Preventing Avoidable Harm and Promoting
Patient safety: the Doctors’ Dilemma
Sukhmeet S. Panesar 1 and Rajan Madhok 2
1 NIHR Academic Clinical Fellow in Public Health, Imperial College London, UK
2 Formerly Medical Director, NHS Manchester, UK; GMC Council Member, UK; and Adjunct
Professor, INCLEN, India
cite as: Panesar, SS., Madhok, R. (2012) Preventing Avoidable Harm and Promoting Patient
In the last decade has seen considerable interest in patient safety globally, and
specifically in the NHS in England.
The landmark report in 1999 - To Err is Human 1 portrayed medical error as key public health
challenge given that health care itself was the eighth leading cause of death; and this was
followed soon after by two other seminal reports- Crossing the Quality Chasm 2 and Organisation
with a Memory 3 which provided roadmaps for addressing the problems and how to minimise
avoidable harm. As a result of concerted efforts since then considerable progress has been made
in understanding the frequency of patient safety incidents, how these vary by care settings, the
reasons underpinning the failures of care and most importantly in the development of
interventions aiming to enhance the safety of care.
Despite these developments over the last decade however, significant concerns remain about
the effectiveness of the approaches to minimise avoidable harm and promote patient safety in
the light of continuing high profile failures, the most notable being the Mid Staffordshire Hospital
incident recently. This begs two questions: why are patients still suffering avoidable harm
including deaths? And are we paying lip-service to the zeitgeist of patient-centeredness and safer
care? The evidence provided by witnesses at the Francis Inquiry into failings at Mid- Staffordshire
NHS Foundation Trust provide a chilling and compelling account of disinterest in high-quality
patient care - ‘‘...one of the junior doctors told me that I needed to get my mum out of there as if
she stayed in the Hospital much longer, we were going to lose her
he said that he was sorry
about the way she had been treated...’’ 4
It will be interesting to see what the final report of the Inquiry, when it does get published, will
have to say about not just Mid Staffs but also about the way in which the NHS has dealt with the
issue of patient safety. Rather than indulge in speculation about the content of the final report,
we would argue that the fundamental solution ultimately will lie with the clinicians; policymakers,
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funders, commissioners and providers can only help (or hinder, sadly) but unless the clinicians
actively engage with the agenda by providing leadership and adopting best practice, we will
remain in this quagmire. This is, however, easier said than done. The last few years have seen
increasing erosion of ‘power’ and ‘authority’ away from the doctors and in any case the culture of
the NHS, which still embodies the ‘who did it’ rather than ‘why did it happen’ spirit does not give
confidence to the clinicians that when they raise concerns that they will be taken seriously. Those
who muster the courage to whistle blow and alert others to situations of unsafe care are penalised;
the 6th Report of the House of Commons Health Select Committee stated that ‘The NHS remains
largely unsupportive of whistle blowing, with many staff fearful about the consequences of going
outside official channels to bring unsafe care to light.’ 5
How can we ensure that patient safety is in the DNA of the organisation when the mechanisms
to promote this are fraught with danger; doctors who have cited poor unsafe care which has
resulted in avoidable mortality have been prevented from returning to work.6 The NHS is not a
learning organisation despite its rhetoric.
Doctors therefore face a dilemma: on the one hand, all good (which is the majority) doctors
recognise the need to minimise avoidable harm and are taking appropriate actions, and on the
other hand, there are considerable barriers in their way. However, doing nothing is not an option.
Our patients deserve better and for the sake of our professional pride we must rise to the
challenge. In any case, leadership is not about criticising or becoming disengaged, rather it is
about making progress in the face of adversity. The recent NHS reforms do provide some
opportunities. Commissioning will be a key driving force for the provision of high quality health
services and one way of ensuring this will be to inter-twine hard measures of safety into the fabric
of the commissioning process. Measures such as complication rates, complaints, compliments,
readmission rates, outcomes, mortality and morbidity data along with procedure specific data and
patient experience questionnaires should be up for scrutiny inthecommissioningprocess7. Quality
improvement measures such as clinical dashboards8, specialty scorecards 9 and system ratings
10 are all important tools that need to be disseminated wider in daily practice.
The introduction of revalidation for doctors offers another way to force the pace
- proper
revalidation cannot be delivered out with the overall clinical governance context. Of necessity
organisations will have to ensure appropriate systems and procedures to enable doctors to
revalidate.
The next few years will be testing times for all in the UK as the economic pressure continues and
as the NHS changes start to embed. Indian doctors in the NHS can be a powerful resource for
the good during these times, not just because of the large numbers but also because of their
strong commitment to the NHS. we hope that BAPIO with its mission of promoting professional
excellence will support them in their quest to minimise avoidable harm and promote patient safety
everywhere. 11
References
1. Kohn LT, Corrigan JM et al: To err is human: building a safer health system. Washington,
DC: National Academy Press, 2000
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2. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-
first Century (Washington: National Academy Press, 2001)
en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4065083
Last accessed 15 October 2012
4. Witness statement of Julie Bailey. The Mid Staffordshire NHS Foundation Trust Public
Inquiry.
Chaired
by
Robert
Francis
QC. Available
online
at
5. Health Committee. Patient Safety. London: House of Commons, 2009
6. BBC News. Baby P clinic doctor Kim Holt to sue NHS. Available online at
2012
7. Strobl J, Madhok R. Commissioning for quality: experience in an English Primary Care
October 2012
8. NHS Connecting for Health. Clinical Dashboards Toolkit
2009.
9. Hammons D. Central East Local Health Integration Network. Orthopedic Quality Scorecard
ard_Meeting_ Submenu/5_3_-_June_29_2011_CEO_Report_to_the_Board.pdf
10. The Leapfrog Group. Leapfrog Hospital Safety Score
2012.
hospitalsafetyscore.org/about-the-score/methodology.html
11. Madhok R, Roy N, Panesar S. Patient safety in India: time to speed up our efforts to reduce
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