Saturday, 18 October 2014

Patient Centredness, Ethics and Why You can' have them.

Two articles in a recent issue of the British Medical Journal illustrate different ways hospitals and healthcare institutions can introduce interventions to improve patient outcomes. The need for a response to poor cardiac surgery outcomes in one hospital in the Netherlands proved to be the impetus to radically change the way the institute and its employees deals with patients is described in the first.

In the second, Daniel Sokol, a lawyer and medical ethicist makes a very strong case for all hospitals or healthcare institutions that treat patients to have a clinical ethics board. Both accounts strike a chord with me.
As a cardiac surgeon who was appointed at around the time the Bristol Heart Surgery farrago blew up, the response of this one institution in the Netherlands, contrasts very sharply with the local and national response in the UK. The proposed national reconfiguration of paediatric heart surgery units in England has, after more than 10 years, become mired in a legal cul de sac because many of the units that were told to stop operating on children rightly pointed out that this radical top down response lacked evidence.
The other effect of the Bristol saga was the introduction of the reporting of surgeon specific data. In my opinion, far more patients' lives have been lost than saved as a result of the current risk aversion of many British heart surgeons. In an earlier edition of the BMJ, Mr. Stephen Westaby also gives other very strong valid reasons why in his personal view publication of individual surgeons' results is so wrong. Many patient advocates argue strongly and cogently in favour of publication of surgeon specific outcomes. The process despite taking years to come to fruition was however designed badly with no checks and balances to ensure that care of risk patients would not be prejudiced  - which is exactly what has happened. 
One reason some (disingenuous) surgeons give, for turning down (usually elderly) patients for a cardiac surgical procedure, is that it is unethical to do so. This takes me nicely to the second article on clinical ethics boards.
I used to be a member of a clinical ethics board and the work we did was indeed very useful and contributed to excellent patient care.
Even if they so wished many surgeons would not be able to consult a clinical ethics board because as Daniel Sokol tells us, most hospitals do not have one. In the modern NHS, whose motto should be Top Down or Bust! , healthcare institutions would not set up such boards unless they are told to do so by NHS England or the regulators - CQC or Monitor- - and as they do not feature in the Bristol, Shipman or Midstaffs stories, NHS England, Simon Stevens or Jeremy Hardy are high unlikely to pronounce on the matter. When every institution has to look up for instructions to do or start absolutely anything it should surprise no one that patient and staff engagement are so poor in the National Health Service. As long as there is this perception that a universally available national health service can only be affordable and safe using this aggressive top down approach paired with local paralysis, nothing is going to change any time soon.