errors, poor communication across sector boundaries being one example. It is likely that problems in relation to poor communication may be exacerbated by the changing public-private mix in provision.

    —  The disintegration of former primary care teams has made it more difficult to achieve coordinated care, which impacts upon the most vulnerable patients in society in particular.

    —  The departure from a no-blame culture in the NHS can lead to an increase in doctors practising defensive medicine. In the long term, this will lead to greater harm than the alternative—the acceptance of an element of risk within clinical practice.

    —  The fragmentation of services poses a significant threat to patient safety. Independent Sector Treatment Centres (ISTCs) or other stand-alone clinics often do not have on-site facilities to deal with emergencies arising from complications.

    —  Comparative data on the clinical outcomes of new providers entering the NHS market is not available, making reliable comparison with NHS providers virtually impossible. We welcome therefore the commitment in the Next Stage Review report to standardise collation of such information from all providers working for or on behalf of the NHS.

    —  The BMA's recent response to the Conservative Party consultation `Delivering some of the best health in Europe; outcomes not targets' (attached separately) sets out in detail our position on how best to assess and measure providers' performance and whether or not it is appropriate to publish this information.

    —  There is some concern among our members around the regulation of doctors practising telemedicine, particularly those not based in the UK, therefore falling outside of the remit of the Care Quality Commission (CQC). We would therefore urge the Health Select Committee to remain aware of this issue and the potential threat that it poses to patient safety.

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

    —  Role of human error and poor clinical judgement

  The risks associated with clinical practice will always be present to some extent however they can be minimised by ensuring adequate training and supervision. Poor clinical judgement is often the result of poor training. Lack of confidence can also lead to poor clinical judgement, particularly for junior doctors if others within the clinical team are in the habit of questioning or undermining their decisions.

  Tiredness can also hamper judgement and thus lead to increased human error. In the secondary care setting, carefully planned rotas that allow sufficient time for doctors to rest following on-call work are essential. The problem of tiredness can also apply to primary care when for example a heavy workload does not allow for GPs to take a break during the working day.

  The role of the consultant is crucial in the delivery of safe and high quality care in the secondary care setting; in fact, many specialties would benefit from focussed consultant expansion. A number of reports including from the Academy of Royal Medical Colleges, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the Royal College of Physicians, show the improvements that a consultant-based system can make to patient safety and health outcomes. A paper from the BMA's Central Consultants and Specialists Committee (CCSC)—`Enhancing quality: promoting consultant expansion across the NHS' can be accessed through the following link:http://www.bma.org.uk/ap.nsf/Content/Consultantexpansion0408

    —  Systems failures

  System failures are by far the most common cause of errors.

  Often the safety concerns of doctors and staff are not taken seriously and the experience of some of our members is that even in cases where adverse inspection reports (AIRs) are raised, sometimes no action is taken.

  Some trusts employ a policy not to appoint locums when doctors are on sick leave or there are vacancies. Temporary, additional nursing staff are employed instead, resulting in an unbalanced skill-mix, which puts extra pressure on doctors.

  A lack of beds in a hospital can lead to early and inappropriate discharges—and consequently increased re-admission rates—or a reluctance to admit patients in the first place; this can delay investigations and therefore treatments.

  Systems failures can also be a consequence of national policies and/or targets. For example, the accident and emergency 4-hour wait target may encourage trusts to adopt poor practices in order to meet the target, rather than looking at how to improve the whole patient pathway. A resolution passed at the BMA's Annual Representative Meeting in 2006 is reproduced below to illustrate this point further.

    "That this Meeting recognises the potential danger to patients' health when non-medically qualified managers put pressure on doctors to admit or discharge patients from A&E or wards to simply abide by government set targets. It believes that this practice is often against the patient's best interests, is reprehensible, counter-productive and wastes rather than saves the NHS money. We call upon all doctors to report all such incidents to the National Patient Safety Agency."

  Communication can be another major cause of systems failure and is particularly poor across sector boundaries, for example, between secondary and primary care. Timely and thorough discharge information from hospitals to GPs is central to ensuring patient safety.

  For reasons of rationalisation, many PCTs have dismantled former primary care teams, resulting in less face-to-face communication between GP practices and other community-based healthcare professionals, including mental health and social workers. This makes the once commonplace multi-disciplinary approach virtually impossible to maintain, leaving the most vulnerable patients more at risk as a result.

    —  How far clinical practice can be risk-free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare

  As stated above clinical practice can never be without risk altogether. Risk that could be defined as avoidable is that which arises from systems failure; risk arising from human error and poor clinical judgement is not always avoidable, but can be minimised.

  Often, a systems failure is blamed on individuals. Such an environment and the departure from a no-blame culture in the NHS can lead to an increase in doctors practising defensive medicine. Whilst some defensive practices may be beneficial, others will have adverse effects on both patient care and resource allocation.[363] For example, such an approach can lead to doctors subjecting patients to more investigations, referrals and treatments or even being reluctant to treat certain patients altogether, which will lead to greater harm in the long term. Outside of the routine investigations that would be undertaken in response to a set of symptoms, we do not consider therefore that the precautionary principle can be applied to healthcare.

    —  The role of public perceptions of risk in determining NHS policy

  Society must recognise that medicine will always contain an element of risk. General practice for one is founded on being able to live with some risk and uncertainty and any move away from this would, as stated above, have more serious consequences in the long term. That is not to say that doctors do not have an important role in trying to minimise risk, where this is within their control. It is also important that doctors lead on the issue of consent, allowing for more informed discussion with patients about the level of risk and success involved in the management and treatment of their condition, including any interventions.

The impact of the changing public-private mix in provision

  It is likely that the problems referred to above in relation to poor communication may be exacerbated by the changing public-private mix in provision.

  Whilst existing NHS contracts with Independent Sector Treatment Centres (ISTCs) mandate them to treat patients that are at a relatively low risk of developing complications, complications do still arise. One significant concern we have with ISTCs and other stand-alone clinics in relation to patient safety is that there are generally no on-site facilities to deal with emergencies arising from complications and patients would need to be transported to the nearest NHS hospital, which may be a considerable distance away. As such, fragmentation of services in general can pose a threat to patient safety.

  Another problem with new providers entering the NHS market such as ISTCs is that they have yet to produce any comparative data on their clinical outcomes that would allow reliable comparison with NHS providers.

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

  Given the point made directly above regarding availability of comparative data for NHS and non-NHS providers, we therefore welcome the commitment in the Next Stage Review report `High quality care for all' to standardise collation of such information from all providers working for or on behalf of the NHS.

  Regarding the proposals in the Next Stage Review report in relation to quality in general, as yet, there is insufficient detail to assess whether or not they will be effective. The BMA's recent response to the Conservative Party consultation `Delivering some of the best health in Europe; outcomes not targets' sets out in detail our position on how best to assess and measure providers' performance and whether or not it is appropriate to publish this information. The paper can be viewed through the following web link:

  http://www.bma.org.uk/ap.nsf/Content/ConservativePartyConsultationDocumentOct08

    —  The appropriateness of national targets

  To address this area, we would refer you to our response to the Conservative Party consultation `Delivering some of the best health in Europe; outcomes not targets', attached separately.

What the NHS should do next regarding patient safety

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

  The sharing of learning must be improved. In general practice for example, neighbouring practices do not routinely share lessons learnt, good or bad, in all parts of the country. Again, we would emphasise that any departure from a no-blame culture in the NHS will make it increasingly difficult to encourage doctors to partake in such exercises.

    —  How to ensure that learning is implemented

  A regular newsletter/circular or national database that highlights lessons learnt by providers across the country could be circulated/established.

    —  What should be measured and assessed and what data should be published?

  To answer this question, we would refer you our response to the Conservative Party consultation `Delivering some of the best health in Europe; outcomes not targets', attached separately.

Additional comments

  There is some concern among our members around the regulation of doctors practising telemedicine, particularly those not based in the UK, therefore falling outside of the remit of the Care Quality Commission (CQC).

  The Healthcare Professional Crossing Borders initiative (or the Portugal Agreement) aims to make a contribution to patient safety and high quality healthcare in Europe through effective collaboration between European health regulators. This consists of three agreements:

    —  Shared principles of regulation;

    —  Transparent and accessible healthcare regulation eg web-based lists of registered professionals, public notifications of disciplinary hearings; and

    —  Competence Assurance of European Healthcare Professionals.

  The BMA is fully supportive of the Portugal Agreement as is the Academy of Medical Royal Colleges and the GMC. The European Commission (EC) is due to issue a set of proposals on patient safety in November 2008 and it is hoped that they will adequately reflect the principles of the Portugal Agreement and thus signal its implementation. If they do not however the BMA intends to lobby the EC accordingly. It is also worth noting that even if the forthcoming EC proposals are adequate this will only apply to telemedicine companies operating in the European Union.

  We would therefore urge the Health Select Committee to remain aware of this issue and the potential threat that it poses to patient safety.

23 September 2008








363   Summerton, N (1995). Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. British Medical Journal 310:27-29 Back


 
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