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In 2013, the stream of recommendations, regulations and quality measures that emerged appeared unstoppable – increased rigour in health and social care inspection, an extended list of 'never events', a duty of candour on organisations, and far more. The year closed with news of proposals to introduce a criminal sanction when an individual or organisation is found to be 'unequivocally guilty of wilful or reckless neglect or mistreatment of patients'.
The Berwick Report, alongside recommending criminal culpability for wilful neglect, called for a low-blame culture. The government has responded by saying that it wants to foster a learning culture where mistakes are analysed and put right. Jeremy Hunt is looking towards a future 'which learns the lessons of Mid Staffordshire so that NHS patients can confidently expect all the care they receive to be safe, effective and compassionate.' No doctor would argue against that, but is the excessive regulation that now overwhelms the medical profession the best way to achieve those aims?
Why would yet more regulation and creation of new sanctions facilitate a culture of greater protection for patients?
The inference is that these measures are necessary because many doctors are incompetent, or worse. Take for example, the suggestion that doctors seek to cover up errors. There is no evidence to support the notion of a lack of candour on the part of doctors when things go wrong. Yet there is now a contractual, and will soon be a statutory, duty of candour. Why are they necessary? It is envisaged the doctor will usually be the first to talk to the patient: but doctors already have such a duty. The MDU is very often the first port of call when something goes wrong. Doctors contacting us know they need to talk to patients and provide a clear explanation and apology, and that is what they do.
It is time to stop and question just how useful regulation upon regulation actually is to patient safety. If something goes wrong, a doctor may spend time trying to work out if the incident is serious enough to qualify for reporting under the contractual and statutory duty. Better surely, no matter how serious the incident, to tell the patient as soon as possible, to explain and to apologise. Whatever the incident, it will matter to the patient and doctor, and that is the crux of it.
The same applies to 'never events'. Anything that goes wrong will be serious to the patient. Isn't time better spent learning from all adverse incidents than concentrating on those that are categorised as never events?
At the heart of this lie the basic ethics of patient care. Every doctor is in practice to protect patients. That is, acting in the patient's best interests at all times, providing excellent clinical care within the limits of your ability, and communicating appropriately and well.
It is also about professional and personal accountability. If an error is your responsibility, then you will rightly be held accountable. Multiple channels exist to ensure accountability and any doctor who has experienced a claim for clinical negligence or a complaint to the GMC, for example, will attest to just how painful that is.
Between the operational complexities of the NHS, the tendency to try and legislate for every perceived gap in care, the encouragement of complaints or claims if something goes wrong, not to mention the power of the press to ignite the public's antipathy towards doctors, something has been overshadowed. That medicine is about treating patients and ensuring their best interests are protected.
Regulations and recommendations seem designed to exacerbate the detrimental culture of fear and blame. It would be better to focus on doctors' vocational imperatives. To protect patients we would be better to let professionals do what they have been trained to do, and give them the right resources to do it.
Dr Christine Tomkins
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