Patient Safety - Health Committee Contents


Examination of Witnesses (Question 660-679)

DR JO BIBBY, DR OLGA KOSTOPOULOU AND CAPTAIN GUY HIRST

5 FEBRUARY 2009

  Q660  Chairman: You talked about simulation of diagnostics as opposed to simulation of surgery that we have in the healthcare system. Is there anywhere in the world that actually does simulation of diagnostics in training?

  Dr Kostopoulou: Yes, only for medical students as far as I know. I am not aware of doing it for doctors. There is much more work involved in developing scenarios for experienced clinicians.

  Q661  Dr Stoate: Having said that, simulated surgeries are used in general practice training much more so by the College now to test competencies and we do have some patients simulating surgeries.

  Dr Kostopoulou: You are talking about actors?

  Q662  Dr Stoate: Actors, yes.

  Dr Kostopoulou: It is actually much easier and less costly to develop these things in computers and much more controllable because then you can also get immediate feedback, have them on the internet, do them in your own time, do all sorts of nice things with them.

  Q663  Stephen Hesford: I have a concern that there may be a sort of class distinction in terms of diagnostic errors. If a database or looking at diagnostic errors is from litigation, given that the propensity for litigation is probably a middle class exercise, is there not going to be a missing of diagnostic errors who are not middle class, those in poorer areas?

  Dr Kostopoulou: Yes.

  Q664  Stephen Hesford: Is there any research evidence to suggest that doctors do not listen as much to unemployed people, black and ethnic minorities, so there is a diagnostic error in the sense they are not giving the same service to those who have not got sharper elbows? Is there any issue around that?

  Dr Kostopoulou: I think there is some evidence that middle class patients are able to demand things more than lower class patients which can easily influence their management. I am not aware of any other evidence in addition to that. What I would say about a litigation database is I think there are ways of looking at diagnostic error and measuring threat beyond litigation and beyond waiting for doctors to report them if we can take advantage of the electronic record that is common between primary and secondary care, and in some areas of the country this exists, if we can use data mining techniques so we can develop some automated algorithms to screen patient records, to identify records that are at high risk of a diagnostic error. This has been done in the US, in a Veterans Affairs Hospital, where they looked at primary care clinics and the algorithms they used were primary care visits followed by another primary care visit or by an unscheduled hospitalisation or an unscheduled emergency admission within ten days, and we can use a month.

  Q665  Stephen Hesford: Meaning that was suggestive that something had been missed?

  Dr Kostopoulou: Yes. These were patients at risk of a diagnostic error and they did find increased risk in those records. Overall, the rate was about 0.67% and for those records they identified it had increased to about 25%. We can increase our chances of identifying patients where errors have happened and then look at those records and see whether an error had happened and then we can inform ourselves about the rate of diagnostic error that has been so elusive so far if we want to convince people that it is an important issue.

  Chairman: We will move on to human factors now.

  Q666  Charlotte Atkins: Captain Hirst, it is your opportunity now. Healthcare is often unfavourably compared with aviation in regards to "human factors". Do you think the comparison is fair and, if so, why do you think healthcare lags behind aviation so much?

  Captain Hirst: The answer is yes and no. It has lagged because there has not been very much of it in the past in healthcare. I was involved in aviation in bringing human factors training in in British Airways and it came about in aviation from a serious of unexplained accidents which were always called "pilot error" in America and basically the regulators in America decided that they would close down a couple of the large airlines if they did not improve their records. They went to the University of Texas who did a lot of work on human error and why it occurred. Then, as usual, after the Americans started we took it on in this country. We went down a lot of rocky roads in getting to where we are now, which is by no means perfect, but if you go on any flight deck of any aeroplane today you will hear people speaking the human factors language, understanding about decision-making processes, situation awareness, teamwork, leadership and all those things. There are little pockets in the Health Service where particular early adopters, as Dr Gawande would say, have realised that this same sort of idea about human factors is applicable because it is about people working together. I would suggest it is individual pockets rather than it has been taken on from the top downwards. I think the reasons are that it is such a complex organisation, healthcare in every country, but in this country particularly, 1.3 million people and there are so many different bodies. Aviation is incredibly regulated, we all know where we sit and stand in the line of things, if you like. There is the Civil Aviation Authority that regulates us, the airline you work for and it all feeds down to the individual pilot, cabin crew member, engineer, whatever it is, so we have a structure and a reporting process and reporting lines. Once it had been decided to implement an innovation like human factors 15 years ago, it could happen fairly easily, whereas the huge amorphous structure of healthcare makes it more difficult.

  Q667  Charlotte Atkins: Obviously one of the things that aviation has pioneered is the "fair blame" environment.

  Captain Hirst: Yes.

  Q668  Charlotte Atkins: What do you think the NHS needs to do to achieve that "fair blame" reporting and learning culture, which clearly has made a difference in aviation?

  Captain Hirst: It has. People bandy around all sorts of words, like "no blame", and I would not be an advocate of no blame because you have to occasionally blame. It is getting the balance right. I think my favourite term would be "just culture", a culture where people are happy to admit when they have made errors so that others can learn from them and not be penalised or punished or have a fear of punishment because, as somebody said earlier on today, that will just drive people underground; it happens in every industry. We have got lots of reporting systems in aviation, we have discrete reporting systems; open reporting systems, but, most importantly, the regulators demand that we do report and if we are found doing something and not reporting it, that is a sackable offence. I have to say that in my own airline they have produced a standing instruction to all employees saying that basically it is not the policy of British Airways to institute disciplinary proceedings in response to reporting of any incident affecting safety, apart from gross negligence. That was there and it said you will not be penalised. That was very favourable for the employee and made one feel comfortable to report things so that people could learn from them. It did not mean that people did not have to undergo some retraining, some embarrassment or whatever it might be, but it did mean that they were not in fear of being sacked, if you like, unless it was culpable negligence.

  Q669  Charlotte Atkins: Presumably there was a whistle-blowing culture as well that if it was not reported for any reason then someone else would report it?

  Captain Hirst: There is a lot of technology blowing the whistle these days. There are cockpit voice recorders, data recorders, all this sort of thing. What it did do was it rooted out the real bad apples, I guess, and people could not behave in a totally inappropriate manner, an unprofessional manner, you had to fit in. I think perhaps with 1.2 million employees in the National Health Service there must be some bad apples in there. At many conferences I have spoken at, a question that often comes up is, "What can we do about somebody who is a completely off the wall character" within an organisation, a hospital, a ward or whatever it might, "How does it get dealt with?" There does not seem to be a process at the moment to do that.

  Q670  Charlotte Atkins: So what can we do about that person then, an obvious person within the NHS that everyone agrees needs to be moved on?

  Captain Hirst: My opinion, without knowing the individual involved, is one has to be sensitive. You have got to first find out why people are like that, is it a lack of skill, a lack of knowledge or a lack of insight, have they just not got it. One has to develop and maybe offer them training and counselling to help them out. If they then do not do it, there needs to be some disciplinary action, they should not be holding down a job, because it does not only affect their patients, it affects the whole cohesion of the team. If people are in fear of some errant character who is senior particularly that makes life very difficult for people to speak up, particularly if their future promotion might depend on keeping in their good books.

  Q671  Charlotte Atkins: So what is the secret then? Is it the regulatory bodies, do they have to be more heavy-handed and say that this will happen, as they did in aviation?

  Captain Hirst: The concern is everyone is frightened of regulation and I cannot understand that, having been part of a very regulated system and I used to regulate on behalf of the Civil Aviation Authority. Regulation does not mean draconian, people have the wrong idea about it. The regulator should be your friend. If you have got a problem, they should be part of the process in helping you. I talk to clinicians all the time, we run courses, and people put their hands up and say, "fear of litigation" and I am not sure the evidence is quite there that the litigation is so fearsome. We do a little bit of work with the Medical Protection Society and I was listening to one of their lectures in dentistry and he was explaining that if you are open and honest with patients when you have made a mistake, people do not tend to go for you, if you like, legally, people understand. Driving people underground, not admitting to errors, not being truthful and cover-ups, that is when people get really angry. Maybe I am being naive, but that is my feeling.

  Q672  Charlotte Atkins: I think that is right. I think from most MPs' postbags often they want to know why it happened. They often want an apology, but most of all they want to understand why it happened and stop it happening to anybody else.

  Captain Hirst: Having worked in the Health Service pretty much full-time for the last four or five years and having talked to lots of people, it is a much more complex thing than flying an aeroplane. With an aeroplane, we tend to get into one which is pretty fit normally, not always but fairly much so, whereas in Healthcare one is dealing with a hugely complex organisation at the sharp end of it with all the potential errors that flow down to the operating table or whatever it might be. They are the last line of defence, the surgeons I have watched and the theatre teams. The human condition is infinitely variable and there are all the pressures of being part of the Health Service. I am not unaware of the huge task ahead and I just hope that you people can sort something out of it. I do feel that the principles involved that we have learnt where every pilot understands these processes, the cognitive processes of how we make decisions, are important. I looked at the curriculum, the ISCP that is produced now and I think we have to get this stuff in the curriculum, but if you look in there and you put the word "error" in, the only mention of error is "Errors and omissions are accepted" in the opening gambit. I think we have to understand why we all make errors and those ideas are transferable to any profession and particularly to the healthcare profession as they are to aviation.

  Q673  Chairman: You said that the regulator would get involved with the aviation industry if they are found not doing something. How would the regulator find them if they were not telling the regulator? I do not know if there are any comparisons with our health system, but how would the regulator know that somebody has—

  Captain Hirst: Has made a big error?

  Q674  Chairman: Yes, other than the obvious.

  Captain Hirst: A heap of wreckage all over the countryside! Obviously there are incidents like that, but we have high fidelity simulators and on four or five days a year we are in front of effectively the regulator demonstrating our skills in abnormal situations.

  Q675  Chairman: That would be one of them?

  Captain Hirst: That is one. Also, medical fitness to practise. Every six months we had a fairly comprehensive medical. I remember a case many years ago when a pilot was not performing, but he had been a really good chap and had been a training pilot on a previous fleet, he came on a new aeroplane type and did not quite progress as he should. People made excuses for him because they considered he was a good operator, and that was a bit of confirmation bias where everybody thought he must be good, he was just a bit slower on this bit, but they found out a long time afterwards he was having a benign brain tumour. We have to pass exams as pilots on the human condition and we have to understand about fatigue and all these things. I was surprised when we first came in to do some work in healthcare that that was not the norm for clinicians or other healthcare workers to understand about such things, because I feel understanding is part of the way to maybe solving.

  Q676  Dr Naysmith: From your experience that you have had working with clinicians recently how far do you think non-technical skills have been integrated into the education and training of clinicians?

  Captain Hirst: Variably. In some places very, very little and in other places quite substantially and significantly. At the moment, human factors and non-technical skill training is voluntary and unless you have got a very strong medical director or matron who make the staff go onto the courses and be partake in the coaching, some people who are not interested in it or do not think it is necessary for them just do not get involved. Jo has already mentioned Luton & Dunstable Hospital. They have a chief executive there who is passionate about patient safety on an everyday basis and they have a medical director who is passionate and, therefore, the staff are passionate. They have a pride in it there whereas maybe in other places it is not so high on the agenda, as you were saying yourself—prioritisation.

  Q677  Dr Naysmith: Do you think it should be mandatory? You said it is voluntary at the moment and in some places it is a high priority, but do you think it should be mandatory?

  Captain Hirst: I personally do, yes. The people who are frightened of it, this new training, this new tree-hugging stuff, are going to be the people who are not going to attend while such training is voluntary those are normally the people who fear they might struggle with it. In aviation and other safety critical industries they say over 70% of accidents are caused by human beings and eight out of ten are not a reflection on their technical skills, it is their interaction with other people that causes accidents. That has got to be a huge driver for people to understand these concepts.

  Q678  Stephen Hesford: While clinicians work in teams, they do not often work in established teams in the NHS. You have already made it clear how different the airline industry is from the NHS, and that is helpful. They are working with different people all the time and almost self-evidently it creates a problem. How do you get round this almost transferable situation?

  Captain Hirst: Actually, that is exactly the case in civil aviation. In my company I flew the Jumbo for the last 10 years and we had 1,000 pilots on the Jumbo and 15,000 cabin crew or whatever it was and we never flew with the same people, but we had protocols, we had standard procedures, we had a full briefing before every flight where we discussed what was going to happen and it was all written down in the book. We changed procedures as a result of incidents. I can remember one where, rather embarrassingly, people almost kept running over the ground engineers when we were taxiing away because you could not see them. The ground engineers were not very happy about that. It was a simple little thing like the protocols we were using in terms of our communication between the air traffic controllers at busy airports and the chap on the ground were poor and there was potential for error. That got picked up, analysed, root cause analysis, and then we changed procedures. I do not think that working with different teams makes teamwork not possible. Sometimes there is probably a lack of understanding of the difference between teamwork and group working where actually people happen to work in the same place, but they are not really a cohesive team with the same goals. Most of our work has been in the theatre environment and ICUs and people are members of three or four different teams, in one part you are a little team in the theatre and then you are part of a bigger team in the hospital and not everybody sees their role as part of the bigger team correctly and maybe do not engage with the management at times, for instance.

  Q679  Chairman: The example you gave about not running over the ground staff, was that a sort of soft skills communication thing or was it as much about technical understanding, about, "At this point I should be on the phone to the air traffic controller"? That is a technical thing.

  Captain Hirst: It was actually communication breakdowns. The Captain said to the co-pilot "Can you see him?" The co-pilot assumed the `him' to refer to another aeroplane which he could see so his response of "Yes" was incorrectly interpreted by the Captain who then taxied while the ground engineer was still in front of the aeroplane. It is about how to communicate effectively, asking the right questions.


 
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