Closes on 16/1/15
1. The effectiveness of the NHS’s current approach to investigating and addressing untoward medical incidents. Currently there is a blame culture, a culture of fear, and a culture of litigation in clinical practice. This is partially driven by the way the NHS has chosen to investigate clinical incidents which has created this cultural environment. Often people who examine untoward incidents in the NHS do not understand the nature or work of the NHS. The GMC is part of this problem. It takes often years to investigate incidents and uses a formal, legalistic process of blame which, as it can strike doctors off, creates defensiveness within medical practice (which may, sadly, be entirely appropriate if one wishes a full career seeing patients, but leads to overtreatment, overtesting, and unnecessary increased healthcare spending.) Currently, conclusions of critical incident examinations are frequently of little practical use to preventing further error or mistakes in the ongoing work of the NHS. Time and again focus is on individual blame rather than systematic oversight and review. For example an average GP consultation will cover 2-3 different problems in under 12 minutes. During this time, the doctor must establish a good relationship with the patient, introduce themselves, ensure privacy. The patient may have a question or issue to discuss. The doctor has to listen, reflect, understand, examine, discuss potential causes or plans, offer choices and evidence to support them, help the patient make an informed choice, and document this, together with coding, on the computer, relevant information. The doctor must be sensitive towards information that the patient would like to discuss but may feel reluctant or embarrassed to do so. During this time, the doctor may be interrupted by phone calls, nursing staff, or receptionists needing urgent advice or information about patients. Urgent house calls may be requested and require to be dealt with. Our hospital colleagues are also very busy. It is not unusual to spend 10-15 minutes on the phone trying to find a bed for an unwell patient. In short, normal working life for a doctor is conducted under great time pressure. The last 50 years has seen us extending our lifespans but also increasing the numbers of people who have multiple illnesses and are taking multiple tablets and medications. Our work has become more intense and complex. There is evidence that insufficient staffing levels are strongly associated with mortality increases (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001705, http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf, http://www.ncbi.nlm.nih.gov/pubmed/24636667, for example. Addressing safety is not just about critical incident reviews but about ensuring staffing levels are sufficient and safe. Instead the NHS has devoted large amounts of resources to feedback from patients. However it is frequently very difficult to establish whether anonymous complaints are justified and it is even more difficult to work out what such complaints relate to and how then to deal with them because they are delivered anonymously in most incidences. This risks applying resources to areas which are not shown to improve care compared with evidence base interventions (staffing levels.) 2. How lessons about best practice, procedures and human factors should be learned and disseminated. The question is not so much about learning or dissemination but of application. The data on safe staffing has been known for some time. In terms of error, very little is done in terms of searching for and addressing problems generated by, for example, computer systems in general practice which make it hard to spot prescribing dangers. Human factors research in the basic day to day running of general practice has been woefully overlooked. 3. The value that a new, single, clinical accident investigation branch of the Department of Health would bring to the healthcare sector and how this could improve the complaints process. I do not know. This should be subject to RCT. 4. The current capacity of the PHSO to manage and investigate complaints relating to clinical incidents, and their ability to analyse and assess medical evidence. I do not know. 5. The impact that Department of Transport accident investigation branches have had in the transport sector and the lessons that have been learnt from the establishment and use of such bodies, in the UK and in healthcare systems in other countries. I am not familiar with the DoT investigation branches. However please note that medicine and airline safety are not very comparable. I have to take off even if environmental conditions (40 extra patients needing to be seen) are unfavourable. If my cabin crew (nurses or receptionists) are off sick at short notice, we simply have to make do. Aircraft respond to well tested and simulated protocols. Human beings are highly complex, do not always fit protocols, do not behave as standard and reliably when interventions are applied. While some aspects of air safety protocols may have some relevance for healthcare, it is possible to make simplistic conclusions which may be misleading. 6. How any such body within the healthcare sector would support the work of PHSO. No comment. 7. The legal drivers behind increased challenges associated with the issue of medical liability, and the failure to address clinical incidents and complaints. There is no doubt that doctors in front line practice often cite fear of litigation as a cause of ordering more tests or treatment. However this risks causing harm through false positives, harm directly done by tests, and treatments which will not benefit the patient and only cause side effects. Fear of litigation drives inappropriate medicine which is also costly and diverts resources from those least likely to benefit. In addition, the stress of legal proceedings can be devastating to clinical staff. There should be clearer demarcations of legal risk. Incompetent, dangerous care should never be condoned. However, in the more common ‘grey zone’ of medicine, it is often unclear what a diagnosis is, what tests are appropriate, what treatment is likely to do more good than harm. The PAC may wish to consider how to support doctors and nurses trying to produce thoughtful, personal care where the balance of risk and benefit is not certain. There is good evidence that blaming individuals does not work, for example, even jailing doctors who mistakenly injected chemotherapy intrathecally did not prevent the same mistake being repeated. It is somewhat shocking that it is still technically possible to inject the same drug into the intrathecal space, causing death, when it is possible to design a device to prevent this from occurring. Blaming individuals is something the NHS seems to strive to do, yet it is systematic change that can prevent many mistakes from being repeated. Margaret McCartney, GP, Glasgow.