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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 151-iii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
DR ALISON HOLMES, PROFESSOR MATT GRIFFITHS and PROFESSOR ANEEZ ESMAIL
DR JO BIBBY, DR OLGA KOSTOPOULOU and CAPTAIN GUY HIRST Evidence heard in Public Questions 535 - 689
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Members present Mr Kevin Barron, in the Chair Charlotte Atkins Sandra Gidley Stephen Hesford Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor ________________ Witnesses:
Dr Alison Holmes, Director of
Infection Prevention and Control and Consultant in Infectious Diseases,
Imperial College Healthcare NHS Trust, Professor
Matt Griffiths, Visiting Professor of Prescribing and Medicines Management,
Q535 Chairman: Good morning. Could I welcome you to our fifth evidence session on our inquiry into patient safety? As you are aware, one of our witnesses is on a train somewhere in the South Midlands at the moment, so not too far away, but we are hoping he may get here in this session. We have an area of questioning for him specifically, and we will not ask those questions of yourselves because it is not your area of work, as it were, and expertise. Could I, for the record, ask you to introduce yourself and the current position that you hold? Dr Holmes: I am Dr Alison Holmes; I am a Director of Infection Prevention and Control at Imperial College Healthcare NHS Trust; I am also an expert member of the Government advisory panel on antibiotic resistance and hospital acquired infection (ARHAI) and I am also a Probing Director at the National Centre for Patient Safety and Service Quality Research at Imperial. Professor Esmail: My name is Aneez Esmail and
I am a Professor of General Practice at the Q536 Chairman: Welcome once again. What do the patient safety problems in your areas of expertise say about the safety culture inside the National Health Service? Is the in-culture easy to change? Professor Esmail: I think the point about primary care, which is where my expertise is mainly, is it is something that has really been left off the agenda in terms of patient safety. I think that we have the least understanding about some of the problems in primary care, but I do think that there is a willingness, and for a long time, in general practice particularly, there has been some sort of understanding of some of the issues and some of the problems. My work shows that there is a willingness to do things about it, but our knowledge base is very limited and very restricted, so I cannot really comment very much on the culture because certainly the work has not been done like it has in the secondary care sector. Dr Holmes: From my perspective within the world of infection prevention and control, I have a good news message here because I think actually the model we have developed and worked on has had a significant impact and I think the organisation model that we used and developed is something that would lend itself to many other aspects of patient safety. I think that is a good news story - a local organisation model embedding infection prevention and control within the very fabric of an organisation. It has had an impact. I think it is a lesson for us. There are three other points I would not mind highlighting. I think it is incredibly important and, also, what we have learned locally is that we must have a framework for surveillance, for gathering data and for continually feeding it back and, of course, that is something that we pointed out in a paper in the BMJ in November about the importance of data, and monitoring, and feedback to get that level of clinical engagement - so the framework for surveillance and feedback is key. The last two points are that it just cannot be a service that is a separate add-on one for some experts, it really must be fully embedded within the organisation for it to work, and clinical engagement is vital. Q537 Chairman: I do not know if you are familiar with the publication; it was ten years ago now An Organisation with a Memory was published. Do you think that progress has been made? Clearly, I think, Alison, from what you have said, you think progress has been made in the last ten years. Has it been made, to your knowledge, in other areas as well? Dr Holmes: I think progress has been made. I am not sure how much from my coal face view. I think maybe the stage was set for us to make these changes and develop an organisation model, but I would like to highlight that it was actually a pragmatic choice to change the way we work and change how an organisation runs, because the historical model for infection prevention and control, with a small service covering multiple sites and everything, was just not practical and we really had to come up with a new way. I think within the context of An Organisation with a Memory people were very happy to use clinical incident reporting as a way of addressing complacency around hospital acquired infection, for instance, but actually it was a pragmatic solution to what has not worked historically with more complicated organisations. We really had to think about new ways of doing things and embedding it within our culture and our management and clinical systems. Professor Esmail: I think a lot has happened since An Organisation with a Memory. I think it did, rightly, set the agenda for us, and those of us who work in primary care. I spent a lot of time trying to persuade organisations about primary care being just as important as the secondary and acute care sector, and we began to try and find out about how big a problem it was. So we did research on trying to find out what others had done around the world, we did small studies to see whether GPs would actually report errors. There was a concern that general practitioners would never admit to doing things wrong, and so we did small studies, for example, to show that they would be very willing to do that. We tried to understand what we could learn from litigation databases. The NHS and the defence organisations do have to deal with litigation arising from things going wrong in primary care, so we looked at that and we discovered a lot about what goes wrong in primary care from that and we began to ask ourselves questions about: how could we engage primary care better? What would be the priorities for doing it? Without a doubt, we are certainly not as developed as in the secondary sector, but I remember at the time having a discussion with the Chief Medical Officer and saying that part of the problem was in primary care. We do not have the same sort of organisational structure that you can have in secondary care. We have a Chief Executive who just says, "This will happen" or "That will happen", or a very powerful medical director. In primary care you have a situation of independent practitioners who are very nervous about any sort of organisational change coming in, people telling them what do, and we have to work with that. There are good points about it, but in trying to implement areas like patient safety culture, when you have to insist, for example, that we want to create reporting systems, all the issues around anonymity and confidentiality, and so on, still have not to this day been worked out really; so to tell people that "you must" and "you have to" is just not going to work in the setting of primary care. I do not think that reflects a desire not to do something about it, but we just have to realise it is going to be very different to how we implement things in the secondary care sector. Chairman: We have got some individual specific questions for you now, starting with Doug. Q538 Dr Naysmith: Good morning, Dr Holmes. I have a couple of questions for you to start with, some of which you have already made reference to, but let me start with this one. Are healthcare associated infections as big a problem as they are perceived to be, certainly by the media, who seem to focus in on them? Is it a really big important problem in terms of what the National Health Service is doing? Dr Holmes: I think we have to acknowledge there is a massive media interest. In terms of the data, in the latest prevalent study of healthcare acquired infections, which is published in the Journal of Hospital Infection 2000, I think, the prevalence was 8% of all hospital in-patients, but, in terms of public perception, the BBC had a national poll last year where hospital acquired infection remains the number one concern above and beyond quality of care, variety of mistakes, et cetera. Q539 Dr Naysmith: What I am asking you is if that perception is the right one? Dr Holmes: That is why I said the number of the prevalence. It is almost one in ten infections, so it is something that we do have to be concerned about. Two things I would like to draw our attention to. One thing that does not feature quite so much, which is a very important aspect of this, is actually antibiotic resistant infections. Q540 Dr Naysmith: We are coming on to that. Dr Holmes: That does not feature highly enough, and that is not just for us now, that is for the future, and that is slightly more difficult to report. It has not got such snappy headlines, and conceptually it is little bit more tricky. However, that is something I would just like to flag. Q541 Dr Naysmith: We will be dealing with that more in a minute or two; you are ahead of the game. What I did want to ask you, and you have already talked about it a little bit, is the framework for surveillance. How can we get better information about the scale of the problem and how much it costs the National Health Service? You have already made reference to the need for a framework for surveillance, but what does that actually mean in practice? Could we tease that out a little bit? What do we have to do to get this better information? Dr Holmes: Could I deal with the
question about cost and then a little bit more about getting good data? I think we are struggling here. We really do need some very good economic
evaluations that are not just about bed days but the impact in primary care,
and I think we really do have to move towards thinking: this is hospital
acquired infection, it is across a whole patient journey, and we should be
working very closely in primary and acute care.
So economic evaluation needs to consider not just what is happening in
the hospital but the impact on people's lives and in primary care. We also have to use data that is useful, that
actually comes from the Q542 Dr Naysmith: You want the validity of some of the information then? Dr Holmes: I think a lot more work could be done on getting economic evaluations. The other thing we need to factor in - it is not just the impact on the whole healthcare economy and within primary care as well - is this issue about 'in the future'. We are using antibiotics and we are treating infections that we might be causing using more antibiotics. The economic evaluation in the present is not merely picking up some of the collateral damage in terms of its impact on antibiotic resistance around us but in the future. Q543 Dr Taylor: Good morning. You are part of (do we call it) ARHAI? Dr Holmes: Yes. Q544 Dr Taylor: I am most impressed with the evidence you have given us, and I am hoping that our experts have read all the references because you have given us an enormous pile of references. However, right at the beginning you said that there was some good news. Does that mean you have identified some solutions? Dr Holmes: I think we have identified
models of working that are new and have been effective. I am being very parochial here, but I think
we have established ways of working with a lot of clinical engagement,
embedding it into the fabric of how we run our organisations, and also a system
that has demonstrated some resilience. One
thing I wanted to mention earlier is actually we should maybe use infection as
a marker of good management and managing multiple complex systems. The way we manage our HR, the way we manage
change, the way we manage service reconfiguration - all these things are a
threat and they can reflect on infection outcomes; so you could look at the
marker of how well we can manage complex organisations. Often when organisations go through massive
change that is when they have problems with c.diff. The Healthcare Commission report in High
Wycombe and the Healthcare Commission report in Maidstone - these are
organisations that were going through much change at the same time, service
reconfiguration as well as other challenges, and I think if we really do embed
it in our organisations and use models which are sustainable - and it is not
all about enforcing, it is about developing good clinical networks, shared sets
of values - that actually is sustainable through change. We published something about this, the Hammersmith
Organisation, a model for infection prevention which uses a whole raft of
internal reinforcement measures which has seemed to work and seemed to sustain
us through massive changes that we have gone through recently in Q545 Dr Taylor: As Director of Infection Prevention and Control at Imperial College, you have close working relationships with every clinician on every ward, do you? Dr Holmes: Most clinicians on most wards. I am a clinician myself, and actually it was very important that the Director of Infection Prevention and Control was seen to be somebody who saw patients. There is a huge amount of clinical chauvinism out there and, actually, it is very important for the person who is engaged in controlling antibiotics to be giving recommendations and seeing patients. So that was important. I hope in the future that will not be quite so important, but it really is critically important if you are working with your clinical colleagues and wanting to address issues around antibiotic prescribing for instance. Q546 Dr Taylor: Coming to the over use of antibiotics, you say hospitals need to have a clear policy on the prescribing of antibiotics. Do most hospitals have that now, or ought we to be doing a survey or finding out how many hospitals do have a proper policy? Dr Holmes: There was a survey that was done many years ago which showed significant gaps. That has improved dramatically. The other thing that has improved dramatically (and I would like to highlight this) is the role of the pharmacist. The role of the pharmacist is absolutely critical. We need to develop them more and they need to be a key member of clinical teams, providing postgraduate education for them in this field. They need to be colleagues working with us. Also, their role in terms of developing, reviewing and revising policies is absolutely key. Most hospitals would have an antibiotic policy, and that is an important quality indicator as well as having a pharmacist working in them. Q547 Dr Taylor: The other crucial thing, you say, is if we were able to collect data on the type and number of antibiotics prescribed and tie that in with the incidence of c.diff, that would give us some really useful information? Dr Holmes: Yes. Q548 Dr Taylor: Can you expand on that? Dr Holmes: Certainly. I mentioned collateral damage when I was talking about antibiotics. They can cause side-effects, but the thing that I am particularly worried about is the driving of antibiotic resistance and antibiotic resistant infections and their relationship to c.diff - how they are linked to c.diff. We absolutely need to understand our antibiotic prescribing and our patterns of antibiotic prescribing to get a handle on it and clearly establish the relationships with c.diff, and not just c.diff but particular strain types of c.diff. That level of understanding would really help us in targeting and choosing what best antibiotic to use. Clearly, antibiotics are completely valuable and we must use them immediately when we need them, but we must use them incredibly carefully. We are running out of choices here and they are driving the c.diff problem. Q549 Dr Taylor: I do like your choice of words: "Antimicrobial agents that induce CDI are believed to perturb the normal gut bacteria." I think that is a lovely way of putting it. You have mentioned other antibiotic resistant infections. Are we talking e.coli? Dr Holmes: We are talking about a whole range, gram positives and gram negatives. MRSA is one, glycopeptide-resistant enterococci is another gram positive. Q550 Dr Taylor: Is there a simple name for any of those that somebody like me might remember? Dr Holmes: No. Multi-resistant bacterial infections. You mention e.coli, which is a gram negative enteric bacterium which lives in the gut. I think we really do need to be mindful that this is a problem also in the community with multi-resistant gram negative urinary tract infections, and for those of us working in hospitals, particularly seeing patients in intensive care units, we are facing enormous challenges trying to treat highly resistant infections and also not wanting to drive resistance any further, and the choices are narrowing because of the organisms we are seeing. Q551 Dr Taylor: One last one in this group: bed occupancy rates. We are reassured by ministers that there has been no correlation in the past two or three years between bed occupancy rates and infection rates. Dr Holmes: Yes. Q552 Dr Taylor: I cannot believe that, if you have got 90% or 92% occupation and you are rushing people through, and you do not have time to change the beds and clean things properly. Are there any facts that do show that high occupancy rates do predispose to hospital acquired infection? Dr Holmes: I think there have been some more recent papers on this. I think the data was very interesting that earlier on - 2001-2003 - there was a clear correlation between bed occupancy and MRSA bacteremia, but that relationship appears to have gone. What they were looking at was only MRSA bloodstream infections, which is the tip of the iceberg in terms of MRSA infections, and it is multi-factorial. One should never use bed occupancy for any complacency in terms of best practice, and there is a huge amount of improvement that can and has been done in spite of the bed occupancy. However, I would just like to expand on a couple of points you made. Bed occupancy is also really important in terms of staff/patient ratios: huge amounts of data about if you get your ratios wrong infection rates climb, particularly in high risk areas such as neonatal intensive care units, or any intensive care high dependency unit; so staff ratios are incredibly important. The other issue about bed occupancy: if you want to clean wards, decant wards so you can do deep cleaning or a planned programme of maintenance, or whatever, it is very hard if you have not go space, because where can you put people to close a ward to clean? Also, for instance, orthopaedic infection. It is critical if you come in for a hip or a knee that you are either admitted to a ring-fenced area where everybody is MRSA screened and free. So that is ring-fenced just for you coming in for your hip or knee. That will mean that you have got to run at whatever it is and keep beds empty. The other issue about bed occupancy is that it is not just bed occupancy. We need to think about what is our bed stock in terms of single rooms and isolation rooms we can use. How often can we isolate a patient with diarrhoea instead of closing all the beds around them? How often are we working in wards that may be not the ideal type of estate to practice 21st century medicine and clinical and scientific aspiration? So it is not just the issue about bed occupancy. Much can be done even if you have got high bed occupancy. It is not the only factor, but it certainly impinges on all those other issues. Q553 Dr Taylor: Just to be clear, MRSA bacteremia, you said, is the tip of the iceberg; the rest of it are the wound infections. Dr Holmes: The pneumonias, urinary tract - absolutely. Q554 Sandra Gidley: The buzz thing in 2007 was big announcements that all hospitals would have to have a deep clean. Locally there was a decision to do that even before the edict came from on high. Did it actually make a difference or was it just a gimmick? Dr Holmes: I think it is very important to have awareness about cleaning, and there was a response also to the public's concern about cleaning, so cleaning is a good thing. However, I think a one-off clean is not enough; we need a sustained programme of deep cleaning which needs to have enough space that we can do it and also co-ordinate it with any planned programme of maintenance so that you can do everything at the same time and decant patients. I think a deep clean is very important, but it is not a one-off, it should be a sustained part of the organisation. There should be a rolling programme of deep clean throughout all clinical areas, but you do need space to be able to do that adequately. Q555 Sandra Gidley: Certainly I know that patient feedback was positive, because the place looked cleaner, but is there any research to show whether it actually made a difference to infection rates or not? That is what I am trying to establish. Dr Holmes: I am unaware of any clear research that has established that. I think it drove some very important messages and I think it was useful. You pointed out how it looked cleaner. The other issue is about de-cluttering, which it helped with, but we do have a big issue with space. Q556 Sandra Gidley: When they design hospitals do they just not put enough cupboards in for everything, because the amount of rubbish these days when you go round. They are very messy, they do not look very clinical, and the staff do not see it. Dr Holmes: It is tricky to see if there is a lot of kit everywhere, but I think the staff do see it on the wards; I really think they do. There is an issue about the fabric of many of our hospital buildings and, whilst wanting to give patients space, sometimes it is compromising on storage space. So the design of our buildings is absolutely critical for patient experience, patient safety and for infection prevention. Q557 Sandra Gidley: We have had a lot of evidence that a lot of improvements can be made if you change the culture: so how important are reporting and learning for infection prevention and control? Dr Holmes: Incredibly important. I would suggest it is the continuous feedback of data, the continuous surveillance and feedback of data, that is really important rather than just the reporting of particular events. For quality improvement within infection prevention and also for monitoring trends and targeting activity, it is having good strong surveillance mechanisms and also ones that are in real-time. Hearing about something six months later is not good enough; we really need the fast turn-around of surveillance data and information that is relevant to the people that are receiving it so that they can make change. Q558 Sandra Gidley: So data is available from the National Reporting and Learning System. What I am not sure about is how you use it. You can see whether something is getting better or worse. It may be not quite so easy to link that to a specific intervention that may have been made or an improvement; so how is this wealth of information used in practice to change things on the ground? I am not quite sure where the link comes in? Dr Holmes: I am talking about several different surveillance schemes. There is the national mandatory reporting of different infections, there is also a raft of local ones and also a range of networks of reporting all around quality improvement and also, locally, key performance indicators that we have set around infection. In terms of the NRLS, there has not been so much in my field, so I cannot answer that. Q559 Sandra Gidley: Why has there not been so much, and should there be more? Dr Holmes: One thing that has been extremely useful that has come from the NPSA has been their Clean your Hands programme. That has been phenomenally useful as a resource in terms of positive reinforcement, in terms of providing masses of resources, in terms of awareness campaigns and everything; that has been extraordinarily useful as a campaign. Q560 Sandra Gidley: When did people stop washing their hands in the NHS? I can remember reading Jean Becomes a Nurse when was about 12, and there was a whole chapter on hand-washing. When did people stop washing their hands in the NHS and why do we need such a big campaign on hand-washing? It is such a basic. Dr Holmes: Absolutely, but continuous reinforcement is needed. The other thing that is important there - I mentioned before issues about staff ratios - hand hygiene and staff ratios is important but it needs to be embedded in the culture, it needs to be taboo not doing it, in just the same as surgeons and scrubbing. It needs to be behaviour that is completely reinforced, that is engrained there, we have got role models and it is always reinforced. Q561 Sandra Gidley: So the data is really tracking progress against what you are doing. Dr Holmes: There is a huge amount of national data but also local data. In terms of what is coming from the NRLS, it is the hand hygiene programme, which I am most familiar with, which has been incredibly valuable. Q562 Sandra Gidley: When you are looking at the data, the information that is coming back, how useful is that for a hospital to say: "Right we tried X, Y and Z to improve our infection control rates. It is obvious that Y is the one that is having the most effect", or is it just not useful in that way? Dr Holmes: It is incredibly useful, and the point you raise is really important because the data needs to be used to target action, and to target action you need more information round that. You either need to drill down to each case, you need to look at themes or you need to look at where are you seeing these cases - what risk groups. So, absolutely, data drives and feedback drives; activity targets action; so it has to be useful data that you can drill down and get more information and investigate. Root cause analysis is very useful around some particular cases, but even just knowing the demographics, the speciality - all of that is incredibly valuable - and feeding it back to the people who can do something in a timely manner is absolutely critical, far more than any individual finger pointing. Continuously feeding data drives quality improvement, particularly if you are measuring something that is meaningful to the people who are getting that information. Q563 Sandra Gidley: So we gave got the datasets about right. Dr Holmes: I think we could do a lot more. MRSA bacteremia is one thing: I think it is fantastic that the data is there it has driven massive change; I think we could do far more. I am particularly anxious about vulnerable patient populations in our intensive care units or our neonatal units, but we are working through networks to get more information and people are welcoming data. Q564 Sandra Gidley: Say you had extraordinary influence on our report, is there anything specific that we should be collecting or looking at that currently we are not? Are we missing something? Dr Holmes: I think we need to have much better data around bloodstream infections in our intensive care units, in our renal and dialysis units and in our neonatal units. These are a highly vulnerable, high risk population. They may not be quite as vociferous, but they are highly vulnerable and I think that is an area we should be looking at. Q565 Charlotte Atkins: Good morning. I am sorry I was not here for the earlier part of the session. Dr Holmes, how do we embed and enforce safe ways of working that will really enforce good infection prevention control? Dr Holmes: I think there are four main ways of doing this. We must ensure that within an organisation, so from my perspective the trust I am working in or the academic health science centre at Imperial that I am working in, we must have a shared vision and a shared belief so that all of us, every one of us, no matter what our role, profession, that this is a good thing to do. For me, it is infection prevention. Everybody must feel it is important and we have a role. So from the Chief Executive through all personnel - clinical, managerial, administrative - ensuring you have a shared belief. The second thing I alluded to is we must have reinforcement systems, and positive reinforcement systems as well. So everything we do must make good infection prevention practice the easy thing to do and also positively reinforced all the time, driving internal networks to get good information, having a research agenda that also supports that and also that all our measures include measures about infection so that all our key performance indicators, whenever people are looking at them, will always have something about infection, outcomes and processes. So a shared belief, ensuring we have reinforcement systems and then, thirdly, we have to provide skills for people. We need trained staff and we need people who actually understand what their role is and how to embed and deliver good practice and supporting whatever role they have. Then lastly, I mentioned before antibiotic prescribing, but in the context of an organisation and culture there must be consistent role models from the Chief Executive, medical directors, nurse directors, heads of estates and facilities - all of them must be involved and be role models - but then there is another aspect of that. We also must make this aspirational for people who are involved in it, not the worst possible job, and also we must develop better research. I think, being on the research agenda, it is very important, and that also drives clinical engagement as well. Q566 Charlotte Atkins: You are talking about leadership, and so on. Do you think that there is sufficient leadership from our senior clinical staff in terms of making this a top priority? Dr Holmes: I think that is absolutely key. We were mentioning earlier about antibiotic prescribing. Antibiotic control and infection control go hand in hand: you do not care about antibiotic resistant organisms; they do not spread. How we use antibiotics to treat infection, it is all joined up - antibiotic control, infection control - and, if we do not get engagement from senior clinicians who influence prescribing and shape the behaviour of junior doctors, we will not be able to embed it and make it part of our culture, so senior clinical leadership is vital. Also, what I was saying earlier, actually it is important that senior clinicians take on senior roles within infection prevention and it is not seen as solely a nursing role but actually it is a multi-disciplinary role. It is not solely the premise of the nursing directorate: all clinicians, whatever role you are in, must be engaged. Q567 Charlotte Atkins: Surely it is not just about prescribing, it is also a matter of washing hands and actually saying that it is totally unacceptable for anyone, including senior consultants, to come in here without washing his or her hands. Dr Holmes: Completely. I am sorry; I take that as a complete given. Why I was highlighting the issue about antibiotics is that that is particularly a prescribing issue, and also I think everybody should be in a position to challenge prescribing. Earlier I mentioned the role of pharmacists - absolutely key. We need to develop them far more, both in acute care and in the community. Pharmacists, as well as nurses, as well as doctors - we must all work together challenging each other, driving best practice, but, absolutely, all practice, from hand hygiene to how you insert a central line, how you manager a dialysis catheter, how you look after a neonate, or how you conduct yourself in your out-patient clinic - all of that must deliver infection prevention practice. Q568 Charlotte Atkins: The committee went to St Thomas' a couple of weeks ago and it was very clear as soon as we entered the room that we were expected to use the hand gel, and so on. I go to hospitals quite a lot, sadly, and that is not always expected. The canister is on the wall and if you feel you are going to be good you go and put it on, but it is not something where generally staff look at you and say, "You are coming in to visit a patient: use the gel"? Dr Holmes: I think this is why it is absolutely key about the senior buy-in - medical director, chief executive, key performance indicator, where they also identify what the professional group is that is not performing in hand hygiene and why hand hygiene monitoring should be up there as a regular indicator of quality. Q569 Charlotte Atkins: Do you think that the regulatory and the performance managing bodies are doing enough themselves to make this a top priority? Dr Holmes: I think there has been an awful lot done. I think what might be useful is if some activity is duplicated. We need to find a balance between working within a framework of regulation and actually letting trusts develop good quality improvement within their own network, so that they are not constantly duplicating activity and maybe needing to think about having extra people on their staff to deliver all that is required for external regulation rather than concentrating on local quality improvement initiatives. Q570 Charlotte Atkins: Maybe commissioning bodies have a part to play. Commissioning Good Quality and Innovation by the Department of Health suggested that PCTs might be able to make payment to providers conditional on performance indicators for things like infection prevention and control; and I have to say that, if I was heading up a PCT and some of my patients had to stay in hospital an extra two or three weeks because of catching some sort of infection, I would want to ensure that my local provider hospital had a financial penalty for that. Instead, they have a financial advantage, because they are paid more for the patients that stay there longer. Dr Holmes: I think external reinforcement like that is valuable. However, I have a slight anxiety. I mentioned before about how critical it is, now that patient stays are getting shorter and shorter, that we really do need to look at healthcare acquired infection and antibiotic prescribing across the whole patient journey, and we are just beginning to work across that and look at it as a problem that is not either acute or primary but is something that we should approach. I am slightly concerned that that may drive a wedge between some of the work we are trying to do about risk across acute and primary care boundaries. However, the quality initiative I completely support and the reinforcement being there is valuable, but I think we have to be mindful that actually we really do need to address this problem, not as a primary care and acute care issue but actually across the whole patient journey, if we really do want to do something about it. Q571 Charlotte Atkins: I appreciate that, obviously, many patients will enter a hospital already with infection, I appreciate those concerns, but where you have hospitals that warning, after warning, after warning their infection rates are much higher than acceptable, and anything is unacceptable but if they are very high, surely there has to be some sort of financial penalty: because it gets to the point where hospital managements can be in denial mode: "Oh well, it is everyone else's fault. It is the PCT's fault; it is the population we are having to serve", and it really has got to get to the point where if they are not performing there has to be some sort of penalty, and financial penalties seem to be the ones that actually have an impact on performance. Dr Holmes: I do think there are some lessons that can be learnt from the mandatory reporting of the MRSA bacteremia and the actions that have been taken at trusts that have driven down numbers in the absence of financial consequences. I do not think I am in a position to comment any more about that. I completely value external reinforcement. In my job it makes it much easier to drive change when there is a level of external reinforcement, but I actually value working with my primary care colleagues to look at it as a comprehensive problem that we can work on together. That is my concern about that. Q572 Chairman: Could I say welcome to Professor Matt Griffiths, who has joined us. We are sorry about the delays; the weather is in nobody's control. You are the Visiting Professor of Prescribing and Medicines Management at Northampton University. I just want to put that on the record. Professor Griffiths: Yes. Chairman: We will come to you in a few minutes, but we are going to move on to Professor Esmail at the moment for some further questions. Q573 Stephen Hesford: Professor Esmail, there is a cross-over from the questions that have just been asked. Probably about 20% of my constituency population is elderly, 65 plus, and a significant proportion of those are in nursing homes. My local hospital's infection rates are low but they have a residual band that they basically cannot get rid of. They think that much of the infection is coming from the elderly coming in from nursing homes. Dealing with primary care, with that in mind, if that is at all representative of what happens elsewhere, there does not seem to be much hard evidence on patient safety in primary care. What can be done about that, either in the GP's practice or health centre or in other primary care settings? Professor Esmail: I think from the specific example you gave, we are only now beginning to understand that things like community acquired infections are a big problem; and we have not had systems in place to make sure that people are screened, for example, before they enter hospital sometimes, because you cannot do it when it happens as an acute emergency. I have noticed with of my own patients that people going in for very complex operations which are planned are now being routinely screened, for example. So we are beginning to understand this relationship between what happens in the community and what happens in hospital. Of course, it happens the other way round as well: people get discharged without being screened and we do not have any idea of that, and then they come in with persisting wound infections or become ill with pneumonia and the source might have come from the hospital; so we do not have that information either. I think we are beginning to understand that more and I think we have got to do a lot more work as we understand the epidemiology of these illnesses and how we have to have a whole systems approach to that. On the issue about evidence, it is not true to say that we have no evidence. We look at literature, we have done pilot studies, and we have looked at litigation databases; so we understand how big a problem it is. Of course, I think part of the problem is we have not concentrated on it enough. If you think that most people's contact with the NHS is through their general practitioner and you then imagine what must be happening, even if you talk about 50 incidents a day but you multiply it by the number of consultations that people have, you are talking about huge amounts of things that potentially can go wrong. So we recognise that it is a big problem, but we do not have a very good means of measuring or putting numbers to it, for example. We always talk about ranges and how big a problem it might be, but we do not have a specific number we can quote, saying, "This is how big a problem it is." Hospital people frequently talk about one in ten admissions or 10% of all admissions have adverse events. We cannot give you that figure for primary care, and that is a problem, but it should not prevent us from doing anything about it. This idea that we can only do something if we know that figure, I think, is misplaced. There is lots happening already and lots which can be done which does not have to be dependent on that idea. Q574 Stephen Hesford: I am slightly confused by that, because if there are no figures to know exactly what the problem is, I am not sure what the solution is to the problem that you do not really know what it is? Professor Esmail: Take an example of something which is widely happening in communities: warfarin prescribing. I cannot tell you at the moment how many adverse events occur in primary care because of warfarin prescribing. Q575 Stephen Hesford: Adverse events meaning? Professor Esmail: Let us say that the patients are getting medication repeatedly without having their level checked, or are getting too high a dose of warfarin so they are at risk of bleeding or having a haemorrhage, or something like that. I cannot tell you a precise figure as to what the problem is, but I do know, based on good practice, what should happen, and I can look at my processes in practice to say: is that happening or not? I know, for example, that before a patient gets a repeat prescription for warfarin someone needs to ask the question: "When were you last assessed? When was your last blood level taken and what was it? Is there a record of it? So that I know that I am giving you five milligrammes of warfarin, that is going to be within the accepted norm, or I am giving you too much and you need to cut back on that. So I do not need to know the exact number there; I just know that in good practice that is what should happen. I think a lot of general practice is like that. We know certain things that should happen but are not happening and we can focus on that, and that means a better understanding of processes. Of course I think that having the numbers helps, because if we want to put in very expensive intervention, something different or unusual, then we do need to be able to evaluate it. Again, we can focus on different areas and see if we can improve those, but I think we should not use that as an excuse to say we cannot do anything. That is the only point I am trying to make in that respect. Q576 Stephen Hesford: So would you agree with the statement that there is awareness at a fairly significant level that patient safety in primary care is an unaddressed problem? Dr Holmes: Yes, I think so, and I think all the big agencies, the National Patients Agency, the Government, even at a European level, are beginning to understand that there is a whole amount of work and understanding to be done in primary care and they are beginning to focus their attention on it. I am, for example, being asked increasingly to talk about areas in primary care, research money is becoming available to work in this area, so I think there is definitely a realisation now that there is a whole lot of work that needs to be done in primary care and think more effort and attention is being directed to that. In terms of awareness, I do not think there is a problem, because I think virtually every general practitioner---. We did a study, for example, when we asked general practitioners over a three-month period to record things that should not have happened, and we were amazed, just in our small practice, how many incidents came up. We had instances where there was delayed diagnosis. Q577 Stephen Hesford: Were those anonymised? Professor Esmail: Yes, they were anonymised. Q578 Stephen Hesford: Otherwise you would not get anyone telling you. Professor Esmail: We had to do it that
way. I made this point earlier before
you arrived. Those sorts of issues still
are not resolved in primary care, for example.
Yes, there is the whole argument if we make them completely anonymised,
we cannot find out the detail we want sometimes, but when we did our study, and
we did it across Q579 Stephen Hesford: But it is a start? Professor Esmail: It is a start. ---that was crucially important because in some ways general practitioners were able to unburden themselves of something, and we do this now in our practice every year. We have a four-week time when we say, "All right; we are all going to report things now for a four-week period", because we know that is sustainable. Our research evidence shows, wherever we have done it, that after about three months it begins to fall completely and people do not do it, so we have a one-month campaign and we say, "Let us report." We have reminders and everyone is doing it, and then we collect the information and we the use it as a feedback, and we plan to do it at different times of the year so we will get a range of things going wrong and be able to investigate what happened. Q580 Stephen Hesford: So it becomes not exactly scientific but it has a representative nature? Professor Esmail: Yes, and I think the point is it has the effect of actually getting you to improve things, and that is very important. It means that when you find out, for example, that a patient had a blood test done and it was not followed up, you invariably go and look at your systems and what are our systems of follow-up. When a patient comes for a blood test what reminders do we have, what sort of prompts do we have to make sure that someone follows up on that result. So it tells us to do things like that, and I think we can hugely improve systems in primary care through those sorts of techniques. We also have techniques like significant event audit. We have a system whereby we ask people to make a record of something that goes badly wrong. It is a significant event, it is not something minor; something that they feel is really big. They will make a record of it and we will discuss it as a team, and, as a result of our discussion, we will say, "Gosh, this is not very good in what happens. It highlights a flaw here. It shows we do not do this very well", and we then actually get someone, or a team of people, to go and make the changes and we hope that it does not happen again, but if the problem arises again, we have a record of what happened before, we can follow the audit trail to see what happened. Those sorts of things can be very important and should not be negated. Q581 Dr Taylor: Going on with significant event audits, do you only look at those four weeks at a time? Professor Esmail: No, that is an ongoing programme. We just talked about reporting. We have a computerised base system. For those four weeks we want them to report everything that goes wrong, from their perception, and we will get everyone to do that - nurses, reception staff, the people who work in the admin office - so everyone knows that that is the four weeks we try to collect information on. That is the purpose; it gives us an idea of how big a problem it is. Significant event audit goes on throughout the year, because I may find out last week something happened. If I got a very poor discharge of someone from hospital, I did not know something that should be happening, then I should log that so that when we come to discuss it we know. How can we actually contact the hospital to make sure that this does not happen again? Can we make sure that it is followed through? Does that audit loop get closed? Can we make sure that we have something in place that we know it is not continuing to happen? That is what significant event audit achieves, and that has to happen all the time. Q582 Dr Taylor: Could you give us some other examples of what are significant events? Professor Esmail: I will give you an example of a patient of mine who was discharged from hospital with a diagnosis of cancer, which I was never told about, and nor was she. Eventually we were able to find out. We kept insisting: "Why have we not had a proper discharge letter?", and we then discovered this happened. That was a terrible case really, and what happened on that is that I discussed this. We discussed it as a team. We wrote a letter to the hospital. We asked them to investigate it. We expected a response back again. We hope we have a system in place so that that should no longer be the case, and things are improving on that. That is an example of significant event audit. Q583 Dr Taylor: That is really something happening in secondary care though. What about significant events in primary care? Professor Esmail: A common problem is someone has a blood test done and is found to have anaemia and we do not follow it up. We look at it, we see that the haemoglobin is low and it is just put down as probably due to iron deficiency anaemia, but actually it might be something more significant. We might have to do more investigations to see is there a cancer underlying that, are those investigations followed up, who is going to carry them out, and so on. It is becoming particularly important in primary care: continuity is a real problem. You might have one doctor seeing the patient and then someone else having to follow it up three or four weeks later, and if the record keeping is not good or the audit trail is not good, that might get missed. That is a very common example, when we have a result which might signify something more serious but is not followed up. Q584 Dr Taylor: Has incorporating SEAs into the QOF made any difference? Professor Esmail: I do not think it has yet. The reason is because the way that people do significant event audit in general practice varies hugely from practice to practice, and we need to have a standard way of doing it, we need to have a standard way of collecting information, we need to have a standard way of making sure that information is shared, and all that the QOF does is say, "Do you do it?", yes or no, and that is it. Q585 Dr Taylor: So you can get the money if you say, "Yes", even if you do not do it? Professor Esmail: That is lying, and that should not be the case. The point is you can do it, but are we learning from it. That is the critical question. Also important is: are we sharing the information? I might have a problem in my practice. I work in a primary care trust where there are 50 other GPs, and what I have found is a problem may also be very relevant to others. Are there mechanisms whereby we can share that sort of learning? That does not happen consistently - even the mechanism of recording them, for example. The Royal College of General Practitioners has just launched a significant event audit tool kit which suggests a format for collecting information, for reporting on it and so on, and that is only recent, but that has been the problem. So the QOF merely asks you: "Do you do it?", yes or no, but really the question is: "How do you do it, what do we learn from it and how can we make sure it does not happen again?" Q586 Dr Taylor: Even though it has been going for some few years, you have only just got a tool kit of how to do it? Professor Esmail: Yes. No, a tool kit for standardising it. Q587 Dr Taylor: Which is what it has to be? Professor Esmail: What it has to be, yes. Actually significant event audit pre-dated QOF. GPs were doing it in some areas of the country ten years back, because they saw it as an important way of driving improvement. So when someone dies unexpectedly many good practices were reviewing that information and saying, "Why did they die unexpectedly? What was going on here?", and they look at the period of care. So that was very, very important. We do it with every cancer death, and we do it, not because of some terminal cancer stuff, but we actually look at the quality of care. Was there a good follow-up? Were people informed correctly what should happen when they died? All this information is very important. We do that routinely, for example, for every cancer death. We do a review of it. Q588 Dr Taylor: Does the tool kit standardise what is significant? Professor Esmail: Yes, it will have. The point about significant event, we tend to leave it to the practitioners and the reporters to determine it. You cannot say that is irrelevant, because from a patient's point of view it might be very important, so we tend to leave that open: either the patient raises it and we say, "Gosh, that should not have happened", or the practitioner raises it. You cannot predefine a significant event. I think it has to be determined a lot by the circumstances and the context it occurs in. Q589 Sandra Gidley: I must admit, I am somewhat horrified that the evidence is that GPs will not report the lower level stuff if they have to do it for more than three or four weeks, because one would have hoped that there would have been sufficient interest in improving things for patients that this would become endemic, embedded good practice. Professor Esmail: It is not that they will not. The National Learning and Reporting system, as you probably know, if you look at the reports from primary care it is point 5% per cent, and most of those from general practice, so it does not even include community pharmacy, it does not include district nursing and areas like that. Is it because they do not want to or is it because they have been asked the wrong question and asked to report the wrong thing? I think that if you look at a practice like ours, when probably about 500 or 600 patients are seen every day - we have 18,000 registered patients - the volume of work is immense. The reality is that you are so caught up in the day-to-day running of things that to have a system without doing a lot more work and without the culture changing, where every incident is reported---. We even have to ask ourselves, "If you report everything what is going to happen to it?", and we do not have the capacity to even analyse everything that comes in. Q590 Sandra Gidley: I am sure there was that attitude in hospitals once, but they seem to have managed it in hospitals. I do not buy into this, that primary care so is rushed that they cannot do things that are good practice elsewhere? Professor Esmail: All right. I understand what you are saying and I
realise that it comes across that we do not want to or we do not care. I am just saying that this is based on a
research project of ours, and that is what we found and we have had to react to
it. We found this was not just the case
in Q591 Sandra Gidley: That is fine, but the lower level events and the near-misses can often educate about a potential problem as much as a significant event? Professor Esmail: Yes, and that is why we have said if we can do it for a month at a time and vary that over a period of years, we will build up a very, very important profile, and we can sustain that and have good quality data and we can then work on that, and that is very important as well. I think that sort of model might work better in primary care than in hospital, where you have better structures and organisations, and so on, to do that. Q592 Sandra Gidley: I am not convinced, but I think we are going to go round and round in circles. Let us get to some specifics. Is there a problem with prescribing and medicines management in primary care? Professor Esmail: The research data shows that there is a lot of interaction. This has come about from all sorts of work where patients are admitted to hospital, for examples. Many admissions are due to drug interaction, so again we understand there is a problem there. I think at one level we have quite good safeguards in primary care. We have been computerised for a long, long time and our computer systems are constantly improving. For example, we get warned now if you prescribe something and there is interaction with another drug. That is quite sophisticated and has been around for a long, long time. We know that there are problems with the system still, but they are constantly being improved and I think people are aware of that, so at that level we are moving towards electronic prescribing. Virtually no-one writes handwritten prescriptions because there are transcription errors, for example. Q593 Sandra Gidley: They are not allowed to; that is why they do not. Professor Esmail: Yes, but the point is that that is an error that rarely exists now. Sometimes when you go on home visits you have to write handwritten prescriptions, so that still happens, but that has become minimal now, so those areas have gone. We, for example, recognise the problem and we employ a pharmacist. In fact the research shows that the solutions are not necessarily in the technology but in the people, and because so much prescribing goes on in general practice, it is so important, we have actually employed a pharmacist who works alongside the doctors and helps us towards identifying problems where things are not going right, develops systems so that things happen properly, and in our case I would say that has made the most impact. We have good computerised systems and I think that that has helped tremendously, and where the problems arise probably are when people go into hospital, because there is not good exchange of information that goes across that, and, secondly, when people are discharged from hospital. I think when general practice handles the prescribing, on the whole, it works pretty well and I think that pharmacists play an increasingly important role in helping us reduce error in that area. Q594 Sandra Gidley: Is there a problem with variable quality of diagnosis in primary care? Professor Esmail: We have always known about---. I would not say variable quality. The research was based really on our small studies which we did, where we got people to report things and find out what went wrong, but also by looking at the litigation databases, for example, and what had people complained about, and what was surprising, what stood out very clearly in primary care, was that 50% of the cases in the litigation databases we looked at were because of delayed diagnosis. What happens is that someone has a condition and it is picked up quite late. Let us take a simple example of a bowel cancer. The problem is, of course, that they present sometimes with very non-specific symptoms, it may take three or four months before the diagnosis becomes known and they get referred at that point. So we know that delayed diagnosis is a big problem, it stands out, it really hits you in the face, and of course the reason for this, when we do work around diagnosis in general practice, is that things that come to general practice in primary care are very undifferentiated; people do not come with a glaring symptom. If someone came to me saying, "I am bleeding rectally", that hits me in the face and says, "Yes, we need to examine and understand why that is happening", particularly if you are in a particular age group, but what happens is they come in and say, "I have not been feeling right for a while and I am not quite right here and I have got a bit of pain in my stomach." You investigate, you look at this, and it is a rolling process and when you have completed the process, you say, "Gosh, this is a cancer", and yet you can see they presented three or four months down the line, and from the patient's perspective they say, "I have had this for three or four months", but, of course, if I just referred everyone to hospital with those non-specific symptoms, we would bankrupt the system; it just could not sustain itself. So there is always that balance of trying to say when is it serious, when are the problems arising and how can we investigate as much in primary care before we refer people on? There are many examples like that: headaches which people talk about. We know that headaches are a sign of brain tumours, yet if we scanned everyone with a headache we just could not sustain that; our system cannot allow that. Q595 Sandra Gidley: Is there not some evidence that there is a huge difference in the way individual GPs would react to those sets of symptoms, which is why the referral centres were introduced? Professor Esmail: That is right, and they have made a huge difference, I think, in making early diagnosis available, but we have not actually done the research to see whether it has reduced that. Q596 Sandra Gidley: Some would say that it has gone the other way and when GPs have wanted to refer, if they are seen to be referring more than the people down the road, they are asked to look again. Who is to say who is right? Professor Esmail: We do not have the research evidence on that - that is what I am trying to say. We have put in these innovations. It is too early for us to even understand whether it has had an impact on things like delayed diagnosis, but what you say is absolutely right: we know there is huge variability. Of course the thing that struck me when I was looking at the research in this area is sometimes you have what I call 'barn door cases' and you just cannot understand why it is that people miss them. You look at the case and you read the medical legal summary and you think, as an outsider, that is an obvious case of a heart attack, and yet it was missed by the doctor, and then you ask yourself: "Is it because they did not know?", and you think that may be the case, but it is highly unlikely, it is something that you learn really early on, so what else was going on there? I think that when we begin to understand this we begin to realise the complexities around the situation. For example, the patient had had a long history of chest pain which has never amounted to much and has been diagnosed as having indigestion, but on this occasion it was because of myocardial infarction, for example, and it can be very difficult to distinguish. These sorts of things become much more complex. So we are beginning to realise that when we look at diagnosis it is as dependent on the patient as it is on the clinician as it is on the context of where you are and when you were, and so on, and it becomes very, very difficult. Q597 Sandra Gidley: You are describing something that is more of an art than a science by the sound of it. Is there a role for automated decision support systems that would mean you have better outcomes? Professor Esmail: I think they can help, definitely, in some areas. The problem is that because things are so dependent upon the context, we do not have good enough systems that can tell us about it. For example, if I get a prompt with someone who comes in with rectal bleeding and the prompt simply says, "Think about cancer", if it is a 20 year old, that is not helpful, but if it is a 50 year old, it is. Somehow you need to have a system which can not only look at it by age, for example, which is a simple example, but, more importantly, might able to look at it by things like ethnicity, might be able to look at it by other factors that they have, other co-morbid conditions, diseases and so on, and can give that information. That is the holy grail we all look for, and I think we are a long way away from that because it is actually very, very complicated. I think the NHS is littered with examples where someone has come along and said, "This will do it" and people have invested huge amounts of money into it and it has not delivered it. I think, yes, we should try and achieve that, but it is far more important probably to try and get doctors to work together, to understand these things, to feed back relevant information, for example, to look at cancer referrals, see what is happening about that. We can do a lot around training and improvement before trying to say: let us put all the money into trying to find a technological solution which I am not entirely certain will work. Q598 Dr Naysmith: Professor Esmail, I want to ask you a question in a minute or two about the role of commissioners and also about the role of registering of GPs and so on. First of all, I would like to ask you: why is it there is still such a large amount of over prescribing of antibiotics by GPs? Dr Holmes went on at some length about the importance of not allowing the emergence of resistant bacteria, but GPs still do it, and we know they still do it, so why? Professor Esmail: I would question whether---. I think, for example, it is very common now; it is part of the commissioning process. We get feedback on the antibiotics prescribed for conditions and we have targets, in effect, and we use those internally. If we see that we are over prescribing, for example, if we look at our diagnosis of upper respiratory infections and we say, "Why is the prescription writing very high?", we look at that and say "Gosh, what is going on?", and we even look at it by doctor then and, as part of our review, we take it up with each other and say, "What is happening here?" So I would question that. I think there are many improvements that have happened. It is always given as example that GPs over prescribe. Looking at it from my part, I get people home, discharged from hospital and I think, "Gosh, they have been given a whole paraphernalia of drugs which I do even go near." Dr Naysmith: No-one would dare over prescribe in Dr Holmes' hospital; they would not dream of doing it. Q599 Dr Stoate: It is our job to stop it all, is it not! Professor Esmail: That is right, yes Q600 Dr Naysmith: You do not think it is a problem. Professor Esmail: I think there is a problem, but I think that things that have happened change hugely. Take a simple example of urinary tract infection, I would imagine if you did an audit of urinary tract infection prescribing in general practice you will find that the vast majority are prescribed for three days, prescribed one antibiotic, trimetheprin, which is used in 90% of cases, and will then follow it up if it is not. If you had looked at that eight years ago you would have found a totally different pattern. I think if you looked at diagnosis of upper respiratory infections you would find that there is a lot less prescribing for sore throats, and so on. I do not have it at my fingertips, but I would like to see that data. Q601 Dr Naysmith: It still goes on, based on some of the conversations I have with GPs, some of whom I know quite well. Let us move on. Do you think that primary care trusts acting as commissioners play enough role in ensuring safe practice in primary care particularly? Professor Esmail: I think primary care trusts are only beginning to wake up to the idea of the importance of their role and what they can do as commissioners, especially in terms of improving patient safety in primary care, and I think they are actually scratching around to try and find out what that role entails because they have only come to it very recently. So I think there is going to be a lot of feeling to see what is going to be acceptable and what is not going to be acceptable. What will not work is if they say to doctors, "You must do X, Y and Z", because from my experience as a researcher am guilty of it, I think up simple solutions and say, "If only everyone did this we would solve the problem", and I know it does not work that way. I think that commissioners are going to have to be careful about what they target, in terms of the way they want to change things, and then work together with people to do that. Q602 Dr Naysmith: Can you include examples of commissioning changing practice? Professor Esmail: Not yet. This is a very new area and I am working
together with our local PCT, and I know there are examples in Q603 Dr Naysmith: It is work in progress? Professor Esmail: Very much so. Q604 Dr Naysmith: It is simply worth pursuing. Professor Esmail: Definitely, and I think they are all looking around, and I know this because I am getting more requests to speak on how to work with PCTs, so I think this is work in progress. I think they can flex their muscles and play a very important role, but they have got to built up those relationships in order to do that change. Q605 Dr Naysmith: Can I move on to question of revalidation and the need for GPs to register with the Care and Quality Commission. Do you think that will affect patient safety, do you think it will help, or do you think it will produce a burden on the system, an unnecessary burden, bringing in the practice of too much bureaucracy? Professor Esmail: I am sure the intention of the policy-makers is that it will help. I think the outcome will be that it will probably provide a burden and, again, we will have to work through what is going to be suggested and what it will involve. I think potentially revalidation, as an example, will become a very powerful instrument for monitoring individual care and, if it is applied effectively, I think it will be a huge tool for improvement across spectrum, so I have high hopes for revalidation, but I hope it does not become burdensome, that it becomes part of quality improvement rather than about regulation. I think will be a great problem if it does become that. Chairman: We are with you now, Professor Griffiths. We are running late but we have a number of questions for you. Q606 Dr Stoate: We have heard this morning that there clearly is a problem with prescribing and medicines management affecting patient safety, but do we have any idea of the scale of the problem? Professor Griffiths: Yes, there is some evidence out there. The NPSA did a report: Safety and Doses. It is a really, really good read and should have been a good read for all practitioners. Unfortunately, it has gone to clinical governance managers and senior managers and I do not think it has hit the practitioners that it should have, because there is a lot of evidence in there and a lot of incidents that are raised. In there is a study by Mohamed et al of about 19,000 patients which showed that about 6.5% of all hospital admissions were down to a direct result of medication incidents or harm, about 9% were preventable, and about 63% were probably preventable. That is a smallish study, 19,000 patients, but there are studies from the US that mirror this, and although it is a different health economy, there are transferable pieces of research that do come across that mirror that we are causing harm with medicines. Q607 Dr Stoate: Do you think there is enough evidence or do you think we need a lot more? Professor Griffiths: I think we probably need to go back and redo similar research, so that we can see, like for like, if we are getting any better. The NPSA report showed 60,000 medication incidents over an 18-month period through the NRLS and it basically cost the NHS around £750 million, let alone the suffering that it caused to patients. Q608 Dr Stoate: Clearly it is something we need to address. Just to pick up on something Professor Esmail has already said, what about doing more research in general practice? Is there a significant gap there? Professor Griffiths: In the report into NRLS, about 80% of the report came from secondary care, even though there are two million prescriptions per day in the NHS and the vast majority of transactions occur in primary care. Although the vast number is in primary care, therefore, there is still vast under-reporting. There are several reasons why there is under-reporting. To some degree, with the old paper reporting forms people felt disenfranchised with the system, that if they did something nothing was going to be done about it. I put in reports about assaults when I was in practice in casualty and nothing ever seemed to change. There is this disenfranchisement that practitioners have: If they are going to put in a report, what is going to happen? I think that the newer forms, the Datex, the computer reporting, although they can take a little while to work through you can copy certain managers in, so you can make sure that it gets to the people who hopefully will make the decisions to action the incidents. Q609 Dr Stoate: What do we do with the problems we do not know about? Okay, we can do significant events. I think most GPs are reporting significant events. It is easy to do so, and most practices now are having quarterly meetings on significant events, so it is a problem that is being dealt with. What about the problems that GPs are not aware of? For example, in many prescription areas or other areas they have no clue that they have made an error, so how do we get evidence on that? Professor Griffiths: Particularly in primary care, a prescription may go out and it may not even be picked up that there is an incident. In secondary care it tends to be a bit tighter, in terms of there are more links in the chain that you have to go through for the process of dispensing medicine. In primary care it can go straight from the doctor to their own dispensing pharmacy, which does not have a pharmacist but a dispensing technician, and then it goes out to the patient, so there are less links in that safety chain. Q610 Dr Stoate: If, for example, a GP has made a wrong diagnosis and given the wrong medicine, that does not necessarily do the patient any harm, so the patient does not come back and complain of side effects but nevertheless a mistake has been made. How do we even begin to address that? Professor Griffiths: There has been opening up of reporting through the NRLS, and through yellow card reporting - which is slightly different: it is about adverse drug reactions. Q611 Dr Stoate: That is only takes up adverse effects. I am talking about a patient who has simply been given the wrong medicine, nothing whatever to do with their diagnosis. The patient takes that medicine for two months, just as instructed, but it is completely the wrong medicine. If no harm happens to that patient, it is a fairly significant event but there is no way of knowing about it. Professor Griffiths: I understand what you are saying, but I was trying to say that the reporting system, through yellow card reporting and NRLS, is open to patients if they know about it. The problem ----- Q612 Dr Stoate: How would they know about it? Professor Griffiths: This is it. How would the doctor know about it? Q613 Dr Stoate: That is my question. Is there any way we could improve education and training to try to reduce this? Professor Griffiths: At the moment there is not a system in place that will necessarily pick up all of those incidents. There are specialist pharmacists that will look at prescribing patterns within PCTs. Like Professor Esmail said, there is PACT data, prescribing data, for practitioners which can be assessed and can be peer reviewed, and so you can see certain things there, but without looking at each individual case and reviewing each individual case it is very difficult to say that was inappropriate. There are two million prescriptions a day. Q614 Dr Stoate: Do you see a case for more automation and expert systems? Professor Griffiths: Yes. We have PACT data in primary care. Secondary care lacks prescribing data considerably. Everything goes on the medication administration review charts. They are paper based or cardboard drug charts, which, as soon as the patient is discharged, go into the medical notes and they get archived and library services take them off and put them away. The problem with that is that it is very hard to audit individual practitioners where you have a paper system, half of which is archived away. Electronic prescribing in secondary care will make a big difference in terms of audit and in terms of a review of prescribing patterns which is not there at the moment. Q615 Dr Stoate: I would like to see, and I do not know whether you agree with me, is effectively NICE guidelines and NICE data being built into a GP expert system. If you, for example, typed in a diagnosis of hypotension, up would come NICE guidelines which I believe would make it less easy to make a significant prescribing error. Do you think there is a place for that? Professor Griffiths: I think there is. I think there are very good systems out there at the moment. Clinical knowledge summaries does a lot of guiding practitioners. I also agree there has to be some flexibility in the system because of co-morbidities, age, different things, but there is a lot of decision support software out there. I have been looking at e-prescribing recently within the Trust I am working in, and the problem with some decision support software is that practitioners can get turned off by it. They do not want to see pop-ups all the time. If you get a pop-up repeatedly coming up for something that is very, very routine, then you can start to ignore those warning pop-ups. There is a potential that they can be overused, in which case you get a sort of burn out for the practitioner. Q616 Charlotte Atkins: Dr Howard Stoate raised issues around non reporting of incidents but is the National Reporting and Learning System Data being used to help in terms of management of safety? Professor Griffiths: Yes, to some degree. Things like this report came as a result of that. The National Patient Safety Agency again does use the reporting where it sees significant incidents in terms of putting out the rapid response reports which are really, really helpful. Although we get the information in, there are feedback reports, quarterly data summaries, organisation level patient safety reports and bulletins which not very many practitioners would probably access. I think patient safety is taken extremely seriously in the NHS, but because there are so many facets to it, practitioners sometimes get overkill in terms of how many emails they receive, how many memos they receive. Pressure care, skin care, child protection, vulnerable adult protection, fire, infection control, you name it, everyone is looking after their own particular area. I am just as guilty in that with anything to do with medicine safety within my trust it is a case of "he who shouts loudest". You try to get your messages out about your particular area and I think that is probably the case. Although the NRLS can get messages out, I think that sometimes practitioners can get swamped by the amount of messages coming to them from different directorates saying, "You must do this for child protection" or "You must do this for infection control" and from me saying, "You must do this from the medicines management point of view." Q617 Charlotte Atkins: Is the whole process of reporting this used as a learning experience, the fact that they have to report issues around safety? Obviously there is no point in just collecting the data if it is not used to improve the experience for the patient. Professor Griffiths: They are used. As I said, that is why it was a shame that
this did not go out as widely as I would have liked it to. I think it should be a "must read". There are lots of anecdotes in here. Okay, there is evidence as well, but some of the stories, being anecdotal, hit
home. Practitioners can think, "Oh,
there but for the grace of God go I."
There are ten-times dose incidents in here. They happen time and time again
internationally. There are cases of
medicines that are meant to be oral going down intravenous lines. We had the famous case of vincristine being
given intrathecally. It has happened
worldwide 20 or 30 times in the last ten years. It is still happening. Vincristine is being given intrathecally
around the world, even though we brought in measures in the Q618 Charlotte Atkins: Does it mean that those particular incidents are not repeated but other similar sorts of problems arise? Is there any real evidence that the reporting of these incidents is leading to an improvement in practice and in systems? Professor Griffiths: Yes, I genuinely believe that there is. There are issues in here about issues for medicines. We have just brought in a new policy into our trust where if Parkinson's disease patients or epileptic patients do not receive medicines, if they have their medicines omitted for one reason or another, because the drug is not in stock, for example, patients can come to harm. In the case of Parkinson's disease, for example, the average patient spends an extra five days in hospital because we do not get their medicines to them on time. Nurses generally are extremely strict on admission units and they will not give a medicine until it is prescribed. If someone has been delayed in the admission period, then they will not give a medicine because it has not been prescribed by the hospital doctor. We have brought in a policy, as a result of looking at medication omissions, to try to ensure that these patients do get their medicines in on time. If we stiffen a Parkinson's patient up by not giving them their medication on time, it can delay the whole hospital process and they suffer as a result. We are tackling things. There is allergy information in here - one of the other recommendations. We are making sure that we are trying to adhere to all the allergy advice, ensuring that we have other things in place. Another common issue is that sometimes patients have a penicillin allergy and it has been documented but they are prescribed a penicillin-type medication. Because it is branded and not down as a penicillin, they can then sometimes get administered that penicillin medication, so we are trying to tighten there so we have workshops around the hospital, seminars, as well as posters, warnings, stickers on boxes where they contain penicillin. We are actioning it and I do think it does make a difference. Charlotte Atkins: Thank you. Q619 Dr Naysmith: Professor Griffiths, if clinicians continue to practise unsafely in their use of medications, at what stage does that become an issue for managers and regulators? Professor Griffiths: Practitioners are working on safety. It is obviously a big concern. The Fitness to Practise Report of the Nursing & Midwifery Council last year showed 14,087 potential new cases. 9.87% were down to maladministration of drugs and 7.75% were down to unsafe practice. The NMC have very, very strict guidelines. Their primary purpose is to protect members of the public. We have very strict medicine standards. They were guidelines and they were made standards. We have strengthened language in there, so that and "should" has been replaced with a "must". We also have very good standards on prescribing. They are very comprehensive. Generally, if nurses are referred to the NMC they tend to be referred by colleagues. Again, we have quite an open process where nurses will refer other colleagues to the NMC. There is an article in yesterday's Nursing Standard which I wrote about medicine storage and security. It basically encourages people if they see poor practice to report to the Nursing & Midwifery Council. I do think it is something we do as a profession pretty well. There are about 30 people doing my role around the country, senior nurses in medicines, and we do a whole host of different things but one of the things is to audit, to look at competencies. We do calculations and assessments of skills around the administration of medicines. At the moment I have 4,500 nurses that have that every year, but we are also going on to e-learning and competencies for our prescribers as well. Q620 Dr Naysmith: In terms of reporting, there must be a balance. We were talking about a fair blame culture and the self-reporting of adverse incidents and so forth earlier with Professor Esmail. At what point does unsafe practice become a disciplinary matter? Colleagues reporting colleagues will eventually lead to a disciplinary matter. Professor Griffiths: I think there needs to be a balance and it tends to come down to the individual manager. Q621 Dr Naysmith: Should it depend on the individual manager or not? Professor Griffiths: I think it should do because there are sometimes extenuating circumstances. Fair blame should be just that: it should be fair. I do not think it should be a scapegoat system. If we go to a scapegoat system completely, I think you will see a huge drop off in the amount of reported incidents, and I think there is a fine balance to be had. In terms of the formalising of the process, at the moment Datex and other type of incident reporting does not require any names. Again they have tried to meet this balance. I am not sure if that is necessarily the right thing. If it is a fair blame, you can be open about it and put names in. I still think it needs to be documented just to see if there are patterns occurring if practitioners move from one place to another. There is a fine balance between where you would have anonymous reporting and where you have named reporting but I think that it has to be balance, as I have said, with the fact that people are not made scapegoats out of and punished unfairly. Chairman: We are nearly running as late as your train, Professor Griffiths, in this session. If any of you have observations coming out of this session or any further observations, we would be more than happy to take them by email or on paper or whatever. Thank you very much indeed for coming along and helping us with this inquiry. Witnesses: Dr Jo Bibby, Director of
Improvement Programmes, The Health Foundation, Dr Olga Kostopoulou, Medical
Decision Making Research Group, Q622 Chairman: Good morning. Welcome to our fifth session on our inquiry into patient safety. For the record, could you please introduce yourself and the current position you hold. Dr Bibby: I am Dr Jo Bibby. I am the Director of Improvement Programmes at The Health Foundation. Dr Kostopoulou: I am Dr Olga
Kostopoulou. I am a research fellow at
the Captain Hirst: I am Guy Hirst. I run a consultancy for research and training in medicine called Trainability. I was for 34 years an airline pilot or involved in training pilots, mainly technical training but also, for the last 15 years, human factors training. I was there from the transition, before we had human factors training until after. I retired two years ago. Q623 Chairman: I will ask a general question to all of you and then there will be specific questions from individual members of the Committee. Which three changes do you think would make the biggest difference in improving safety culture inside the National Health Service? Dr Bibby: The first of the three things we would advocate in The Health Foundation is that there needs to be a greater awareness around the avoidable harm that arises from routine clinical care. We also feel that there needs to be a building of the belief that this harm can be avoided if clinical teams have the right skills to address patient safety issues. We feel there needs to be a much greater culture of openness and learning by looking at the reliability of routine clinical care, so that clinical teams can engage in that and the defects that are arising. In the organisations we have worked with in our programme Safer Patients, we feel that all those three culture changes have played a part as a result of the programme. Dr Kostopoulou: Since most of the NHS consultations take place in primary care, I think that any improvement in safety in primary care is likely to have a large impact on patients. One thing we have been ignoring or under-researching is the importance of prompt and accurate diagnosis of serious conditions in primary care. GPs, as the first point of contact, are very well placed to catch these conditions early. Conditions like the cancers that we talked about earlier, rapidly evolving infections, ischemic heart disease can really benefit from early detection and treatment. It is a very difficult job and sometimes it is not done well. We know that it is not done well because patients complain. More than 60% of claims against GPs are about diagnostic errors. The way we can support a diagnosis in primary care is through medical education, through training of doctors and, also, through the improvement of the electronic health record to include things like diagnostic support or other types of support during the consultation. Captain Hirst: These are all small ideas,
things you could do on a day-to-day basis.
First, accept that error is normal.
It is ubiquitous. We all make errors. Good, successful team working can avoid, trap
and mitigate the consequences of those errors.
Second, a bit of discipline in procedure and practice - and most of my
work is being done in secondary care, in the hospitals - so that all the team
can take individual responsibility for safety.
That can be done quite easily by having a decent briefing before the day
starts and a debriefing afterwards to learn from it. Third, general human factors training and
coaching. A study in Chairman: Thank you. Q624 Dr Taylor: Dr Bibby, your foundation is running the Safer Patients Initiative and Safer Clinical Systems programme. Can you tell us a bit about these and what they have achieved? Dr Bibby: A little background on The
Health Foundation. We are an independent
charity. We have been working on patient
safety for the last five years and we have invested upwards of £10 million on
these programmes and other work.
Perhaps I could give you an overview of the Safer Patients Initiative,
which is our longest running programme and then move on to the Safer Clinical
Systems. Safer Patients started over
four years ago with four hospitals, working with the Institute for Healthcare
Improvement in Q625 Dr Taylor: I think you tell us that under Phase 1 there were impressive safety improvements at the four hospitals. After just two years they had on average halved their number of medical mistakes. That is really very impressive. Then you have added another 20. What are the initial results there? Dr Bibby: There were five work streams within the programmes, so I could give you some examples, a flavour, of some of the results that have been achieved there. One of the work streams was around safety on the general ward and we mentioned in our submission around the reduction in cardiac arrests at Luton and Dunstable Hospital that were achieved by a system of an approach that ensured that they were monitoring the condition of patients much more reliably, carrying out key clinical observations on a reliable basis, making sure they were detecting any deterioration and acting on that earlier, so that patients were not deteriorating to a point that they might ---- Q626 Dr Taylor: So you really did reduce crash calls by 30%? Dr Bibby: The reduction in crash calls
was around six fewer crash calls a month at Q627 Dr Taylor: We have a list of the targets you set and the target for crash calls was a 30% reduction. Did you achieve that? Dr Bibby: I would say that the targets
were not necessarily uniformly achieved but we would say that the purpose of
putting targets in to this programme was to set something to aspire to rather
than saying this is a success or fail.
We then looked at what was achieved in the individual organisation - so
we can say, yes, that there was a significant reduction, six fewer cardiac
arrests a month at Q628 Dr Taylor: That is pretty impressive. Did the Safer Patients Initiative go on to other safety issues like slips and patients falling out of bed and the feeding of vulnerable patients? Dr Bibby: In Safer Patients we were interested in looking at the clinical aspects of care rather than necessarily the physical environment of care - not that that is not important but that is just what we chose to focus on for the programme. Obviously with some of the work around medications we would expect to see impact on falls, because better medication, better prescribing leads to less confused patients and less risk of falls, but we were trying to approach it from a clinical perspective rather than, as I say, the environment of care. Q629 Dr Taylor: I think you said you were going to extend into mental health and community. What about into primary care? We have already heard that this is the great big gap. Dr Bibby: We would like to do that and we are having discussions with Professor Esmail and others around that. The reason we started with mental health and community is that it is easy to see the transferability of some of the approaches we have used in the acute sector into those sectors. Because of some of the discussions we have heard this morning, primary care is a different beast, in a sense, and we need different approaches, so we do not want to rush into trying to transfer something without properly thinking through what we are doing. Dr Taylor: Thank you. Q630 Charlotte Atkins: Dr Bibby, following on from the Safer Patients Initiative, was there measurable improvement in all the targeted areas that you selected? Or were there areas where there was not measurable improvement? Dr Bibby: One of the areas that was probably harder to track improvement was around surgical site infections. Some of the reason for that is not necessarily that there was not improvement, but it was harder to measure, because obviously we were having to look at infections post discharge and it is not necessarily easy for hospitals to track what happens to patients once they are discharged, particularly because there is much earlier discharge nowadays. That is an area where we perhaps have not been able to quantify the improvements as clearly as we would have liked, but that is not to say there have not been improvements. The approach that Safer Patients took was to say that there is evidence in the literature that if you implement, say around surgical site infections, a care bundle, so five key steps around management of a patient pre and post operatively, there is evidence that it will lead to a reduction in infection. We were able to say that, yes, theatres are now reliably implementing those components of the care bundle, but, as I say, it is sometimes harder to transfer that into outcomes. Q631 Charlotte Atkins: But you are happy that broadly you achieved measurable improvements right across the board. Dr Bibby: Yes. Q632 Charlotte Atkins: Did you encounter barriers of any sorts in the pilot sites? To introduce this new system you must have seen some barriers. Dr Bibby: There are probably three barriers I would identify. First, I think there was an issue around a recognition of avoidable harm Working in a clinical setting people often normalise harm and it becomes something that it is felt is unavoidable in the context of working with very ill people. First of all, there was something about raising the awareness that harm could be avoided. People having got that awareness, it is then: "What do we do about it?" and having the skills set to know how you can improve systems of care so that you can improve the safety and the outcomes. A lot of the programme support was around building those skills. Looking forward, we are hoping that we are able to use the hospitals we have worked with as mentor sites for the wider NHS. The third area is that, inevitably when you bring in something new to a clinical setting where clinicians have ways of working, there can be, appropriately, questioning and challenge to that. The approach we would take is that, rather than saying, "You are going to do this and you are going to do it across the board," we would start with an enthusiast, somebody who was keen to test and develop, and allow experimentation in the local theatre, in the ward or wherever it started, and prove that it worked there before we tried to spread it further within the hospital, and so it would build up ownership and belief that it was worth doing. Q633 Charlotte Atkins: I am sure there were many success stories but are there any in particular that you would like to share with us? Dr Bibby: I have talked about some of the improvements we have seen around crash calls, central* line infections, medication. The other thing is around the change in culture. One of the approaches that the hospitals that we worked with used was called Leadership WalkRounds. The idea of that would be that usually two members of the board would visit an area in the hospital on a weekly basis, different members of the board. These were not spot checks, so it was not about trying to find things that were wrong, it would be planned ahead, the team would know they were coming. The idea of that would be to start to have a conversation about issues around patient safety in this organisation, the directors might say, "What was the last safety issue that happened? Tell us about it so we can understand how we would prevent that again. What could be the risk that it could happen next?" When you go into the organisations where they have been doing this, you get a real sense of recognition that patient safety is something that the senior leadership are paying attention to and that they are willing to act on system practice to improve patient safety. Charlotte Atkins: Thank you. Q634 Dr Naysmith: Dr Bibby, you have just talked about good practice with boards and whether boards took it seriously. In general, do you think NHS boards prioritise safety now? Do they take it seriously? Dr Bibby: Obviously all NHS organisations are concerned with ensuring the safety of patients. I think we would accept that. In a sense, the question is really about where the focus is. Q635 Dr Naysmith: It is about prioritising safety, is it not? You have chief executives and boards and they have so many different responsibilities. We obviously think in this inquiry that they should place safety quite highly, but in your experience what do you think happens? Dr Bibby: We work with over 20 organisations. We have networks of other organisations we work with where we see safety being put, quite literally, at the top of the agenda. For instance, at Torbay Hospital, one of the hospitals we worked with, they will start every board meeting with an item on patient safety, so it is sending some very visible signals there that this is something that is a priority for the leadership of the organisation. There will be a whole group of organisations in the NHS that know safety is important but do not necessarily have the ideas, the approaches, to tackle that. Q636 Dr Naysmith: What can we do about boards like that? Dr Bibby: I think there needs to be more board development. There needs to be the sharing and development of the sorts of techniques we have used in safer patients to enable boards to engage in the safety agenda more effectively. Q637 Dr Naysmith: Does having a "no blame" or "fair" culture that we have talked a bit about this morning mean that boards and chief executives have an excuse, so they do not have to take safety seriously? Dr Bibby: No. We would not say that at all. We would say it is the board's responsibility to ensure that clinicians can practice in a safe environment. It is essential that boards are understanding the clinical business of their organisation and they are able to look at how they can ensure the right systems are in place to support safe care. Q638 Dr Naysmith: You say in your memorandum to us that ministers in top NHS management need to ensure "....a co‑ordinated use of managerial commissioning and regulatory levers" in order to make patient safety the top priority in the NHS. Why do think these levers are not being properly used now? Dr Bibby: I do not think we are saying they are not being properly used, but if you look at the patient safety agenda at the moment, quite rightly it is a complex agenda: there is a number of different levers being used, with different lines of responsibility to different agencies that have a role in patient safety. The responsibility for those different areas and those agencies is spread across the Department of Health, so what is important is that there is effective co‑ordination. We would want to see that that co‑ordination is taking place at the NHS management board, so that we ensure we are not getting duplication of effort, that we are not having conflicting messages going out to the NHS. The NHS finds it very difficult if it is getting different messages about how it should be addressing issues. Q639 Dr Naysmith: You have seen areas where the practice is good and the co-ordination does take place, it does happen. Have you seen examples of good practice? Dr Bibby: Of good co-ordination? Q640 Dr Naysmith: Yes. Dr Bibby: Clearly there has been a concerted effort across the infection agenda, but we would want to see that same concerted effort around some of the things you have been hearing this morning about medication errors, for instance, or errors in surgery and so on. When the Department has a priority and puts full weight behind it you can see it has an impact, but patient safety is much bigger than infection and we need to make sure there is the same co-ordinated effort across all the areas of patient safety. Q641 Stephen Hesford: In your memorandum there is a quote: "The failure of the National Patient Safety Forum to make significant progress in driving forward the patient safety agenda has been disappointing". Why do you say that? Dr Bibby: Hopefully it comes across that we are an organisation that is very passionate about patient safety and we were very pleased with the formation of the Forum because that clearly sends out a signal of the importance the Department attaches to that. At the time of writing our submission we felt that the Forum was being useful in bringing together some of the different interests around patient safety. In a sense, it is not a delivery mechanism and we need to make sure there are very clear delivery mechanisms around the patient safety agenda. Since submitting our evidence there has been a new Head of Patient Safety appointed at the Department of Health and that will certainly help with some of the co-ordination issues. There have also been some changes to the way in which the Forum is working which will make it more effective as an information sharing and shaping forum. As I say, there needs to be some very clear sense of what the delivery mechanism is around the patient safety agenda. Chairman: We are now moving on to look at diagnostic errors in primary care. Q642 Dr Stoate: Dr Kostopoulou, as the Committee well knows I am a GP who still does some general practice so I am well aware of the issues facing general practice, but I want to explore the patient safety culture within primary care and start with your memorandum which says that there is a problem with diagnostic error amongst GPs but they are often not aware of it. How would you define "diagnostic error" in primary care? Dr Kostopoulou: How would I define it? Q643 Dr Stoate: Yes. Dr Kostopoulou: It is difficult to define, which is why it has been so elusive and under-researched. We only get to find out about it when patients sue or when doctors become aware of a patient deteriorating or patients come back. This does not happen very often though because, as you are aware, some GPs work in large practices, patients may go to see different doctors or they may get lost in the secondary care system. Feedback is missing and the problem is that without feedback we do not learn. We cannot change the healthcare system in the way primary and secondary care are organised to give doctors more feedback, but we can construct more structured training environments where feedback is immediate and provided on a large number of cases if we want to improve learning, for example. Q644 Dr Stoate: For example, if you have got a delayed diagnosis, if somebody comes in with symptoms of an everyday nature, as Professor Esmail was saying earlier, undifferentiated, and it does take a while for the GP to have gone through the diagnostic sieve, to await new developments, to use time as a tool in diagnosis, is that a diagnostic error or is that simply the nature of general practice? Dr Kostopoulou: That is very true. Some things will not be diagnosable and we are not really talking about those things where no GP would really be able to diagnose that. We are talking about things that can be diagnosed and can be caught early and GPs may not consider something that is slightly less common but more serious, or they may miss some red flags if they are there. There are ways of getting them to become more aware of those situations, possibly through education and training, so we can "de-bias" the way people think. Because GPs serve a population with a lower rate of serious disease they tend to think it is the most common thing, and they are usually right, and once you consider that this is the diagnosis and it explains most of the symptoms you may just stop there and not explore other possibilities. Q645 Dr Stoate: Does that tell you anything about the culture of safety in general practice or does it just tell you a bit about how GPs are trained? Dr Kostopoulou: It is not necessarily the culture of safety. GPs have adapted to the population they serve and also to the healthcare system. Do not forget that we have got time limits on consultations. If you need to finish a consultation within ten minutes you are more likely to think of the most obvious or most common diagnosis, you have got less time to explore other possibilities. Also, the healthcare system puts pressure on GPs to reduce unnecessary investigations or unnecessary referrals. Even if a GP may consider there is something more serious, they may wait, they may want to be convinced and collect more evidence before they decide to refer. This is an interaction of the system where they work, the difficulty of the population they serve and the cases that they see. They do have a difficult job to do. Q646 Dr Taylor: Sure, but that does not tell us anything about the safety culture because that is what I am trying to get at. We all know the problems of diagnosis, and we will come on to training in a minute, but does that tell us anything about the culture in general practice? Do you think there is a real problem that GPs are not taking patient safety significantly seriously? Dr Kostopoulou: There may be. I cannot say that there is or there is not. Because they have to work under such difficult conditions it is possible they forget patient safety in some cases. We know that they do not report diagnostic errors, but I am not sure whether other kinds of doctors report their own diagnostic errors, so it might not be a GP problem. Q647 Dr Taylor: Do you see a solution to this? Dr Kostopoulou: Yes, and I have already mentioned a couple of things. I am a big believer in catching things early, so medical education and training. Also, supporting GPs while they work through better designed systems, electronic systems, the electronic record and decision support. These are long-term and we need to put a lot of effort into research on how to do these things properly. Q648 Dr Taylor: How would you change the education and training of GPs in particular to try and put this right? What changes would you make? Dr Kostopoulou: Simple things, like what I called "de-bias" earlier. Simple things like, "Why might my diagnosis be wrong? Are there any features here that I have not managed to explain or I have ignored?" These are little things that will open up our minds to other information that we may not be paying attention to. These are things that could be taught much earlier at medical school. I do not think students are taught at medical schools how to diagnose formally, how to form differential diagnoses, how to test diagnoses. They need to know about probability, for example, about the diagnostic value of information and also that diagnosis is a psychological process and what are the common pitfalls. Q649 Dr Stoate: Do you think that has changed over the years because I remember all that being taught when I was a medical student? Has that changed? Dr Kostopoulou: Students learn typical features of diseases, but as a doctor you probably know you do not often see patients presenting typically. As a doctor you need to differentiate competing diagnoses, so what you need to know is not the list of features of each diagnosis but what features help you differentiate between easily confusable diseases. Q650 Dr Stoate: You think that is not taught sufficiently well? Dr Kostopoulou: No, there is no formal teaching on diagnosis and clinical reasoning, nothing like this. Q651 Dr Stoate: That is obviously an issue which we need to look at. If I can just briefly pick up on your statement that you want to see more automation and more electronic support effectively. Do you see any drawbacks to that type of usage of expert systems? Dr Kostopoulou: The most obvious drawback is the expert system suggesting the wrong diagnosis. We need to make sure they are more reliable than their users. Also, they may increase referral rates or investigation rates, but I am not sure how bad that is. Can I just go back to the training. We have not explored at all training students or doctors with simulated patients, that is computerised scenarios that will give them immediate feedback, large numbers of them carefully structured. At the end of the day we train our pilots and we train our surgeons on simulations, so why can we not train our doctors to learn diagnosis on simulations. That is completely unexplored in medical education. Q652 Dr Stoate: That is also very interesting. If a GP is practising unsafely or making consistent errors, how much is that an issue for the GMC or other professional body to be responsible for? Dr Kostopoulou: There may be very bad GPs; I do not think there are very many. I am talking mostly about the average GP, how most GPs practise. If we want to improve safety we need to look at how most GPs practise. The GMC has a role in setting standards for medical education, for example. Q653 Dr Stoate: You would involve them much more in setting the curriculum and training? Dr Kostopoulou: I think so, yes. Q654 Dr Stoate: How does the "fair blame" culture apply to general practice? Dr Kostopoulou: It is not really something I am involved in, there are probably other people much more knowledgeable who can talk about that. I worry sometimes. We know that there is an increase in the rate of litigation against GPs so it might be that they are becoming more reluctant to discuss their errors. That might be a problem. In terms of a "fair blame" culture, I am not sure. Dr Stoate: Thank you very much. Dr Taylor: Very quickly on that. I am horrified when you say there is no teaching on diagnosis because, as Howard and I both remember, the diagnostic process was history, exam, differential diagnosis and investigation. Dr Stoate: Clinical Method. Dr Taylor: Clinical Method, surely that is still taught. Dr Stoate: We remember it cover-to-cover even after all this time, do we not? Dr Taylor: Inspection, palpation, percussion, auscultation. Chairman: We get these reminiscences regularly. Q655 Dr Taylor: Surely that is still taught? Dr Kostopoulou: The problem is that when students start practising this goes out of the window. Q656 Dr Stoate: I am shocked! Dr Kostopoulou: You are doctors, you know that you do not go over a list of things. You employ shortcuts, you do not go over a whole list and do these things systematically. That is how people become experienced and faster at doing these things. Q657 Dr Taylor: And they miss out some of the very important things. Dr Kostopoulou: Inevitably. Chairman: Can I thank the historical wing of the Health Select Committee for that intervention! Dr Stoate: It is called experience. Q658 Chairman: I am an ex-member of the General Medical Council as of last month and it is often said that people come out of training quite well and then go into work with an individual to get the experience that is vital for them and pick up the habits of the individual and have to drop off some of the things they have learned in school. Would you go along with that? Dr Kostopoulou: Yes, I do. That is why I think there needs to be continuous training as a type of professional development for practising doctors. Q659 Chairman: Do you see revalidation as a part of that doctor's journey? Dr Kostopoulou: Yes, why not. 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 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 by 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 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 people 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 dispute 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, and it then went on 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 copy 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 one of their people was saying 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 naïve, 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 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 you are dealing in 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 chap was not performing, but he had been a really good chap and had been a training pilot before, he came on a new aeroplane and did not quite progress as he should. People made excuses for him because they thought he was a good bloke, 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 anybody to understand about those 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, but not all by all of those. 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 part
of 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 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 go along and 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 their technical skills, it is their interaction with other people that causes them. 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, "Can you see him?" they asked another aeroplane, "Was it the chap on the ground" and the answer was "Yes". It is about how to communicate, asking the right questions. Q680 Chairman: You mentioned "it is in the book". Captain Hirst: It is in the book. Q681 Chairman: I am not sure if the NHS has a book. Captain Hirst: There is not a book, but maybe there should be. Q682 Chairman: There may be books or pamphlets or something. Is it possible to have a book? Captain Hirst: Yes, of course it is. I have talked with them at the cardiothoracic
unit at Q683 Chairman: Is there a gap there? Captain Hirst: I think there is, yes. Dr Taylor: I was going to ask you about bad apples but you have already answered that. Really, I would just like to make a comment. I have often been called a medical dinosaur and he is coming close to me! Dr Stoate: Humbug! Q684 Dr Taylor: Non-technical skills were not even thought of when I trained. Looking through the list now it is absolutely marvellous that they are now being actively trained. I hope people are being trained how to diagnose as well as being trained about the non-technical skills. My question has been answered. Captain Hirst: For instance, there is a lot of exposure at the moment about checklists, the MPSA in the World Health Organisation, and it is a wonderful idea. We have had checklists in aviation since 1930. Nobody knew about human factors training and understanding about communications until 20 years ago in aviation. It is no good saying "use a checklist", people have to understand it has to be sympathetically introduced with the right sort of training to know why you are using it, how you are using it. I do not think just saying, "Use that, everything will be okay", will work. I am concerned that in some hospitals we go to they are bringing in sensible programmes to introduce it and in others it is almost by email, "From next week you will use a checklist" and I do not think that will work. That is my concern, that a from on high downwards dictat is not the way to really get serious change. What you need to do is get people in the areas in the hospitals who adopt and really believe in these ideas and they will transfer them to their colleagues and the bad apples will be the only people who are not doing it the same way as everybody else and it will either bring them in line or --- Q685 Dr Taylor: Hopefully the bad apples are going to be exposed by their juniors. Captain Hirst: We do not want a snitch culture but as a patient, which I have been, I would hope if there was someone who was completely out of kilter there were people who would do something about it. Q686 Chairman: It is part of a doctor's professional code of conduct, if you like. The regulator would say they have a duty and a responsibility to report a fellow doctor under those circumstances. Could I just go back a little bit with you. You mentioned the issue of the threat of litigation that may be one of the things that is not altering the culture in medical care as it does in aviation. What about the other issue about the media? You have obviously spoken to a lot of people who do work in teams. Do they feel that the media is an individual threat or a threat to the institution or the wider team? What do you feel? Captain Hirst: I think people are always concerned about the media. Pilots are concerned about the media. Sometimes a story that everything has gone well is not good news, is it? I have a very close friend who is a news editor on one of the main stations and I keep saying this to him and he said, "Well, we can't tell them boring things like everything was successful in the hospital today". There is a perception that they are concerned about it. Whether that is a right perception I cannot really comment. All of these things are a concern, but the fear of it is probably worse than the actuality, if you know what I mean. We did some training recently at a hospital and this consultant surgeon said he had been most impressed by this idea of briefing and debriefing, and it seemed anathema to me when I walked into the operating theatre for the first time and nobody got the team round and said, "This is what is going to happen today. We can expect that and, by the way, that list has changed the order". It all happened by luck rather than judgment. He said he could not have understood the benefits of it without actually doing it. A lot of places we go to say, "We have got a really busy list today, we haven't got time for a briefing beforehand because we have got to get the list started". Our view from practice as well and research is that if at eight o'clock in the morning people have five minutes together, they know each other, they are not as in awe of the consultant perhaps and may feel happy to speak up if they have spotted a potential for error. It is all those things of, if you like, lowering the power gradients and such like that we feel is part of introducing a safety culture. They are only little things, we are not talking about a zillion pound robotic computer but almost not quite commonsense, the sorts of things we do in everyday life. Q687 Chairman: A football manager's culture. Captain Hirst: Yes. Q688 Dr Naysmith: Could I ask a question about air safety, it has nothing to do with the National Health Service. What did you think about the guy who came in and landed on the Hudson River? Captain Hirst: One of my jobs these days is I am ITN's sort of expert on aviation and they asked me live on the lunchtime news a couple of weeks ago and I said I thought he did a sensational job, however it was not only him, it was his colleague, the cabin crew and the air traffic controller, and benign conditions, there were no waves and no ferries in the way. A lot helped him, but I think it was stunning because it was the first time it ever happened that somebody landed on water. Q689 Dr Naysmith: What will they do about birds then? Captain Hirst: They do it at Heathrow. If you ever pass Heathrow on the Bath Road you will see the odd flash and it is not 5 November, they fire flares up to frighten them away, but that is as far as the technology has gone. Do not worry about it, it does not happen very often. Chairman: We have practically got the network back on time now. Could I thank the three of you for giving evidence at this second session. If you have anything to add in view of what you have heard here this morning, please feel free to get that to us. Thank you very much. |