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August 2, 2015

Private Eye 1397
Filed under: Private Eye — Dr. Phil @ 8:16 am

The Right Care

The eighth patient safety congress in Birmingham (July 6&7) turned out to be feistier than MD had predicted. In a show of hands, the vast majority of the audience – largely patient safety experts – declared it wrong that NICE had been told by Simon Stevens, CEO of NHS England, to halt its work on safe staffing levels in different NHS settings, including emergency departments. The work was a recommendation of the Francis report into failures at Stafford Hospital. Professor Mark Baker, director of the centre for clinical practice at NICE, told the conference “I think the reason they don’t want it is they don’t like the answer to the question. … The underlying problem is that the NHS has survived for most of its history by taking risks and not getting found out.”

NICE appeared to show commendable balls in announcing it will press ahead and publish its recommended nurse staffing levels for accident and emergency departments which are likely to propose minimum nurse to patient ratios. It would not be official NHS England policy but trusts may feel obliged to comply. NICE later announced a U turn – probably under pressure from the DH and NHS England – which is absurd and unsafe given the research was publically funded and is the best available evidence on safe staffing not just for the NHS but for other health systems that rely on NICE’s evidence.

Safe staffing levels for nurses per se don’t make the NHS safe – it also depends on the skill mix of other staff (doctors, paramedics), their competence, teamwork and leadership. But it’s very hard to deliver a safe NHS without enough frontline staff and with the pressure on to save another £22 billion, and a national shortage of doctors and nurses, NHS England is clearly worried that hospitals will either fail to hit financial targets or simply not be able to fulfill the required staffing levels in many parts of the country. Would units then be forced to close or struggle on under-staffed? Either way it would be a field day for lawyers if patients came to harm.

In 2013-14, the NHS set aside £15.6 billion to deal with clinical negligence claims and paid out £1.1 billion in settling claims. As it becomes more transparent about staffing levels and the duty to tell patients and relatives when they have been harmed by NHS care, the fear is that the legal bill will rise further. The safety congress made a business case for patient safety, arguing that giving patients the right care, right first time, is a lot cheaper than getting it wrong but the right care is not always easily apparent.

The right diagnosis is clearly critical but around half of all symptoms are ‘medically unexplained’ and don’t fit easily into a diagnostic box. Some hospitals spend so much on expensive investigations for chest pain, abdominal pain and headaches with ‘normal’ results, that they’ve set up ‘Medically Unexplained Symptoms’ clinics. If you do get an initial diagnosis, it’s likely to be wrong 15% of the time. That’s not usually negligence, just the way informed guesswork goes. Always ask ‘What else could it be?’ And ‘How would I know?’

The right care also needs the right treatment but for most diagnoses, there are now a lot of options to choose. Doctors try to go through all of them – what’s right for one patient may be completely wrong for another – but sharing complex decisions in ten minutes is near impossible. Fortunately, most decisions don’t need to be made immediately, many symptoms improve in time and many treatments and screening programmes are surprisingly ineffective. If you ask ‘What’s most likely to happen if I just watch and wait’, the answer is often that you’d live just as long as if you have your life expensively and inconveniently medicalised.

If you opt for treatment, the chances are NICE will have published what standards of care you should expect. Patients generally take even less notice of NICE than NHS England. Hence 135 amputations a week are performed on diabetic patients, the vast majority of which could be prevented if they were treated to the standard that NICE dictates. But patients and a surprising number of NHS staff either aren’t aware of the standards, or don’t have the resources and staff to follow them. High quality care costs money, and the biggest cost is staffing. And yet 70% of what can be done to prevent chronic diseases – and to prevent them getting worse – is down to lifestyle and life circumstances. The NHS is powerless to deliver the right health care unless patients do the right self-care. Education may help, and so may taxing sugary drinks. 26,000 children were hospitalised for rotten tooth extraction last year. A third of 5-year-olds and half of 8-year-olds were found to have decay in their milk teeth. Healthcare begins with the education and support to self-care.

MD’s book on how to self-care and get the best from the NHS is available here