Learning from Bristol?
Five years ago, the Bristol Royal Infirmary Inquiry — under the chairmanship of Sir Ian Kennedy — published its final report. The inquiry examined the catalogue of surgical disasters in paediatric cardiology at the hospital between 1984 and 1995 and revealed — among many shortcomings — woeful gaps in medical accountability and patient safety.
Last week, Sir Ian revisited some of the report’s conclusions and
gave a lecture entitled “Learning from Bristol: are we?” based
on an essay of the same name, published on his behalf by the Healthcare
Commission, of which he is now chairman. Sir Ian’s overall personal
conclusion is that some progress has been made but that it is patchy.
In some respects, he says, the NHS has come a long way in a short time.
The underpinning theme of Sir Ian’s five-year review is the issue
of patient-centred care. Some progress has been made but putting patients
first in all circumstances is easier to say than to do. It impinges on
the way services are delivered. It also impinges on the way health care
professionals interact with patients and, therefore, on their concept
of professionalism. To some health care professionals, Sir Ian suggests,
treating patients as people and considering their experiences and safety
as paramount is second-nature; to others it remains a challenge.
Increasing patient safety is, of course, something that nobody would
be against. Yet, the health service kills the equivalent of three jumbo
jets full of people every week through errors of one sort or another.
As Sir Ian points out, these are not usually mistakes made by individuals
but errors made as a result of deficiencies inherent in the system. Compared
with five years ago, safety is considered more important, and there are
many agencies responsible for it: the National Patient Safety Agency,
the Medicines and Healthcare products Regulatory Agency, and the Healthcare
Commission for starters. But no single body is pulling all their strings.
Sir Ian detects that there has been a significant shift in the culture
of the professionals who provide health care and acknowledges that their
leaders have embraced the need for the changes called for in the original
report.
Although this shift of emphasis may have been accepted by the leaders
of different professions, The Journal suspects they have not been successful
in persuading all their members that change is essential.
But there is no question that change will continue. Sir Ian Kennedy’s
vision for the health of the nation is achievable — but it may
take rather more than another five years to get there.
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