Health and Social Care (Safety and Quality) Bill

Lord McColl of Dulwich Excerpts

Friday 6th February 2015 Lords Chamber

[Lord McColl of Dulwich (Con)]

My Lords, I thank Jeremy Lefroy for starting this Bill and the noble Lord, Lord Ribeiro, for bringing it here so expertly.

I would like to address one or two aspects and look back to how we dealt with them in the past. First, on the issue of protecting the public from avoidable harm, as a young house physician, the first problem I came across was a situation where a number of young ladies had attempted suicide—which of course was a criminal offence in those days. I was astonished to see the police hovering around, insisting on interviewing them. I explained to the police that the patient was not completely compos mentis and was in no fit state to be interviewed by anyone, certainly not the police. This created a great deal of trouble for me and I was summoned before the senior superintendent of the hospital and the local inspector of police. They harangued and shouted at me. I realised that they were just common bullies—and that one of my jobs was to protect patients from bullies.

We then came across the problem of operating on the wrong patient or operating on the wrong side. As a young surgeon I thought that there must be a way of preventing this, so I used an indelible pen to write the name of the operation at the site of the operation. Sometimes this presented problems, and arrows had to be put in to show roughly where it was, but it worked well. However, one day I went into the operating theatre and the anaesthetist said, “I wish you’d make up your mind which operation you’re doing on this patient”. I replied, “Look, I have written on his groin ‘right inguinal hernia’”. He said, “Yes, but look at this”, and he pulled the sheet down to reveal a dotted line across the front of the patient’s neck with a big arrow pointing at it, and on his chest, in big letters, were the words, “Cut here”. It was a tattoo that he had had put on 20 years before. Apart from that, the system worked very well indeed.

We developed at Guy’s Hospital something that had been done in many other hospitals. We would meet every week to discuss all the complications and deaths that had occurred in the previous week. Surgeons, junior staff, students, nurses and even some administrators would come. It was the most amazing and enjoyable meeting of the whole week, and it was relevant to what was going on. You could not hide anything because people knew what was going on. Complications would be presented, and we were very fortunate in having a very senior surgeon to chair these meetings. He had a good sense of humour and he was both brilliant and humble. When some poor junior surgeon would stand up and explain a complication for which he was responsible, the chairman would say, “That’s nothing, old chap. Only the other week…”, and he would go on to describe a complication for which he had been responsible. What he was cleverly doing was creating an atmosphere that was friendly and unthreatening, thus encouraging people to be absolutely honest. It was a great learning experience. It became rather like the general confession and was just as therapeutic.

We are all fellows of the Royal College of Surgeons, the Royal College of Physicians, the Royal College of General Practitioners and so on—but what is fellowship? Fellowship is sharing experiences, both good and bad. That is part of the fun of medicine. Another thing about those meetings was that they did not cost anything and we did not have bureaucrats from above directing and inspecting us. Local accountability is the answer.

The second thing I want to talk about is the appropriate sharing of information and the question of identification of patients. Years ago, I suggested that one solution to the problem of sharing information would be to give the patient his or her medical records. This was objected to on the basis that people could not be trusted and that they would lose them. A friend of mine gave away 20,000 medical records over a period of 20 years, and only three were lost. One was lost in a fire, one in a flood, and the third was eaten by the dog. That is a pretty good loss rate when we consider that some medical records departments were losing around 20% of their records at any one time.

Another thing we started doing was inviting patients to keep their operation note so that they could take it with them. One day I had to operate on a patient who had been operated on in Edinburgh in 1935. It was a complicated operation in the abdomen. I asked the patient if he had any idea what the surgeon had done. “Yes, I do”, he said, and he pulled from his pocket a piece of paper with the most beautiful diagram of all the plumbing that had been operated on inside his abdomen. The patient had kept the piece of paper safe for all those years.

The third thing I would like to talk about is something that has been aired quite a bit: will the Bill leave healthcare workers reluctant to treat or operate on poor-risk patients? Some years ago we conducted a big research project in four London hospitals. We measured the quality of care by what the doctors were doing to the patients—process—and the outcome of that. The third method was to ask a friendly, knowledgeable person in each of the four hospitals to put the consultants in order of merit. The three systems gave the same answer. People in a hospital know what is going on.

To make it fair, we measured 12 variables to find out whether the patient’s contribution to his illness would have any effect on the result of the operation. We recorded blood pressure, anaemia and other things, including marital status—whether they were married or had a stable relationship. Strangely enough, the only one of those variables that had any effect on the outcome of treatment was whether or not they were married or had a stable relationship. That was not an original finding; it had been established for some time.

The fourth thing I will talk about is the whole culture of blaming other people for what is going on. Of course, in medicine we have been guilty of this. If we could not establish the diagnosis in a patient, there was a tendency to say, “Ah well, it is in the mind. It is psychiatric”. Of course, that is quite wrong. Psychiatric diagnosis should be a positive thing, not a diagnosis of exclusion. We must not blame the patients for what is going on.

Of course, one thing that has happened in recent years is the obesity epidemic, and what have they done? They have blamed the people who closed the playing fields for children not getting enough exercise. But of course the obesity epidemic is simply due to people eating too much. That is perfectly straightforward.

The Bill concentrates on the vital overarching duty to protect the health, safety and well-being of the public —and these things we must continue to fight for.

--- Later in debate ---

[Earl Howe]

I would be happy to do so.

[Lord McColl of Dulwich]

Before the Minister sits down, could I ask him about the WHO checklist? When I go into an operating theatre, the operation cannot start until that list is completed by the surgeon, the anaesthetist and the nurses. Could that be put into regulations?

[Earl Howe]

My Lords, I am sure that anything is possible, but I would hesitate before giving a commitment along those lines because it seems to me too granular to be included in statutory regulations rather than in guidance or best-practice manuals.