RESPONSE TO THE KENNEDY REPORT
The BAPS welcomes this report, which is fair, balanced, and fulfils the terms of reference of the inquiry. The recommendations are sensible and lay out a timely blueprint for the future of the NHS. It is likely that the profession will cooperate fully with the introduction of these recommendations because there are clear direct benefits both to themselves and to their patients.
We welcome the emphasis given to Child Healthcare in the NHS. The events in Bristol have shown very clearly that needs of children must be given a high national priority; the death of as child can no longer be considered a cheap option. Further, the report has highlighted that standards of care in the smaller sub-specialities, such as paediatric cardiac surgery are as critically important as in the case of high volume services, for example hip replacement.
The Report covers events in the late 1980s and early 1990s and many of the recommendations have been identified already as part of current good practice. Others, which have no significant revenue consequences can be implemented without delay. Several recommendations require significant additional funding, for example, for audit and revalidation, and it is likely that these will be implemented in stages. They will remain ineffective unless the Government makes the necessary commitment. If funding is not forthcoming, one of the Reports main objectives, namely to facilitate the identification and re-education of clinicians and units performing below standard, will fail because the process can not be undertaken appropriately.
As things stand in the NHS, the events leading to this Report could happen again, and indeed may already be taking place. Implementation of these recommendations therefore is urgent.
Relationship with patients:
We welcome the patient-centred approach and the concept of
working in partnership with patients.
Providing reliable and comprehensible information is fundamental to this
relationship.
A kite marking system (recommendation 9) is commendable but
there is no indication of how this should be achieved, and by whom. It is not
realistic to expect that the Internet can be monitored.
A tape recording (10) may be a good idea in selected
instances, but has significant implications in terms of time and resources, and
there are legal implications relating to ownership and the need to retain
copies.
Copying doctor’s letters to patients (17) is already done by
some doctors when this is thought to be helpful to the patient. Although most letters are factual, because
of their professional nature there is a risk of their being misunderstood. Further, the need for flexibility must be
recognised because inevitably some letters will contain comments which are of
clinical relevance but which are sensitive and could cause distress to
patients. In the absence of
professional confidentiality, such comments may no longer be included in correspondence.
Consent (24) -The concept that consent is a process,
supported by appropriate visual and audit information, is sensible. Consent should be obtained by each specialty
team providing a service, be it surgical, anaesthetic, radiological etc.
Performance information (27) – in most specialties, outcome
measures and standards are still lacking. This is in part due to failure to
identify responsibility for co-ordinating the development of outcome measures,
and failure to provide the necessary resources for this.
When things go wrong (33) – ideally, a candid relationship
between clinician and patient should be taken for granted, but in some
circumstances this may be threatened by fears of retribution. A ‘no blame’ culture is fundamental to an honest
relationship, and the proposal (37) for a review of the clinical negligence
system is strongly supported.
Leadership in the NHS:
The concept of two over-arching organisations, the Council
for Equality of Healthcare and the Council for Regulation of Health
Professionals (39), both of which would be independent of Government, is a
pragmatic move to coordinate the activities of a number of relevant
organisations without government interference.
There is a concern that this new structure may increase the levels of
bureaucratic control in the NHS, and may not necessarily sharpen performance.
The new NHS Leadership Centre would identify and train those
with leadership potential (65). An effect of this may be to move from the
current relatively egalitarian order amongst Consultants to a hierarchy within
the Consultant body.
The recognition that clinicians filling managerial roles
must be appropriately trained is long overdue (93).
Where there is a conflict of interest, for example where the
performance of a Medical Director is in question, he/she must relinquish that
post.
Competence
Development of new clinical skills (100) – the principal
that a local research ethics committee should approve new invasive clinical
procedures is sound, but the definition of “new and untried” could pose
difficulties. When does a modification
of a surgical procedure become “new”?
We welcome recognition that the Royal College of Surgeons of
England should take a lead role in the training of Surgeons (103). However, the other Royal Colleges have a
role in this, as do the SACs, JCHST, and the Intercollegiate Boards.
Provision must be made for developing and supporting
re-training programmes for surgeons whose skills are found wanting.
Is there evidence to support curtailing surgical practice
based on age (103)?
At undergraduate level, we are not clear about the perceived
benefits of a common first year for all healthcare professions (75).
Discipline (104) – the recommendation that a more flexible
approach be adopted towards the definition of misconduct, and the desirability
of dealing with cases at local level, are welcome. Methods of dealing with suspected misconduct must be reviewed, in
particular the potentially devastating practice of suspension from duty while
allegations are investigated. The assumption of ‘guilty until proved innocent’
which underpins the GMC’s approach to alleged misconduct is distressing for the
innocent, who are permanently stigmatised, as the doctors at Alder Hey who were
referred to the GMC in the aftermath of the Redfern Report have discovered.
Safety of care (106 -112) – We support the recommendations
for identifying, reporting and managing sentinel events. In particular we welcome the recognition
that sentinel. events must be assessed in the context of the whole system and
not focus on individuals. Revision of the current clinical negligence system
(119) is fundamental to the success of the proposed reporting system and we
agree that an alternative system for compensation should be sought and
implemented. This would require a massive
change in attitude amongst both the medical profession and the legal
profession. The emotive and negative media responses to adverse events in the
NHS have a destructive effect on the Service as a whole, and recommendations
for curbing this would be welcomed.
Standards of Care:
We support recognition of NICE as an independent
coordinating body (123) and again welcome recognition of the roles of the Royal
Colleges and specialist associations in developing standards of care
(124). Most, if not all of the
specialist associations have published standards of care relevant to their
speciality; these should be submitted to NICE for approval. Continuing
involvement of the medical profession in setting standards is essential, to
ensure that the many influencing factors, which may vary across the country,
are taken into account.
We support the concept of inspecting and validating Trusts
(131) but this will have major resource and manpower implications, which have
not been addressed.
We strongly agree that where only a small number of centres
offer a specialist service, the requirements of quality and safety should
prevail over ease of access (142). The
designation of so-called Supra-Regional Units must be based on performance and
outcome measures and not their geographical situation. Centres must be constantly monitored by the
designating authority to ensure that their continuing status as a
Supra-Regional Unit is justified.
Monitoring standards depends on robust clinical audit, which
can only be carried out with appropriate support. This requires resources that currently are not available and we
welcome the recommendation that the necessary support for the audit process
must be forthcoming (144).
At national level
CHI must ensure that resources are adequate and appropriately and effectively
used. A system of incentives and penalties (152) may be required not only for
Trusts but for clinical departments and individual health care professionals.
The inadequacies of the IT systems currently available in the
NHS have long been a source of frustration, and the recommendation for
investment in a world-class system is to be applauded (154). However, it goes without saying that this
will require a very significant investment on the part of the Government.
Children’s Services
We support the recommendations proposed for children’s services, in particular the National Service Framework for child healthcare (172). The appointment of National Director for Children’s Healthcare Services (167) is a welcome development and the choice of the first Director has our support.
We strongly support
the recommendation that children’s acute hospital services ideally should be
located in a children’s hospital close to an acute general hospital (178). The
Report does not distinguish between specialist paediatric surgery, which
is provided in specialist centres, and general paediatric surgery
provided by appropriately trained general surgeons at DGHs. We presume that the model proposed above
applies to specialist services for children. District General Hospitals also
provide acute care for children. Whilst
a separate children’s hospital may not be appropriate at District level,
nonetheless the facilities for children, notably the wards and day care unit,
should be separate from those for adults, and staffed by qualified children’s
nurses.
The delivery of healthcare for children on split-sites,
rightly recognised in the Report as a cause of poor performance, is all too
frequent and occurs in different forms. A range of specialist paediatric
surgical services may be provided by the same staff at more than one site in
the same geographical area, or a single specialty hospital may provide a
service for adults and children. Neither of these is acceptable. In addition, a
split-site service frequently is found where the main neonatal unit is based in
a maternity hospital some distance from the specialist children’s
hospital. In these circumstances,
continuity of care of surgical neonates in the neonatal unit may be
compromised. Wherever possible, neonatal and maternity services should be
located as near as possible to a children’s hospital.
The amalgamation of children’s acute and community services
in a geographical area is a positive way forward (180). An example of this in the United Kingdom is
the Royal Liverpool Children’s NHS Trust, which combines the Alder Hey Hospital
and Children’s Community Services.
The recommendation (186) that all surgeons who operate on
children must obtain a recognised professional qualification in the care of
children requires clarification. For specialist
paediatric surgery the pathway is clear, with the Intercollegiate Specialty
Examination the relevant professional qualification. For general paediatric surgery no specific qualification
in paediatric surgery currently exists. This has been recognised by the SAC for
General Surgery. The recently revised curriculum for general surgery
incorporates general paediatric surgery, but there are still hurdles to
overcome in ensuring that the assessment process within general surgery
embraces this component of the curriculum.
This is a matter for all the Royal Surgical Colleges. The provision of
general paediatric surgery by appropriately trained general surgeons in DGHs is
an important component of the surgical care of children and must be encouraged
and preserved. The Senate of Surgery
and the Royal College of Surgeons of England have published clear criteria for
this. The same issues apply to surgeons in all specialties where adult surgeons
also treat children.
On the issue of validation and revalidation (186), whilst it
is appropriate to consider the range of procedures that surgeons may undertake,
we recommend that clinical outcomes should take priority over a mandatory
minimum number of procedures.
Emphasis of the importance of training health professionals
in skills for communicating with parents and with children is welcomed (190).
This has been recognised already by the inclusion of communication skills in
some training curricula.
Footnotes:
1. The Report does not comment on the expectations of the
NHS, and what happens when clinicians give their best, and that best is judged
by some at a future point in time to be not good enough.
2. Although not within the remit of this Report, it is to be
hoped that these proposals can also be applied to the provision of healthcare
for children treated in the private sector (non NHS patients).
Professor David Lloyd
President
The British Association of Paediatric Surgeons. 24 September 2001