Address by Mary Harney, T.D., Minister for Health and Children, at the Annual Consultative Forum of the Department of Health and Children
I would like to welcome you all here today to this important event in the health calendar.
Patient safety – three promises to patients
The organisation of health services is complex in any country and for any population. As in any large organization, this complexity challenges us to find a radical simplicity that guides our work and decisions.
In health, in our country, what do we want to promise to patients? There are many things we can promise to patients, for example: ‘we will do our best to make you well’, ‘we will use evidence-based medicine’ or ‘we will treat you based on medical need not means’. These are all good promises.
I would like all of us in health to unify first around one very basic promise to patients before all else: ‘You will be safe’.
I would like us to allow that simple promise to drive everything it possibly could in health: policy, practice, organisation of hospitals, organisation in hospitals, individual and group behaviour, resource allocation, recruitment, training, education.
I also want to see patients actively involved in helping us make good on that promise. I want to see our organisations at every level seek out, encourage and take on board patients’ feedback. Patients and their families have a key role to play helping us improve safety.
So another promise we can make to patients is,
‘We will actively seek your views and we will listen’.
It is our challenge to make sure that patients are confident that their views and feedback make a difference, that they carry weight.
None of us take part in meetings or organisations on the basis that we will get our own way all the time, and that we know it all without having to listen to others. But equally none of us take part if we think that our contribution makes no difference at all. And no-one at all will speak in trust if the atmosphere is one of blame and recrimination.
This is the context in which active and fruitful patient participation should take place. It is a challenge to us to achieve it.
I have met many distraught families who felt that they were not listened to and were not communicated with adequately when adverse events occurred.
Let me say that most patients in Ireland clearly receive effective and safe treatment. As in every part of our health debates, we do an injustice to many thousands of people and their excellent work to ignore the positives, while we talk about the problems.
But we are conscious, and many of you are keenly aware, that international studies suggest that a significant minority of patients can be harmed through their care either in hospital or in the community. It is a problem in nearly all health care systems.
For example, some international studies suggest that adverse events in health care affect around 4% of patients with 1% experiencing serious harm. An Australian study found a 16.6% adverse event rate with half being judged preventable and about 1% serious harm. UK, Denmark and New Zealand studies found adverse event rates of about 10%.
It goes without saying that this causes significant suffering to patients. It can also be distressing to clinicians and other staff. And it brings additional costs to the health service.
19% of errors arise from medication maladministration.
Most errors appear to result from one or more of the following factors: system design, product safety, service environment, communication failures and institutional culture.
So when adverse events happen, I want our organisations and each of us working in health to make a third promise to patients:
‘You will be told the truth’.
This has to be the most basic test of trust between the patient and our service, and each person working in the service. Patients entrust their health, their secrets and their lives to us. The least they can expect in return is the truth, especially when our efforts fail them.
It is so clear that the withholding of truth undermines all trust. Without trust, health services are reduced to adversarial, legalistic transactions. None of us here wants any part of that.
I want to see our health services driven by these three promises to patients, these three at least. And I challenge our organisations to examine what changes are necessary to make good on them.
The Department of Health and Children in partnership with the HSE has reviewed current initiatives to engage the consumer in the health services and has found evidence of much good work to involve patients and the public in different ways across the service. There are consumer panels, communities working with primary care teams, patient surveys and much more.
The Department review identified a number of issues that need to be addressed in order to bring this work to involve patients and the public up to best practice. Initiatives need to be evaluated for effectiveness. The best ways for involvement and feedback from patient groups have to be distinguished from ways to ensure individual patient feedback. We need to have a clarity and consistency of approach, as well as ways to monitor our effectiveness.
I want to take this agenda forward and I would be interested in hearing your views today.
Specialisation and volume
Patient safety is also driven by specialization and volume.
The compelling evidence that frequency and specialisation of surgical procedures affects patient safety cannot be set aside as merely ‘interesting’. It has to drive our decisions, and not our decisions far off in the future, but our decisions now, for the future.
I have quoted before statistics in relation to breast cancer surgery. We are making progress towards specialisation for safety.
The proportion of patients treated by consultants doing more than 50 procedures per year increased from 23% in 1997 to 58% in 2003.
But still 308 of 1,800 patients had their surgery performed by consultants doing fewer than 30 procedures.
Of the 76 consultants who carried out breast surgery in 2003, 45 carried out fewer than 10 procedures a year. Thirty-seven consultants performed five or fewer such procedures.
Put that beside authoritative cancer research from Britain telling us that
‘Patients treated by low workload surgeons had poorer survival. The risk of death was increased by 15% and by 10% for patients managed by surgeons with workloads less than 10 and between 10 and 29 cases per annum in comparison to patients managed by surgeons with workloads of more than 50.
“Surgeon workload and survival from breast cancer”, British Journal of Cancer (2003) 89, 487-491
A New England Journal of Medicine review made a compelling case that high volume units for 14 different cancer or cardiovascular procedures had lower mortality rates for all procedures.
There are other research papers suggesting improved outcomes for Aids treatment, aortic aneurysm surgery, total joint replacement and paediatric heart surgery in high volume centers. High volume centres attract better clinicians and support staff thus improving quality.
My point here is that better outcomes for patients – that is, increased safety and quality – simply compels us to organise our services and our hospitals differently. We must assess and compare outcomes based on evidence to determine the need for training and the best service configurations.
There can be no other responsible course of action.
This is not an issue about resources. Even if we had unlimited resources, it would not be safe for patients to have large numbers of surgeons in any particular hospital performing certain procedures very infrequently because the population served by that hospital did not give rise to many such cases. Surgeons would become de-skilled and patient safety would be compromised.
No downgrading patient safety
So in terms of hospitals and services, I can best summarise policy as the following: we will provide as many services as possible, as locally as possible, and as safely as possible. This will mean change for the better for patients.
For as long as we can remember, accusations have been made about plans to downgrade hospitals. Sometimes this can sound like an argument for ‘no change, ever, in anything, at any hospital’. We all know that there have to be plans, and there has to be change.
What I am absolutely clear about is that we simply cannot, and will not, plan to downgrade patient safety.
To those who argue about downgrading hospitals I can only say, it would be absurd if we cared more about hospitals than patients, more about staffing than service, more about resources than results.
Hospitals come second to patients. We will not downgrade or degrade patient safety.
All of us involved in our health services can contribute to better patient safety. I will shortly be bringing forward the legislation to establish the Health Information and Quality Authority and I hope to have it enacted early next year.
I see a key role for HIQA in building the patient safety agenda, alongside the operations of the HSE and, of course, clinical decision-making by consultants.
I see also a key building block in achieving better quality assured, safe patient care in the new Medical Practitioners Bill.
The end result of all of this must be that we put the patient at the centre of our health service and that we develop high quality and safe services guided both by evidence and by the wisdom of those who use them.