bma publishes interim response to bristol royal infirmary inquiry report

(issued Tuesday 18 Sep 2001)

The British Medical Association today publishes its interim response to the Bristol Royal Infirmary Inquiry report, showing work is in hand on more than a third of Professor Kennedy’s recommendations for making the NHS safer, more open, more patient centred and more accountable.

The interim response, which has been sent to Professor Kennedy and to Health Secretary Alan Milburn, commits the Association to working for change.

An important aim of the current negotiations to develop new contract for GPs and consultants will be to secure more time for patients with their doctors. The BMA backs Professor Kennedy’s analysis that resource constraints contributed to the problems at the BRI and seriously affect the ability of doctors to deliver high quality care. However the BMA’s response acknowledges the report’s direct criticisms of doctors and medical practice and says that doctors have both an individual and a collective responsibility to respond to the report’s recommendations.

The Interim Response highlights the Association’s work to encourage good practice in gaining informed consent. The Association produced a consent toolkit earlier this year which was sent to junior hospital doctors in May and is now being sent to the new cohort of newly qualified doctors. The BMA’s Board of Medical Education is updating its 1998 report on communications skills and has started a research project on teaching and learning methods for doctors. Its Board of Science is preparing a report on clinical trials to help patients decide whether to participate and to aid doctors in preparing information for patients.

Dr Ian Bogle, Chairman of BMA Council, says :

“It is clear to anyone reading Professor Kennedy’s report and the tragic set of circumstances it details, that it provides a unique opportunity for all those involved in the NHS, to bring about real change in the way patient care is delivered. This opportunity must not be lost.”

The full text of the Interim response follows.

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Report of the Bristol Royal Infirmary Inquiry

An Interim Response from the BMA

The report of the Bristol Royal Infirmary Inquiry, chaired by Professor Ian Kennedy was published on 18 July 2001. In making its initial response, the BMA welcomed the Health Secretary’s commitment to encouraging a new climate of trust and openness in the NHS and his acknowledgement of the skill and commitment of NHS staff. It indicated that it would be studying the Kennedy report in depth to see what lessons could be learned and what action needed to be taken.

It is clear to anyone reading the report and the tragic set of circumstances it details, that it provides a unique opportunity for all those involved in the NHS to bring about real change to the way NHS care is delivered. Coming as it does, at a time when the medical profession is already taking unprecedented steps to assure the quality of medical care, this opportunity must not be lost.

The report identifies a number of cultural and environmental factors, some of them stemming from resource constraints, which contributed to what happened at the BRI. Responding to the report is a matter for all health care professionals and the organisations to which they belong, for the regulatory bodies, the educational institutions, for a variety of agencies, for Government and the Public. However, it must be acknowledged that many of the criticisms in the report relate to doctors and the way that medicine is practised in the UK. For this reason, the British Medical Association believes that doctors must look to the recommendations and consider the actions that they can take collectively and individually.

It is the BMA’s intention to respond to the whole of the report , working through the recommendations individually to determine how we can best contribute. We are particularly keen to address the following issues raised by the report:

Achieving patient centred care;
Improving consent processes and communication with patients and their relatives;
Putting patient safety at the core of what the NHS does;
Improving team working and communication amongst all those working in the NHS.

A list detailing action being taken by the Association in the short term is appended.

In his report, Professor Kennedy outlines the developments in NHS culture which he feels to be essential to allow the NHS to serve patients. He identifies the need for a culture of openness, of accountability, of quality and safety, of public service and of teamwork. The BMA looks forward to working with the Government and all those committed to the future of the NHS to ensure that the action needed to bring about these cultural changes is taken.

Appendix
The BMA is considering the actions it can take on all the recommendations of the report of the Bristol Royal Infirmary Inquiry
. Set out below are some areas of action to which we are already committed, particularly in the areas of quality, education and continuing professional development and contractual negotiations. For ease of reference we have reproduced some of the recommendations to which they refer. Further information on action to be taken on the report will be produced in due course.

In addition to the action to be taken by the BMA, the BMJ Publishing Group is continuing to develop work on issues such as patient involvement, and quality, working with the BMA and other key groups such a patient organisations and the academic community.

In a patient-centred healthcare service patients must be involved, wherever possible, in decisions about their treatment and care.
The education and training of all healthcare professionals should be imbued with the idea of partnership between the healthcare professional and the patient.
The notion of partnership between the healthcare professional and the patient, whereby the patient and the professional meet as equals with different expertise, must be adopted by healthcare professionals in all parts of the NHS, including healthcare professionals in hospitals.
Information about treatment and care should be given in a variety of forms, be given in stages and be reinforced over time.
Information should be tailored to the needs, circumstances and wishes of the individual.
Information should be based on the current available evidence and include a summary of the evidence and data, in a form which is comprehensible to patients.

The BMA has emphasised the central importance of shared decision making in health care in its advice to doctors for many years. In publications on consent, on Medical Ethics generally and on specific issue advice such as that on withdrawing and withholding treatment we emphasise the need for conveying factual information sensitively, emphasising that the aim is to give the patient the information tools to enable him/her to make decisions about his/her care. We also stress the importance of seeing all information sharing as part of a process in which patient and doctor come to agreements about treatment and investigation plans. The materials we produce are designed to support the education of doctors, and are used in undergraduate and continuing medical education.

We will continue to reinforce this advice in all our publications and seek to encourage practical educational initiatives.
Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.

The BMA Board of Science and Education through the BMA library makes awards every year to medical publishers. In the last few years new categories have been added. Two years ago the category of patient information awards was added. We will continue to use this award to encourage the NHS, charities, lobbying bodies and others to develop innovative information provision for patients and for carers.
The NHS Modernisation Agency should make the improvement of the quality of information for patients a priority. In relation to the content and the dissemination of information for patients, the Agency should identify and promote good practice throughout the NHS. It should establish a system for accrediting materials intended to inform patients.
The public should receive guidance on those sources of information about health and healthcare on the Internet which are reliable and of good quality: a kitemarking system should be developed.

The BMA believes that a kitemarking system would be of enormous benefit to patients and to health care professionals. We would be happy to work with others to produce standards to which those producing materials for the Internet should aspire.
Tape-recording facilities should be provided by the NHS to enable patients, should they so wish, to make a tape recording of a discussion with a healthcare professional when a diagnosis, course of treatment, or prognosis is being discussed.
Patients should always be given the opportunity and time to ask questions about what they are told, to seek clarification and to ask for more information. It must be the responsibility of employers in the NHS to ensure that the working arrangements of healthcare professionals allow for this, not least that they have the necessary time.

This is a key aim of the negotiations underway between different branches of the profession and government. Doctors have long recognised that their time is a key resource in the NHS. It is also a resource that is heavily over committed. They wish to be able to spend more time with patients, in particular so that patients have time to enter into proper informed discussions with their doctors about the decisions they are striving to make about their health and health care. The BMA recognises the recent Government commitment to increase the number of senior doctors within the NHS – both in primary and secondary care. Without such an expansion of the numbers of GPs and consultants patients will continue to find that the time they have with their doctors will be squeezed by the needs of other patients.
Patients must be given such information as enables them to participate in their care.
Before embarking on any procedure, patients should be given an explanation of what is going to happen and, after the procedure, should have the opportunity to review what has happened.
Patients should be supported in dealing with the additional anxiety sometimes created by greater knowledge.
Patients should be told that they may have another person of their choosing present when receiving information about a diagnosis or a procedure.
Patients should be given the sense of freedom to indicate when they do not want any (or more) information: this requires skill and understanding from healthcare professionals.

As above, the BMA will continue to produce educational materials for doctors which cover all aspects of communication skills. We believe that the right “not to know” is as important for individual patients as the “right to know” and agree with the Kennedy report that it requires considerable expertise and sensitivity from health care professionals to understand when that individual patient has received as much information as he/she currently wants. Conveying information in a manner which is sensitive to the needs of the individual takes time; medical time is under too much pressure. For doctors to communicate properly with their patients’ time must be made available.
Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Parents of those too young to take decisions for themselves should receive a copy of any letter written by one healthcare professional to another about their child's treatment or care.

The BMA agrees with the concept behind this recommendation but would caution that this must be handled sensitively. For example a woman who is referred for investigation and treatment of an injury following domestic violence may well fear further violence if her partner opens a letter which sets out her complaint. Similarly children may not wish, despite the advice of their doctor, to share certain health concerns with parents. Therefore while copies should always be available to patients, and to the parents of young children, they should not be sent as a matter of course unless previously agreed with the patient. In addition doctors would not want patients to receive all such letters without having available medical advice to explain their contents. The NHS will also have to deal with the practicalities and the resource implications of these recommendations

23.	We note and endorse the recent statement on consent produced by the DoH:`Reference guide to consent for examination or treatment', 2001. It should inform the practice of all healthcare professionals in the NHS and be introduced into practice in all trusts

24.	The process of informing the patient, and obtaining consent to a course of treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient's signature on a form

25.	The process of consent should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication

26.	As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives and about the likely outcome, to enable them to make a choice about how to proceed.

	As in our general comments on communications and decision making, the recommendations on consent reflect BMA policy.

	The BMA produced guidance on consent and a “consent toolkit” earlier in 2001. Copies were sent to junior hospital doctors in current practice in May 2001; copies are now being sent to all newly qualified doctors. The aim of the toolkit is to help doctors understand the process of consent and how that fits in with specific clinical situations. It takes the doctor through some common dilemmas, reinforcing both the principles that underlie consent and the processes which put those principles into practice. We emphasise in all our guidance that consent must not be seen as a mechanistic process; care must be taken to respect the bodily integrity of the patient. However the consent process should not stop a health care professional from, for example, comforting a distressed patient.

27.	Patients should be referred to information relating to the performance of the trust, of the specialty and of the consultant unit (a consultant and the team of doctors who work under his or her supervision). (See further the Recommendations on care of an appropriate standard.)

	The BMA produced a report on clinical indicators in March 2000. In it we emphasised the need for information which would help patients and their doctors make choices about where to go for treatment. We will continue to produce research on this area and to participate in academic and practical discussions.

	Additionally the Central Consultants and Specialists Committee of the BMA has set up a working party on Quality initiatives in the NHS which is considering Clinical Indicators alongside the many other Quality Initiatives and machinery (such as CHI, NICE, NCAA, NPSA, and Clinical Governance). The committee will decide later this year how best to take its work on the quality agenda forward.

37.	There should be an urgent review of the system for providing compensation to those who suffer harm arising out of medical care. The review should be concerned with the introduction of an administrative system for responding promptly to patients' needs in place of the current system of clinical negligence and should take account of other administrative systems for meeting the financial needs of the public. (See further the Recommendations on the safety of care.)

	The BMA has campaigned for an alternative to the current system of clinical negligence for many years. In addition to the reasons stated in the report we believe that the current system fails to address the needs of some injured by the health care they have received where that was not negligent – that is they suffer an injury where no-one is at fault. This is, however, an enormous issue and we recognise that there will need to be much detailed discussion of alternative models. We have recently published a policy paper on mediation, clinical negligence claims and the medical profession and we have started to undertake further work on the concept of no fault compensation. We are happy to work with the Department of Health on this issue. (These comments also relate to recommendation 119, which covers the same ground).

38.	The DoH's roles in relation to the NHS must in future be made explicit. The DoH should have two roles. It should be the headquarters of the NHS. It should also establish an independent framework of regulation which will assure the quality of the care provided in and funded by the NHS, and the competence of healthcare professionals.

39.	The framework of regulation must consist of two overarching organisations, independent of government, which bring together the various bodies which regulate healthcare. A Council for the Quality of Healthcare should be created to bring together those bodies which regulate healthcare standards and institutions (including, for example, the Commission for Health Improvement (CHI), the National Institute for Clinical Excellence (NICE) and the proposed National Patient Safety Agency). A Council for the Regulation of Healthcare Professionals should be created to bring together those bodies which regulate healthcare professionals (including, for example, the General Medical Council (GMC) and the Nursing and Midwifery Council); in effect, this is the body currently referred to in `The NHS Plan' as the Council of Healthcare Regulators. These overarching organisations must ensure that there is an integrated and co-ordinated approach to setting standards, monitoring performance, and inspection and validation. Issues of overlap and of gaps between the various bodies must be addressed and resolved.

40.	The two Councils should be independent of government and report both to the DoH and to Parliament. There should be close collaboration between the two Councils. The DoH should establish and fund the Councils and set their strategic framework, and thereafter periodically review them.

	The BMA will be responding to the Government consultation on “Modernising Regulation in the Health Professionals” which covers issues relating to the role and function of an overarching regulatory body. (These comments also apply to further recommendations on this issue which appear later in the report – recommendations 69-74)

43.	The contractual relationship between trusts and consultants should be redefined. The trust must provide the consultant with the time, space and the necessary tools to do the job. Consultants must accept that the time spent in the hospital and what they do in that time must be explicitly set out

44.	The system of Distinction Awards for hospital consultants should be examined to determine whether it could be used to provide greater incentives than exist at present for providing good quality of care to patients. The possibility of its extension to include junior hospital doctors should be explored

45.	The doctors' Code of Professional Practice, as set down in the GMC's `Good Medical Practice', should be incorporated into the contract of employment between doctors and trusts. In the case of GPs, the terms of service should be amended to incorporate the Code.

47.	Trusts should be able to deal as employers with breaches of the relevant professional code by a healthcare professional, independently of any action which the relevant professional body may take.

	Consultants are currently renegotiating their nationally agreed terms of service. All the above matters will be part of that series of negotiations. The negotiations on a revised contract for GPs will also consider these issues.

57.	Greater priority than at present should be given to non-clinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals:
	skills in communicating with patients and with colleagues; education about the principles and organisation of the NHS, and about how care is managed, and the skills required for management; the development of teamwork; shared learning across professional boundaries; clinical audit and reflective practice; and leadership

59.	Education in communication skills must be an essential part of the education of all healthcare professionals. Communication skills include the ability to engage with patients on an emotional level, to listen, to assess how much information a patient wants to know, and to convey information with clarity and sympathy.

60.	Communication skills must also include the ability to engage with and respect the views of fellow healthcare professionals

	The BMA’s Board of Medical Education produced a report on Communication Skills and CPD in 1998. It is now working to update that report, taking into account the recommendations of the Kennedy report. It will invite others to work with it on that revised report, including the RCN and the Medical Royal Colleges.

	In addition the Board has commenced a research project on teaching and learning methods for doctors which is designed to help teachers help their students get maximum benefit out of learning opportunities.

65.	An early priority for the new NHS Leadership Centre should be to offer guidelines as to leadership styles and practices which are acceptable and to be encouraged within the NHS, and those which are not.

66.	Steps should be taken to identify and train those within the NHS who have the potential to exercise leadership. There needs be a sustained investment in developing leadership skills at all levels in the NHS.

67.	The NHS's investment in developing and funding programmes in leadership skills should be focused on supporting joint education and multi-professional training, open to nurses, doctors, managers and other healthcare professionals

68.	The NHS Leadership Centre should be involved in all stages of the education, training and continuing development of all healthcare professionals.

	The BMA is beginning work to identify the types of training which would enable doctors and other clinicians to be better leaders, and to prepare them better for the roles of clinical and medical directors. We hope to work with others, including the RCN and the BAMM in this project.

75.	Pilot schemes should be established to develop and evaluate the feasibility of making the first year's course of undergraduate education common to all those wishing to become healthcare professionals.

76.	Universities should develop closer links between medical schools and schools of nursing education with a view to providing more joint education between medical and nursing students.

77.	Universities should develop closer links between medical and nursing schools and centres for education and training in health service and public sector management, with a view to enabling all healthcare professionals to learn about management.

	The BMA’s Board of Medical Education has commenced work on these issues. It will research evidence of success on other countries in establishing such courses as well as considering the implications for course development by medical schools, time spent in training and other matters.

78.	Access to medical schools should be widened to include people from diverse academic and socio-economic backgrounds. Those with qualifications in other areas of healthcare and those with an educational background in subjects other than science, who have the ability and wish to do so, should have greater opportunities than is presently the case, to enter medical schools.

79.	The attributes of a good doctor, as set down in the GMC's `Good Medical Practice', must inform every aspect of the selection criteria and curricula of medical schools.

80.	The NHS and the public should be involved in (a) establishing the criteria for selection and (b) the selection of those to be educated as doctors, nurses and as other healthcare professionals.

	The BMA has already produced a report on selection for medical school. A conference and the publication of a report of that conference followed this. The premise behind the report was that medical schools should broaden their recruitment criteria. It is recognised that current criteria have the advantage of being simple. The BMA has welcomed the moves to make medical schools more accessible, not least by increasing the places available for those studying medicine as a second degree. It should be noted that doctors already graduate with considerable debts; those studying medicine as a second degree have still higher debts. The BMA is aware that many potential doctors are unable to finance their studies; means to aid such students must be found.

82.	CPD, being fundamental to the quality of care provided to patients, should be compulsory for all healthcare professionals.

83.	Trusts and primary care trusts should provide incentives to encourage healthcare professionals to maintain and develop their skills. The contract (or, in the case of GPs, other relevant mechanism) between the trust and the healthcare professional should provide for the funding of CPD and should stipulate the time which the trust will make available for CPD.

84.	Trusts and primary care trusts must take overall responsibility through an agreed plan for their employees' use of the time allocated to CPD. They must seek to ensure that the resources deployed for CPD contribute towards meeting the needs of the trust and of its patients, as well as meeting the professional aspirations of individual healthcare professionals.

	These matters are within the remit of current contractual negotiations.

85.	Periodic appraisal should be compulsory for all healthcare professionals. The requirement to participate in appraisal should be included in the contract of employment

86.	The commitment in `The NHS Plan' to introduce regular appraisal for hospital consultants must be implemented as soon as possible.

	Negotiations on including appraisal within a consultant’s contractual obligation are already concluded.

87.	The requirement to undergo periodic appraisal should also be incorporated into GPs' terms of service.

	Negotiations on the revised GP contract includes consideration of appraisal.

92.	Where clinicians hold managerial roles which extend beyond their immediate clinical practice, sufficient protected time the form of allocated sessions must be made available for them to carry out that managerial role.

	This matter is part of the consultant contractual negotiations.

96.	To protect patients, in the case of clinicians who take on managerial roles but wish to continue to practise as clinicians, experts together with managers from the NHS should issue advice as to the minimum level of regular clinical practice necessary to enable a clinician to provide care of a good quality. Clinicians not maintaining this level of practice should not be entitled to offer clinical care. This rule should also apply to all other clinicians who, for whatever reason, are not in full-time practice, and not only to those in part-time managerial roles.

	The BMA is considering this recommendation. We are concerned to ensure that changes do not make it more difficult for doctors who are taking a career break from maintaining their ability to return to clinical practice, for example through the doctor’s retainer scheme. The efficacy of the retainer scheme may help in evaluating the safe minimum level of practice for clinician managers.

97.	To facilitate the movement of clinicians in and out of managerial positions, the proposed systems for the revalidation (and re-registration) of doctors, nurses and professions allied to medicine should distinguish between professionals who are managers and also maintaining a clinical practice and those who are not. Those who are not maintaining a clinical practice should be entitled to obtain the appropriate revalidation (and re-registration) to restart a clinical practice, after retraining, and should be assisted in doing so. (See Recommendation 95.)

	The BMA is considering the issues which relate to medically qualified clinicians in management.

100.	Before any new and hitherto untried invasive clinical procedure can be undertaken for the first time, the clinician involved should have to satisfy the relevant local research ethics committee that the procedure is justified and it is in the patient's interests to proceed. Each trust should have in place a system for ensuring that this process is complied with.

101	Local research ethics committees should be re-formed as necessary so that they are capable of considering applications to undertake new and hitherto untried invasive clinical procedures.

102.	Patients are always entitled to know the extent to which a procedure which they are about to undergo is innovative or experimental. They are also entitled to be informed about the experience of the clinician who is to carry out the procedure.

	In addition to general ethical advice on consent and on communication with patients, the Board of Science and Education is preparing a report on the participation in clinical trials. It is intended that the report will help patients make decisions about whether or not to be involved, and to help doctors prepare information on individual trials which will put them into the correct clinical context for patients.

106.	We support and endorse the broad framework of recommendations advocated in the report `An Organisation with a Memory' by the Chief Medical Officer's expert group on learning from adverse events in the NHS. The National Patient Safety Agency proposed as a consequence of that report should, like all other such bodies which contribute to the regulation of the safety and quality of healthcare, be independent of the NHS and the DoH.

106.	Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.

	(The following comments also apply to recommendations 108-118).

	The BMA is looking in detail at the issues of patient safety, risk management and communicating with patients about risk. We strongly support a system which encourages the reporting of events, provided that it does not prevent appropriate action being taken where necessary.

	These recommendations also form part of the consultant contract negotiations.

143.	The process of clinical audit, which is now widely practised within trusts, should be at the core of a system of local monitoring of performance. Clinical audit should be multidisciplinary

144.	Clinical audit must be fully supported by trusts. They should ensure that healthcare professionals have access to the necessary time, facilities, advice and expertise in order to conduct audit effectively. All trusts should have a central clinical audit office which co-ordinates audit activity, provides advice and support for the audit process, and brings together the results of audit for the trust as a whole.

145.	Clinical audit should be compulsory for all healthcare professionals providing clinical care and the requirement to participate in it should be included as part of the contract of employment.

	The development of clinical audit has been strongly supported by the BMA. The report rightly points out that participation in audit is seriously under-resourced, especially in terms of “closing the audit loop”. The Board of Medical Education will produce more advice to doctors on this matter.

153.	At national level, the indicators of performance should be comprehensible to the public as well as to healthcare professionals. They should be fewer and of high quality, rather than numerous but of questionable or variable quality.

154.	The need to invest in world-class IT systems must be recognised so that the fundamental principles of data collection, validation and management can be observed: that data be collected only once; that the data be part and parcel of systems used to support healthcare professionals in their care of patients; and that trusts and teams of healthcare professionals receive feedback when data on their services are aggregated.

155.	Patients and the public must be able to obtain information as to the relative performance of the trust and the services and consultant units within the trust.

	In addition to further academic work on clinical indicators the BMA is currently working directly with the HES to promote ways of producing better and more useful clinical indicators.

167.	A National Director for Children's Healthcare Services should be appointed to promote improvements in healthcare services provided for children

168.	Consideration should be given to the creation of an office of Children's Commissioner in England, with the role of promoting the rights of children in all areas of public policy and seeking improvements to the ways in which the needs of children are met. Healthcare would be one of the areas covered by such a commissioner. Were such an office to be created, we would see it as being in addition to, rather than in place of, our other recommendations about the need to improve the quality of leadership in children's healthcare services.

	167 and 168 were recommendations in the BMA’s Board of Science and Education report on “Growing up in Britain”. We will continue to pursue recommendation 168 with relevant ministers. We will also follow up other recommendations below by sending copies of this report to those devising the National Service Frameworks.

176.	The NSF must include plans for the regular publication of information about the quality and performance of children's healthcare services at national level, at the level of individual trusts, and of individual consultant units.

	The Report “Growing up in Britain” recommended the publication of an annual report on children’s health, similar to the CMO’s report on the state of the public health. We believe this would help the early identification of trends in children’s health so that early remedial action can be taken.

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