Patient Safety - Health Committee Contents

1  Introduction

    As to diseases, make a habit of two things—to help, or at least to do no harm—Hippocrates, Epidemics (Book I, Chapter XI), c. 400 BC

    [F]or all but the last hundred years, the therapies [medicine] relied on must have done […] more harm than good. For some two thousand years […] the main therapy used by doctors was bloodletting […] which weakened and even killed patients—Professor David Wootton[1]

    Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous—Professor Sir Cyril Chantler[2]

1. Not harming patients has been a key principle of professional medical practice for at least 2,500 years. Even so, a great deal of harm has been done to patients over the centuries. Many a treatment has killed rather than cured.

2. The modern NHS does a great deal of good; in England, for example, it has contact every 36 hours with around a million people[3] without significantly harming the vast majority. Nevertheless, patient safety[4] has remained a concern not just in the NHS but in all healthcare systems.

3. Over the past two decades, notorious cases of harm have come to light in many areas of healthcare, including primary care, acute hospital services, mental health and services for people with learning disabilities. Some of these cases have involved a healthcare worker deliberately causing harm, which is extremely rare—the worst cases being the serial killers Harold Shipman, a GP; and Beverley Allitt, a nurse. Others have involved healthcare workers who were chronically and catastrophically inept, such as the gynaecologists Rodney Ledward and Richard Neale.

4. Other cases have involved failings by individual healthcare workers, but in the context of major systemic failure on the part of the NHS organisation concerned. Examples include heart surgery carried out on very young babies at Bristol Royal Infirmary in the 1980s and 1990s, and the much more recent case of Mid-Staffordshire NHS Foundation Trust. Both of these came to light through public outcry and scrutiny of mortality data, which revealed unacceptably poor clinical outcomes.

5. In the 1990s it was increasingly realised that most harm was not done deliberately, negligently or through serious incompetence but through normally competent clinicians working in inadequate systems. This is the key theme of landmark documents, To Err is Human (USA, 2000) and An organisation with a memory, the report of the Chief Medical Officer's Expert Group (2000). Whilst there can never be such a thing as entirely harm-free or risk-free medicine, it is now widely agreed that much, and perhaps most, of the harm caused by medical practice is actually avoidable.

6. Despite this recognition, there have continued to be cases of appalling care, including Stoke Mandeville Hospital, and Maidstone and Tunbridge Wells Trust, which involved stark failures in preventing and controlling healthcare-associated infections, and Mid-Staffordshire Trust, where wholly inadequate Accident and Emergency (A&E) care led to unnecessary deaths and harm.

7. These cases are unlikely to be typical of today's NHS as a whole, but they are, nonetheless, deeply dismaying—especially after nearly a decade of policy focus on patient safety. International studies involving reviews of case notes have found that many patients have suffered avoidable harm. Against this background it must be asked how far the Government's policy has succeeded in reducing harm to patients and what more needs to be done. Accordingly, we decided to hold an inquiry into the subject. The terms of reference are given in Annex 1 below.

8. We received memoranda of written evidence from 108 bodies and individuals, and held eight oral evidence sessions. Witnesses included families of harmed patients; Presidents of medical Royal Colleges; nurses; junior and senior clinicians; academics; experts in Human Factors training; a representative of the Health Foundation; representatives of arm's-length bodies, including the Chairman of the National Patient Safety Agency; and the Chairman of the National Institute for Health and Clinical Excellence. We also held evidence sessions with Ben Bradshaw MP, then Minister of State for Health Services at the Department of Health (DH); Ann Keen MP, Parliamentary Under Secretary of State at the DH; Professor the Lord Darzi of Denham KBE, Parliamentary Under Secretary of State at the DH; Professor Sir Liam Donaldson, Chief Medical Officer (CMO) for England; and other officials from the Department.

9. We visited Charing Cross Hospital in London to look at developments in electronic prescribing and barcoding (which we thank Professor Bryony Dean-Franklin for organising), St Thomas' Hospital, London, to look at a patient record system (which we thank Maxine Hoeksma for organising) and Luton and Dunstable Hospital in Bedfordshire to examine the improvements brought about by the Safer Patients Initiative (which we thank the Chief Executive, Mr Stephen Ramsden, for organising). We also saw how patient safety is being addressed in New Zealand, through visiting three hospitals and meeting representatives of the Ministry of Health; the Quality Improvement Committee; the Royal New Zealand College of General Practitioners; the Accident Compensation Corporation; the Health and Disability Commissioner; the New Zealand Medical Association; and several academics. We thank the staff of the British High Commission in Wellington who organised our visit.

10. The voices of frontline healthcare staff are too rarely heard in discussions about patient safety. To ensure that their views were considered, we commissioned the Centre for Patient Safety and Service Quality at Imperial College to interview junior doctors, nurses and therapists, as well as non-clinical frontline staff (porters, cleaners and ward clerks). We thank Susan Burnett and her team for undertaking this work quickly and to a high standard. In addition, we thank the National Audit Office for providing us with the results of separate research undertaken among junior doctors regarding patient safety, using focus groups and a small sample survey.

11. We are especially grateful to our specialist advisers, Mr Tony Giddings (retired surgeon and Chairman of the Alliance for the Safety of Patients at the Royal College of Surgeons of England); Dr Ike Iheanacho (Editor of Drug and Therapeutics Bulletin); and Professor Charles Vincent (Director of Imperial Centre for Patient Safety and Service Quality), for their expertise and assistance.[5]

12. In the report, chapter two summarises the main initiatives to improve patient safety since 2000. Whilst the NHS has undoubtedly been a world pioneer in this field, for which credit is due, there are, however, doubts about how effective patient safety policy has been. In the following chapters, we examine the implementation of patient safety policy since 2000. We evaluate progress and, where policy appears to have failed, discuss barriers to change and other reasons for slow progress, and make recommendations for improvement. While we do refer to particular types of harm done to patients (such as healthcare-associated infections), we have deliberately not looked at these specifically. Instead, we explore the key means of establishing a culture and systems capable of addressing unsafe care whatever form it takes.

1   David Wootton, Bad Medicine: Doctors Doing Harm Since Hippocrates (Oxford, 2006), p 2 Back

2   Cyril Chantler, "The role and education of doctors in the delivery of health care", Lancet, vol 353 (1999), p 1181 Back

3   Q 707 Back

4   "Patient safety" can be defined as freedom, as far as possible, from harm, or risk of harm, caused by medical management (as opposed to harm caused by the natural course of the patient's original illness or condition). Back

5   Mr Giddings declared his interest as Chairman of the Alliance for the Safety of Patients and as an occasional adviser to the Healthcare Commission and the General Medical Council. Dr Iheanacho declared no interests. Professor Vincent declared his interest as Professor of Clinical Safety, Imperial College, London, a consultant to a number of organisations on patient safety and as Director of Safe Quality Care, a company which carries out research on patient safety. Back

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