Editorial

I was honoured to be invited to speak at the World Health Organization (WHO)/National Patient Safety Agency (NPSA) conference to launch the Safer Surgery Checklist in the Euro region in London in January. As I said at the conference, it is a sign of how far things have come that it is considered essential to have the perspective of patients represented at such events these days. It provided me with the opportunity not only to represent AvMA and the experience of the many thousands of patients we have supported, but also the worldwide network of Patients for Patient Safety ‘champions’, which WHO has nurtured and of which I am a member. The occasion was also notable for the strong and rather mixed reactions which the checklist initiative, and in particular the Department of Health's attempt to make the use of the checklist ‘mandatory’, continues to provoke. The Safer Surgery Checklist has been made the subject of an NPSA patient safety alert to all NHS bodies in England and Wales. It is a simple list of things to check before starting surgery, such as: Is this the right patient? Are we operating on the correct site? Are there known allergies? Is there a chance of significant blood loss? And so on. It takes less than five minutes to go through.

I first heard Lord Darzi use the ‘M’ word in a TV interview on the morning of the launch. I thought that it might just have been a slip of the tongue. In recent times it has been politically incorrect to make almost anything in the NHS mandatory. It is not even mandatory to report patient safety incidents, for instance. In England at least, as opposed to the more centrally managed manifestations of the NHS in Wales and Scotland where responsibility for the NHS is devolved, it proves nigh on impossible to tell anyone to do anything when it comes to patient safety. Many hailed the publication of Safety First ¹ as the blueprint for moving forward on patient safety in England. However, even the implementation of the recommendation to establish Patient Safety Action Teams in each Strategic Health Authority (SHA) area has apparently become bogged down in regional politics and in-fighting. Primary Care Trusts (PCTs) don't like to be told what to do by SHAs. SHAs don't like to be told what to do by the NPSA or the Department, and so on. Consequently, there is no consistency between one SHA and another as to the shape or remit of what could be described as a Patient Safety Action Team or indeed to their approach to patient safety. AvMA's close involvement in the Patients for Patient Safety project for England and Wales has given us first hand experience of just how different the culture and approach can be from one SHA to the next.

One presumes that the rationale for devolving power to this extent is that this will lead to better decisions which are better suited to each local area. Clearly some local discretion is needed in order to be able to best meet local needs. However, I am not at all convinced that this approach works when it comes to most patient safety work (except of course particular local problems). Most of the problems which are known to be patient safety hazards are generic and would benefit from a generic, centrally-mandated approach. This is why the administrations in Scotland and Wales have chosen a much more directorial approach, concentrating on a set of interventions developed by the Institute for Healthcare Improvement, and for which there is evidence that they reduce risk and save lives. The NHS in these countries is being told what they need to do and this is accompanied by the message that when they do, they will save lives. Far from causing uproar and resentment about being told what to do, the NHS staff in those countries I have spoken to, very much welcome being given clear unequivocal and evidence-based instructions. There is a real feeling that things are going to get done. That NHS staff can make a difference. That patients' lives will be saved by taking action on patient safety.

Certainly when it comes to patients, in my experience this kind of common-sense approach rings the right chords. Too often in patient safety work, there is an apparent inertia due to the complexity of the issues involved and the size of the task. Even if something is common sense, some people will require that the right evidence is presented in the right way in order to get their buy-in to do something. Look at how long it took to get central direction over hand-washing for example, not to mention the surgery checklist approach now being advocated. Sometimes there is the temptation to go for the shiny new toy rather than grapple with the basics which we already know about. AvMA has consistently argued, for example, that while reporting systems are a good thing (and indeed reporting patient safety incidents should be mandatory), we already knew about some of the most serious and prevalent patient safety problems (for example healthcare-associated infections and the kind of errors in surgery which can be prevented from use of the checklist). Use of resources should be much more prioritized to dealing with problems we know about and can do something about rather than further research or data collection.

So, well done to the Department of Health and NPSA for attempting to make use of the safer surgery checklist mandatory. Technically, implementing an NPSA patient safety alert is not mandatory but the Department has signalled its intention to make it as good as. There have already been howls of disapproval about local NHS organizations (even Foundation Trusts!) being told what to do by the centre. However, the biggest challenge, as made clear by a number of speakers at the conference, will be to win the hearts and minds and change the practice of surgeons, some of whom remain sceptical and resistant to anything which they perceive as diminishing their individual role in decision-making. They would be wrong to assume the use of a checklist diminishes the importance of their clinical judgement. It is just a tool. Moreover, it is a tool, like the checklists that airline pilots go through before take-off, that complements the role of highly-trained professionals and ultimately saves lives. I would argue, however, that the benefit of the checklist initiative extends beyond the simple truth that it will directly reduce the number of perfectly avoidable errors. By focusing on the interaction between the whole team involved in surgery and by challenging the notion that healthcare organizations and individual surgeons should be left to their own devices, it has the potential to help change culture.