Quality and safety in healthcare and the role of anaesthetists

As part of its evidence to the Mid Staffordshire Public Inquiry, a patient group, ‘Cure the NHS’ (National Health Service), stated: “It is this professional commitment which has collapsed in the NHS, across the professions represented by a series of royal colleges, colleges, and unions, principally UNISON. They failed utterly at Stafford Hospital to protect patients they continue to fail to this day. They have been and continue to fail at acute hospitals across the country” [1]. This is a sad indictment of the medical profession, but is it correct? The Harvard Medical Practice study, published in 1991, showed that there were ‘adverse events’ in 3.7% of admissions in 51 New York hospitals [2]. This study has been repeated, with similar findings, in 10 other countries, with an overall figure of adverse events detected of 6.6% of admissions, half of which are preventable and 8% of which lead to death [3]. Applied to the UK, this equates to about 21 000 preventable deaths related to adverse events in England per year. The National Patient Safety Agency’s National Reporting and Learning Service records only 3500 incidents that involve the death of the patient in England in 2008 [4]. The recent report of the Ombudsman described very poor care of some elderly patients about whom she had received complaints [5]. The complaints actually ‘accepted’ and investigated by the Ombudsman are only about 0.1% of the written complaints about hospital and community health services in England.11 In 2008–9, in England, there were 89 139 written complaints about Hospital and Community Health Services (see http://www.ic.nhs.uk/) and the NHS Ombudsman received a total of 16 317 enquiries from the public, but of these only 401 (3%) were ‘accepted’ (2830 were considered ‘out of remit’, 6902 ‘not properly made’, 2681 ‘premature’, 2121 ‘discretionary’ and 704 ‘withdrawn’). Only about a third of the complaints that the Ombudsman accepts relate to hospital services, so this third represents about 0.1% of the written complaints about NHS hospital services in England (see http://www.ombudsman.org.uk/about-us/publications/annual-reports). The 2001 Bristol Inquiry report on paediatric cardiac surgery at Bristol Royal Infirmary [6], together with the 2009 Healthcare Commission report [7] and 2010 Mid Staffs Public Inquiry report on Mid Staffordshire NHS Foundation Trust [8], revealed ‘appalling’ standards of hospital care. At both hospitals, the regulators of healthcare failed to detect the problems, as was the case at Basildon and Thurrock NHS Foundation Trust, which has not had a similar thorough investigation [9, 10]. At Bristol, parents were not told that they could have chosen another hospital with a quarter of the death rate. The adjusted mortality for paediatric cardiac surgery in children under 1 year of age was 29% when the national rate was 12%. The Bristol rate dropped to 8% one year after an external, non-public, investigation led to improvements and to 3% two years later. Bristol now has about the lowest mortality for paediatric cardiac surgery in England. At Mid Staffs, a similar situation arose and the adjusted hospital death rate has dropped significantly, although changes in the coding of palliative care have contributed to part of the apparent reduction of hospital standardised mortality ratio [11]. At both hospitals, there had been queries about the quality of care for a decade and information was available about high death rates; in both cases this information was not acted on. The current Mid Staffs Public Inquiry is largely to find out why the government regulators missed the problems in that acute hospital trust [8]. Many Royal Colleges and official UK healthcare organisations have quality of care in their mission statements. The Royal College of Physicians of London stated in its 1518 Royal Charter that one of the functions of the College and its members was to “uphold standards …both for their own honour and for public benefit” [12]. The current Royal College of Physicians website mission statement [13] states that “We will be relentless in our pursuit of improvements in healthcare and the health of the population.” Bye-law 168 of the College states that ‘a ‘disciplinary offence’ shall occur if any Fellow, Member, Licentiate, Affiliate or Associate has “…performed his work incompetently (and whether by act or omission) to such an extent or on such number of occasions as to affect his professional or personal standing or to bring discredit to the College…” [14]. In 2004, the British Medical Association (BMA) added to the first of the reasons for which the Association was established, as stated in its Memorandum of Association: “(1)… to promote the achievement of high quality health care” [15]. The Association of Anaesthetists of Great Britain and Ireland’s primary objectives include: “To advance and improve patient care and safety in the field of anaesthesia and disciplines allied to anaesthesia” [16], whilst the Royal College of Anaesthetists states: “Its principal responsibility is to ensure the quality of patient care through the maintenance of standards in anaesthesia, pain management and intensive care.”[17]. How interested are doctors in ‘doing something’ about patient safety, and what are the barriers to their doing so? It is not a subject that appears prominently, as a specific topic, in medical school curricula. An American doctor gave his opinion that: “Everybody is interested in patient safety, but only about 20%of the people are convinced that we should do something about it and then only 10%are committed to actually doing something” (Richard Shannon, Chairman of the Department of Medicine, Allegheny General Hospital, Pittsburgh, PA, USA; quoted in Modern Healthcare, 20 March 2006). A US survey of 1000 doctors and 500 members of the public concluded: “It appears therefore that a much higher proportion of the general public are concerned about the safety of healthcare than doctors” and “If healthcare was an airline, only dedicated risk takers, thrill seekers and those tired of living would fly on it” [18]. A related question is how England/the UK compares with other comparable countries. An assessment of healthcare in six English-speaking and some European countries is carried out annually by the Commonwealth Fund [19]. It is based on surveys of the experiences of, usually, 1500–3000 patients with at least three chronic diseases. Broadly speaking, the findings are that the UK has relatively good primary care, good continuity of primary care, good information technology systems, an equitable distribution of care, low healthcare expenditure per capita and few worries of the population about their ability to pay for their care – but, on the whole, it does not achieve such good outcomes from hospital care. This last assessment is supported by Nolte and McKee who showed that the UK has one of the highest standardised mortality ratios for conditions amenable to healthcare in Organisation for Economic Co-operation and Development (OECD) countries [20]. This agrees with my own findings that we have the highest adjusted hospital mortality of nine ‘western’, mainly OECD, countries. My studies indicate that, in England, patients admitted to hospital have much higher hospital standardised mortality ratios than other countries [21]; we also have high levels of alcoholism and obesity, low physicians per head of population and almost the lowest level of acute beds per head in the OECD [22]. The UK also requires non-emergency patients to be referred to hospital by their general practitioner, which is not the case in most low-mortality countries. In the period covered by the Bristol Inquiry, 1984–95, the UK spent a considerably lower proportion of its gross domestic product on healthcare than the OECD average [22] and there were certainly funding problems at Bristol [6]. By the time covered by both the Mid Staffs Public and Independent Inquires, 2005–09, the UK percentage had been increased to much nearer the OECD average, but shortages of nurses and the detrimental effects of targets were still important factors [8, 23]. There will always be complaints about underfunding of a public service and the fact that NHS funding had been increased by the time of the Mid Staffs inquiry to nearer the OECD average [22] suggests that there may be additional factors at work. A recent opinion expressed by the former clinical director at Mid Staffs was: “The reason for this has been picked over at length but it essentially boiled down to poor managerial and clinical leadership in some areas, lack of clinical staff, particularly nurses, with inevitable low morale and, to some extent, lack of equipment…In my opinion a major underlying cause of the ‘Stafford scandal’ was that most of us, including politicians and healthcare professionals, had lost sight of the fundamental priority of a national health service. That is to provide excellent and immediate care to those who become suddenly very unwell.” [24]. In May 2009, the BMA carried out an online survey of a sample of 3034 doctors in England and Wales [25]. Analysis of the 565 responses received after 2 weeks showed that 74% had had concerns about ‘practices or behaviours by staff (e.g. relating to patient safety, malpractice or bullying) within your workplace’; 73% of these were related to the ‘standard of patient care’ but about half of the respondents were unaware that anything had happened as a result. Of the 288 who had elected to report their concerns to a responsible person within their NHS Trust, 10 (3.5%) agreed that “The Trust indicated to me that, by speaking up on sensitive issues, my employment could be negatively affected.” Doctors are required, by the General Medical Council (GMC) rules of Good Medical Practice (2006) [26], to: “Make the care of your patient your first concern” and to “Protect and promote the health of patients and the public”. Regarding ‘Raising concerns about patient safety’ the GMC says: “If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment, or other resources, policies or systems, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them.” However, as shown by the BMA survey and the experiences of Steve Bolsin, a consultant anaesthetist at Bristol [27] and Peter Daggett, a consultant physician at Mid Staffs [28], taking ‘independent advice on how to take the matter further’ can be a problem. The GMC ducks this difficult issue and does not suggest that those who have problems should contact the GMC. There are independent external opinions of ‘standards and quality of care in the NHS’. In 2007, Lord Darzi, a surgeon and Parliamentary Under-Secretary of State (Lords) at the Department of Health from June 2007 to July 2009, commissioned three independent reports from three respected US organisations: the Joint Commission International (JCI); the RAND Corporation; and the Institute for Healthcare Improvement (IHI). These were submitted to him in January/February 2008 [29-31]. They were based on official publications and interviews of individuals from a range of agencies, organisations and roles related to the NHS. They were largely in agreement and mainly critical. Inter alia, they refer to a ‘pervasive culture of fear in the NHS’, a ‘shame and blame culture of fear’, managers who ‘look up, not out’, ‘light-handed regulation’, a lack from the regulators of any ‘improvement advice or expectation of use of the core standards to drive improvement’, ‘poor clinical data’, a ‘virtual absence of mention of patients and insufficient data for patients to make informed choices’, ‘too much change and restructuring’ and the fact that ‘most targets and standards appear to be defined in professional, organisational, and political terms, not in terms of patients’ experiences of care’. These are serious criticisms. These three US reports were not referred to when the House of Commons Health Committee debated patient safety in 2009 [32] after the Healthcare Commission report on Mid Staffs appeared in March 2009. They were released in January 2010 as a result of a Freedom of Information request. They are not in disagreement with the views of Cure the NHS and the Mid Staffs clinicians. If there is a ‘pervasive culture of fear in the NHS’ and managers ‘look up, not out’, it is not surprising that some doctors will have difficulty reporting problems with patient safety. The question is: where is this policy determined? On the day of the final submissions to the Bristol Inquiry, Mr Rohan Pirani, on behalf of the Department of Health, stated: “If I may move on, Sir, to the area of responsibility and accountability, and make it absolutely clear again that the Department of Health accepts that it is responsible and is accountable for any failings of the systems that were in place during the period covered by the Inquiry. Ultimate responsibility rests with the Department of Health and the Secretary of State” [33]. In practice, “The Secretary of State’s duties are delegated to an intermediate tier of management lying between the Department of Health and clinicians. Thus, there has always been an intermediate statutory tier of organisation established to perform the Secretary of State’s duties (above) by planning and organising (and, more recently, ‘commissioning’) health care for their local communities. These statutory bodies are currently called strategic health authorities (SHAs) and primary care trusts (PCTs)” [34]. The SHAs (about to be disbanded) have the responsibility for performance management of trusts. There is no lack of good quality data about the NHS. The Bristol Inquiry concluded: “From the start of the 1990s a national database existed at the Department of Health (the Hospital Episode Statistics database) which among other things held information about deaths in hospital. It was not recognised as a valuable tool for analysing the performance of hospitals. It is now, belatedly.” and “Bristol was awash with data. There was enough information from the late 1980s onwards to cause questions about mortality rates to be raised both in Bristol and elsewhere had the mindset to do so existed.” [6]. Our unit at Imperial College has produced Hospital Standardised Mortality Ratios, published by Dr Foster, since 2001, and we have sent monthly mortality alerts to trusts since April 2007 [35, 36]. The February 2010 Independent Inquiry stated: “There is a genuine public concern that the present system of regulation cannot ensure that no such situations re-occur.” [8]. The previous chief executive of the SHA had “‘vigorously encouraged’ [the trust] to pursue the application for FT status in 2005…[at]…a time at which apparently we now know the hospital was providing standards of care which were not up to scratch routinely; we know that in 2002 there had been a CHI review which had identified many of the problems which might be thought to have continued – lack of nurses, lack of nurse leadership, poor clinical governance, to name but three.” [8]. The Mid Staffs Public Inquiry was set up “to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry will look at why the serious problems at the Trust were not identified and acted on sooner, to identify important lessons to be learnt for the future of patient care.” [37]. Anaesthetists are often centrally involved in the organisation and provision of services within trusts, and so have a crucial role to play in maintaining and improving the quality and safety of healthcare [38-40]. Our Bristol report stated: “During the Inquiry’s seminars, we were impressed by the extensive experience of anaesthetists in applying a ‘systems approach’ to safety. The work of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland deserves to be commended.” [6]. Let us hope that the anaesthetists will continue their systems approach to safety and continue to promote and enact such commendable practice. I work at the Dr Foster Unit at Imperial College and the company Dr Foster Intelligence funds part of our work and publishes some of our data. None of the members of the Imperial College Dr Foster Unit has any shares in, or claims any expenses from, Dr Foster Intelligence. I receive a consultancy fee only for my international work.