THE REPORT OF THE COMMISSION ON PATIENT SAFETY AND
QUALITY ASSURANCE.

The Commission issued its report in the early part of August. In the words of Dr. Deirdre Madden, Chairperson of the Commission, its purpose is to help provide a framework of patient safety and quality. She says: “A patient safety culture will develop open communication with patients, and ensure learning throughout the system when things go wrong”. This is a worthy aspiration, and is reflected in part in the report.

The report is a long document, and is not always written in plain language. It contains 109 (or is it 111) recommendations, many of which are not only welcome, but essential, have been demanded by patient activist groups for a long time, and will no doubt improve the health services in Ireland if adopted. However, there are some aspects of this report which I find deeply worrying.

Among the recommendations I particularly like is the one proposing the adoption of the WHO standards of data collection, which I have been advocating for a few years now. In Ireland, when collecting health statistics, we have been using codes which other members of the WHO finished with in 1996. This means that we are unable to record the numbers of people who have died as a result of Health Care Acquired infections. This is unacceptable; how can we tackle a problem when we have refused to acknowledge the full extent of it? I also approve of supplying more information to patients and researching the effects of adverse events on patients and their families, both of which projects we, in the SIN Campaign, have already begun.

The introduction of licensing is a positive step, but the actual administration of it needs a lot of clarification. Because of the recommendation that both the hospital and different areas of it such as the X-Ray department and the lab will be licensed, it means that several licenses could attach to the one hospital. It is proposed that the cost of the administration of these licenses will be borne by the hospital, so that those hospitals which are already in financial difficulties will have find themselves further stretched, with savings having to be made on services which, as history shows, is the usual method of solving such problems. This is the part of the report which Minister Harney has singled out and promised that she will implement. It is difficult not to be cynical and suggest that her reasoning is that this is the one recommendation that will bring in money, and most of the others are going to involve spending money. If the licensing system is introduced without the enforcement of the standards such as recently proposed by HIQA, what criteria will be used to justify the continuation of the licenses or the suspension of them? If licenses have to be suspended, will hospitals or parts of them be closed down, and how will that work for patient care? While the Minister is considering the recommendations of this report she might like to look at no. R7.43 which states that: “Having regard to the need to balance accessibility, safety and effectiveness, care should ideally be delivered as close as possible to where the patient lives”. She might then ask the Commission to explain what they mean by this and how it relates to HSE policy.

Here is another concern I have. In the enquiries that have been held over the recent past into incidents in health care that have resulted in mis-diagnoses, late diagnoses and consequent harm to patients, the ‘system’ has been identified as the cause of the lapses. Many people find this unacceptable, as systems are devised, supervised and run by individual people. According to this report, “The ‘systems’ view of patient safety is now widely accepted internationally’ (p. 41), and this fits nicely in to the ‘no blame’ culture which the Commission also advocates. By contrast, however, the report does recommend that: “The Chief Executive within each organization must be ultimately responsible and accountable for patient safety and quality within that organization”(p93). This would be a very welcome development, as the lack of an identifiable person who will take responsibility for problems has led to much frustration, but it is difficult to see how such accountability can sit comfortably with the concept of the ‘system’. How can a person take responsibility for adverse advents while at the same time being enabled to put that same responsibility onto ‘system failures”? How, as Dr. Madden advocates can people learn if their failures can always be attributable to ‘the system’?

The recommendation that the reporting of adverse events (including hospital acquired infections) should be made mandatory, and that this should be included in the ethics of health care professionals (p181) is a very positive one. However, this is followed very closely by another recommendation which states that such reports must be: “strictly confidential, protected from legal discovery and exempted from freedom of information legislation” (p181). It is obvious, as the report states, that health care professionals do not set out to injure patients, but adverse events do happen. Many of them, such as hospital acquired infections, are largely preventable, and in some of these cases patients suffer injury which leads to disablement or death. If such patients, or their representatives, are unable to get the information necessary to obtain the redress which is otherwise refused by the state, surely this compounds the injustice. How does advocating such secrecy promote the : “Open dialogue, trust and mutual respect” mentioned on page 72? This strategy surely exposes as a sham the invitation to service users to see themselves as ‘partners’ in the health care process. Partnership involves equality of ownership and power. The Commission does mention that the Bristol Report, published in Britain in 2001 suggested that an administrative system, other than that of clinical negligence, should be considered to compensate those who suffer form harm arising from medical care. This approach would go some way towards looking after patients who have been injured, but the Commission, however, does not go on to recommend such a course for Ireland but proposes setting up another expert group to examine the possibility.

Carrying out the Commission’s recommendations will involve setting up 7 groups and 5 sub-groups to oversee the various processes, and at least one independent report is to be carried out (as mentioned in the previous paragraph). I would like to ask the question whether we don’t already have enough staff within the Department of Health and Children, the HSE, HIQA, The Consumers Affairs Division, and the Commission itself without more groups having to be set up spending more time and money and deferring the time before anything needs to be actually done rather than talked about.

Finally, in Ireland, there is the attitude within succeeding governments that once a report has been issued with all the bells and whistles accompanying it, the matter in hand has been dealt with. This tendency is implicitly acknowledged in this report where there are proposals which advise that the recommendations made in previous reports should be carried out. Patient safety is a matter that needs to be dealt with urgently. It would be a pity to see this report join the many others on the dusty shelves of wherever dungeon in the Department of Health they are consigned to before the positive aspects of it are adopted. Looking at my own collection of such reports which is getting bigger by the month, I am not holding my breath.

Dr. Teresa Graham. Stop Infections Now Campaign.