Final Report > Chapter 26: The Safety of Care > The components of safe care > Pressure for change

Pressure for change

6 Thankfully, a number of factors are forcing change. Knowledge and understanding of how multiple causes contribute to things going wrong is increasing all the time. Major inquiries in other areas of public life have played an important part (notably the inquiries into the sinking of the Herald of Free Enterprise [8] and the fire on the Piper Alfa platform). [9] The work of academics has been influential, [10] as have the major studies already referred to on the incidence of error in the USA and Australia. All of these have begun to influence thinking about safety, and about the possible extent and causes of avoidable error, in the complex system of the NHS.

7 Within the NHS itself, a major pressure for change is the duty of care recently imposed by law on trusts to ensure that the quality of care delivered to patients is of a proper standard. This is helping to focus attention on the risks to which patients are exposed and on risk management. Another pressure is the rapidly growing awareness of the cost of adverse events, in both human and financial terms. Professor Vincent's study suggests that the cost may be as high as £1 billion a year. The mounting bill for clinical negligence arising from claims against the NHS is part of that cost. The National Audit Office reported recently that the liability in March 2001 for clinical negligence settlements could be as high as £3.9 billion. [11] The report also stated that the total annual charge to NHS income and expenditure accounts for provisions for settling claims has risen sevenfold since 1995/96. Of course, it must always be remembered that the cost of error has a direct effect on the resources available for the care of patients. The funds to meet claims for clinical negligence in hospital (which includes the cost of dealing with claims that are ultimately abandoned), are drawn from taxpayers' money. This money could otherwise be available for healthcare services. Moreover, to the extent that adverse events cause moderate or permanent impairment to the health of those affected, such events have a further direct impact on health services. The NHS and the social services have to bear an extra burden of care of the NHS's own making. All this is quite aside from the human toll exacted by unsafe and careless systems and practices, in terms of the impact on the individuals themselves, their families and their livelihoods.

8 Pressure for change is also growing out of a greater understanding of the nature of adverse events: that many are avoidable and rooted in the systems of care. Patients and healthcare professionals see that it is possible to do something about them. The starting point must the realisation that such is the potential for the occurrence of adverse events in these times of ever more complex care, that a concern for the safety of patients must be both constant and active rather than sporadic and reactive. The implications of the words of Sir Cyril Chantler, former Dean, Guy's, King's and St Thomas's Medical and Dental School, must be grasped. He wrote: `Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.' [12] Of course, with very rare, notorious exceptions, healthcare professionals and healthcare organisations seek to help patients. They do not intend to harm them. But, we now know that safety is not just a matter of what an individual `at the sharp end' of care and treatment may do. Indeed, a professional can be as competent as possible, and yet a patient's safety may still be at risk. What the NHS corporately, and each individual trust, must do is engender a culture of safety, by putting in place systems which maximise safety. Equally, healthcare professionals must ensure that, in caring for patients, the safety of the patient is their paramount consideration. Care will only be safe when a concern for safety is recognised and embraced by the individual and the organisation.

Footnotes

[8] Mr Justice Sheen, `1987 mv Herald of Free Enterprise' (formal investigation). London: HMSO, Report of Court No 8074

[9] The Hon Lord Cullen. `The Public Inquiry into the Piper Alfa Disaster' London: HMSO, 1990

[10] See particularly the work of Professor James Reason, University of Manchester, and, in relation to healthcare, that of Dr Charles Vincent, University of London; Professor Donald Berwick, President, Institute for Healthcare Improvement, Boston MA, USA and Professor Lucian Leape, Adjunct Professor, Harvard School of Public Health, Cambridge MA, USA. See also the seminal work of the US Institute of Medicine, particularly `To err is human'. Washington, DC: National Academy Press, 1999. www.nap.edu/readingroom

[11] The figure of £3.9 billion comprises `provisions to meet likely settlements for up to 23,000 outstanding claims ... £2.6bn' and `a further £1.3bn to meet likely settlements for claims expected to arise from incidents that have occurred but have not been reported.' `Handling clinical negligence claims in England'. Report by the Comptroller and Auditor General. HC 403 Session 2000-01, 3 May 2001. www.nao.gov.uk

[12] Chantler C. `The Role and Education of Doctors in the delivery of Healthcare'. `Lancet', 3 April 1999; 353 (9159): 1178-81