One Bristol, but there could have been many
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7306.179 (Published 28 July 2001) Cite this as: BMJ 2001;323:179All rapid responses
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3rd August 2001
Editor- The widow of a man who died in a private hospital after a
minor operation recently received an award of over £500,000 for her self
and two young children after a prolonged medico-legal action. In a letter
of thanks for my contribution to the case such as it was, she writes
"...despite all we have proved regarding the mistakes and inadequacies of
his care there has been no admission of liability. More worrying is the
fact that the case is at an end but nothing has changed as a result. The
whole system will carry on as before so I know more people’s lives will be
shattered unnecessarily".
It is remarkable that whilst paying enormous sums, doctors and their legal
advisers cannot admit the liability they patently recognise amongst
themselves. Any system of abolishing clinical negligence litigation with
an administrative scheme for awarding compensation1 must meet the need for
accountability that litigants have been demanding but not getting for far
too long.
Achieving accountability is a major recommendation of the Bristol inquiry
and one I would suggest the medical profession should put high upon the
ranked list of priorities your editorial finds wanting in the Kennedy
report2. In terms of resources little more is needed than a determination
to be able to admit our errors. Our patients and their relatives deserve
to know that lessons have been learned and will be put to good use.
Barry Hoffbrand
consultant physician
Dyer C. Bristol inquiry condemns hospital’s "club culture." BMJ
2001;323:181.
2 Smith R One Bristol, but there could have been many. BMJ 2001; 323:179-
180.
Competing interests: No competing interests
While sympathetic to much of the argument in Richard Smith's
editorial, I must challenge the use of the word "Scapegoats". The key
individuals in Bristol declined to face up to growing evidence and growing
anxiety among their colleagues about their own standards of work. There
are other examples, in pathology to name one, where subsequent review of
failures in standards and governance could be attributed in part or in
full to the unwillingness of senior doctors to consider that they might in
some way be wrong. This in turn is linked to training and management of
doctors, which continues to encourage a strong degree of individual rather
than team working. I have personally visited regional specialist units
where senior clinicians have not spoken or met with each other for ten
years. They seemed proud of it, management felt powerless and so a
situation that was inevitably damaging to the services given to patients
was allowed to continue. It is taking the point about wider difficulties
in the health service too far to say those involved in Bristol were
scapegoats. Nor is it fair on the many in the NHS who have not allowed
similar lapses in standards to occur. Those at the centre of the problems
in Bristol were indeed to blame even if they were not wholly to blame.
Competing interests: No competing interests
Sir
The Bristol Report recommendations may be many, but they are
essential. We need to turn the NHS on its head, to give doctors and
patients a fresh start. A blamefree culture would not only reduce
accidents, but allow doctors to acknowledge, without blame, that
treatments can cause harm. A survey recently undertaken for CancerBacup
showed that much cancer pain and treatment-related pain is not adequately
addressed, if at all. Isn't it shameful that there is even a need for
CancerBacup's 'Freedom From Pain' Charter?
The recommendations in the Bristol Report must be implemented if we
are to have a safer NHS which values both staff and patients, where each
respects the other and job satisfaction comes from knowing there was
optimum care as well as treatment. It is surely up to all of us, health
professionals and involved 'users', to make sure these recommendations are
not filed and forgotten in the usual way. Perhaps we, too, need an 'over-
arching body', a meaningful, proactive partnership, with a brief to do
precisely that. It's a unique opportunity for change. We owe it to each
other. Let's do it - mail me!
Competing interests: No competing interests
Sir
"Bristol" has added more support to the system of Clinical Governance
that drives our new culture of only delivering excellence. Laudable; but
what if this excellence is not immediately achievable?
There is a national crisis in the care of severely burn injured
children. The historic mismatch of location of burn units and paediatric
centres has left us with a tiny number of facilities where a child can
receive both expert burn and intensive care. These few alone do not
currently have the infrastructure to cope with the national workload.
The Paediatric Intensive Care Society has set a standard that burn
injured children are better cared for in a PICU with no burns expertise
rather that in a Burn Centre without a lead PICU. The National Burn Care
Review has set a standard that is the complete antithesis of this.
Several units, using the issue of Clinical Governance, have addressed
this quandary by ceasing to provide a service for severely injured
children. Most have done so without making alternative arrangements for
their likely patients. Bristol continues to provide a service and now has
to take additional cases from other regions. We do not meet all of the
standards. Our results, however, are as good as any other unit in the UK.
We have a long term strategy that will meet the standards but will take
severeal years to implement.
Our service is now critisised locally for continuing to accept the
more complex cases. The critics are clear that to provide no service is
better than one which is flawed. If, however, there is no where that
provides a better service, where do I send the cases? Unfortunately the
response to this question is often, "we don't care".
My fear is that this will become a more favoured option. Why take a
risk afterall? If we have to provide only excellence then should we be
denying children of a good service until we get there and how do we get to
excellence if we are not actually doing the work?
Yours faithfully
Alan Kay
Competing interests: No competing interests
It is our “three monkey” culture which led to Bristol so it is our
culture which should be examined – we have all been brought up to hear no
evil, see no evil and speak no evil of professional colleagues. While that
may be helpful in public, we have no private forum for juniors (colleagues
who form opinions about their seniors) to give early warning of problems
with their seniors. This is exacerbated by the need for juniors to comply
with seniors in order to progress their careers.
The Royal Colleges are set up by with and for those of us who have
established ourselves in practice, initiation requires compliance and
acceptance of our view of the world. If our view of the world is wrong, we
are protected by the letters after our names which were probably awarded a
generation or so earlier. If we are to be brutally honest, we probably
enjoy the protection of our restrictive practice and are content to see a
few scapegoats thrown to the lions in public.
Juniors see our practice and could easily be tapped as a resolve to
report on it. We could set up our colleges to require trainees to make
regular, reasoned reviews of the departments in which they are working.
Such reviews could be confidential and develop audit skills in the
trainees while flagging up problems to the Colleges who could (if they
cared) develop quality control mechanisms. Of course we could always wait
for the Government to set up a PFI College of Juniors to do the same job!
As we whine about ourselves we might reflect that whistleblowing in
the medical profession is the only crime still punishable by
transportation. Isn’t it about time we stopped the monkey business and
started actively listening to our juniors to ensure that the profession
will have peace in their time?
Competing interests: No competing interests
A thought provoking piece but how is quality going to be
defined?
I have yet to see a satisfactory definition of quality in the
dellivery of medical care.
They all come close but surely no closer than the
hacknied response of the patient asked to define this
vexing question.
He replies : "Quality, I can't define it but I knows it when I
experiences it!"
Competing interests: No competing interests
Re: Definition of Quality
Nothing has baffled me more than the inability of health care
providers to see clearly their purpose.
Quality, while a characteristic or trait of something, can best be
defined in terms of outcomes for health care. What is meaningful is the 1)
individual health outcomes, and 2) population health outcomes. Quality may
be defined in the context of these two areas. The 'asking' patient to
define quality is a production/industrial method of defining quality in
terms of customer perferences. This is predicated upon the belief that if
you build what the consumer wants, they'll buy it and you'll make a
profit. Not valid logic for not-for-profit health care. Unfortunately,
many graduate health care administration programs use juxtaposed business
models that actually undermine health care. (pet peeve of mine).
Anyway, I suggest defining quality in terms of what is meaningful to
different patient segments. For business folks, this is market segmenting.
This is a gross approach that results in programs and intiatives intended
to deliver net positive outcomes for targeted patient population segments.
Leave the individual health quality definitions up to physicians and
individual patients in a well-structured relationship.
Competing interests: No competing interests