14/9/01
Incorporates
responses from The Surgical Colleges and Specialist Associations so far
received and Council on 13.9.01
Prepared
by AOM
The report is constructed with great compassion towards the families who were involved in the events leading to the report and we share that concern.
The report demonstrates a deep understanding of the
dilemmas confronting the health care professional. It expresses an
understanding of the difficulties of providing an adequate service with
inadequate resources. As the report of the Bristol inquiry states “a tragedy
took place. But it was a tragedy born of high hopes and ambitions, and peopled
by dedicated, hard working people. The hopes were too high; the ambitions too
ambitious. Bristol simply overreached itself.”
It
is a fair report. It provides a framework for improvements in the delivery of
health care which we welcome.
We
wish to develop those improvements and to build on changes which have already
taken place since the events leading to the report.
The
report concentrates on;
·
Health care in
Bristol in the NHS
·
The care of Children
and their families
·
Paediatric cardiac
surgery
·
Audit
·
Standards
·
Regulation
Its
recommendations go beyond those areas and are likely to result in initiatives
unrelated to paediatric cardiac surgery.
For
this reason it seems to us to be important to record some of the areas not
touched upon in the report which are likely to impact on future developments.
For example most patients enter the hospital system through either A&E or via Out Patient clinics. This is less apparent in the newborn and infants in this inquiry but which would need to feature in taking the recommendations forward. Many of the tensions experienced by clinicians and by patients arise in these two areas.
There is scant mention of the involvement of clinicians in teaching at undergraduate or postgraduate level. There is virtually no mention of private practice and the colleges and specialist associations wish to see standards maintained across the delivery of healthcare.
We welcome a shift in emphasis from finance and volume to one of quality. The report recognises the need for finances to support quality and this is welcomed by all.
Meanwhile
there is no reduction, indeed a rise, in volume. The constant need to provide
high quality care to a growing number of patients, with increasingly complex
needs in an ageing population provokes anxiety. The daily requirement to find
beds and facilities is demoralising. Similarly there is a problem in finding
time to provide adequate communication and we recognise the urgent need for
this especially in the out patient setting.
Although on page 257 there is recognition of the dedication and commitment of NHS staff and on page 267 the culture of ‘doing the best’ for patients, the level of frustration is perhaps less well appreciated and may well be responsible for the perception [page 275] that loyalty to the NHS has diminished.
We
can see no evidence of a lessening of support amongst surgeons, rather a desire
to see the enterprise strengthened in many of the ways suggested in the
document.
Strengthening will promote a greater desire to enter the healthcare professions generally and a change to a ‘no blame’ ethos will improve morale.
The report proposes “excellent and reliable” audit and we would strongly endorse the need for the provision of the tools which are necessary for this. The audit tools used by the cardiac surgeons, the vascular surgeons and others were developed and financed by the surgeons and are extremely sophisticated as compared with the data available from PAS and HES. The cost of extending this to the whole profession must not be underestimated.
The difficulties of providing reliable comparative data
about long term outcomes in non surgical areas such as diabetes,
gastroenterology etc will be major. There is a serious deficiency in this area
and this will rapidly become more apparent when revalidation is up and running.
We would see this as a top priority. There is a real need for denominator data
which has hampered CEPOD and which can only be addressed by significant
investment in information technology.
The Royal College of Surgeons of England is criticised for failing to extrapolate from its inspection of junior hospital training posts to a concern for the welfare of patients.
ALL the surgical colleges and specialist associations have the
welfare of patients as their first concern. It is the sole reason for
inspecting training posts. The process sets out to ensure that the training is
capable of producing surgeons of a good standard. Unfortunately we have no
statuary powers to take any action beyond the training grades.
We
would welcome such a responsibility and have demonstrated our willingness to
take this additional role by carrying out a series of pilot peer review visits
looking at the activities of career grade surgeons. We have also carried out a
number of visits, the so called rapid response visits, when questions have been
raised about a surgeons practice.
In
England we have been in contact with Dr Alastair Scotland and the NCAA and we
are keen to work with them. We are supportive of the involvement of lay members
in these groups.
Our document Good Surgical Practice aims to provide standards of care for surgical practice in a manner similar to the GMC’s Good Medical Practice. We are in the midst of preparing the second edition of this booklet. The colleges and the specialist associations wish to progress the area of outcome measures and much work in this area is ongoing. Assistance in achieving this by means of the provision of robust audit and reliable I.T would be welcomed. Without accurate data this cannot be achieved.
It is our view that an independent authority on the standards of surgical practice should be provided by the surgical colleges and specialist associations.
There is a great need for consistency of approach and for the financial support as proposed. RCSE had to abandon the production of patient booklets because of escalating costs. Regular revision needs to be built in to any such exercise. The colleges and specialist associations would welcome the opportunity to be involved in the production of information for patients.
The proposed improvements will require a major investment of time. Consent often has to be obtained in the setting of the Out Patient Clinic where circumstances are not ideal at the present time. Tape recording could be done but the resources to do so and to file the product would be major. Records in general require investment and this should be the starting point. Adequate time in which to do this properly is the main requirement.
A
review of this would be greatly welcomed.
The
colleges and the specialty associations would be pleased to provide training
and education in the areas of interpersonal skills and communications.
When
a new procedure is to be introduced it is usually possible to devise an
appropriate training course and, when indicated, mentoring of surgeons
beginning to do the operation. We have the facilities and expertise to do this
and wish to do so. Further training when needed by, for example, the NCAA
requires a number of areas of concern to be discussed.
The
common first year of education for health care professionals was generally felt
to be inappropriate although some common learning can be developed.
There was general uncertainty
about the need for a special qualification for those doctors who care for
children. The required training is already part of the curriculum for those who
go on to provide a service. These areas can be reviewed and if necessary
revised and strengthened.
The surgical colleges and specialist associations welcome this report. We have expertise in and the facilities for assessing surgical skills and communications and are keen to develop these further. We would welcome the opportunity to oversee in some way the practice of career grade surgeons. We are keen to continue with the work on outcome measures.
Robust, regular and reliable audit is the cornerstone of appraisal and revalidation.
We
need the provision of the tools to do this and the proposed investment in IT
and in the NHS in general is warmly welcomed.