The ACPGBI Governance Board’s Recommendations for Surgeons and Patients
The Heart of England NHS Trust (HFET) and the Spire Group of Independent hospitals have borne the brunt of the criticisms made by the Kennedy Report into HEFT and the Verita Report on Spire (www.heartofengland.nhs.uk/wp-content/uploads/Kennedy-Report-Final.pdf). Both have been criticised for not acting promptly in response to concerns about Mr Paterson’s practice, and thereby limiting the scale of damage to patients, which continued for some 4 years longer than it need have done.
Colorectal surgeons may not know that the Verita Independent Report undertaken for Spire reported in March 2014 that Mr Paterson undertook 14 colonoscopies on one patient, 13 of which were totally unnecessary. Spire has since adopted the JAG Accreditation Scheme to ensure that no surgeon can conduct endoscopies at the Spire Group without suitable experience. Whilst JAG could not have prevented harm here, at least it was available and primed to be adopted for the future, highlighting the crucial need to establish and disseminate standards of care to protect patients.
The Clinical Governance Board at the ACPGBI recommends that all surgeons should always practise within the area of their specialty training, and carry out the requisite number of procedures to ensure the maintenance of their skills to ensure patient safety and optimal outcomes. It is particularly important that procedures, which are rarely performed, are undertaken at sufficiently high levels. Treatments should follow national guidelines, but where there may be grey areas, a colleague’s opinion should confirm the wisdom of undertaking an ad hoc procedure in the best interests of the patient. However, such divergence from established practice should be a rare occurrence.
An important area, which was entirely overlooked, was that Mr Paterson breached Good Surgical Practice with regard to consent. This “aversion of gaze” may have resulted in his being suspended from practice much earlier if it had been reported. It demonstrates the need to reflect on ensuring genuine patient consent to treatment with full information, both in the NHS and with the same rigour in private practice.
Both surgeons and patients may seek to avoid a growing waiting list and what they may regard as under treatment in the NHS, and instead be offered an operation in the private sector. The Board reminds surgeons to consider whether their own subconscious treatment biases or the temptation of monetary gain might result in over treatment of their private patients and under treatment of some on the NHS.
Mr Paterson failed lamentably to use the MDT process and maintain protocols which would have enabled his patients to benefit from the best collective advice, with transparency and scrutiny of decision making by a range of professionals. There have been concerns raised by the ACPGBI about MDTs for private patients, and it is hoped that this case may act as the catalyst to ensure they are always undertaken where appropriate.
The Kennedy report refers to the need to be a team player and is a reminder of the need to embrace transparency and peer review as the norm, however excellent one might judge one’s own practice.
Clinicians, including 2 oncologists who raised concerns about scans and who were based at another hospital, and 2 GPs who requested an audit of Mr Paterson’s practice by another surgeon, were largely ignored. It is acknowledged that whistleblowing is problematic and perceived as a high risk undertaking, especially when the surgeon is more senior and remains unchallenged by a hospital management described by Sir Ian Kennedy in his report as “remote” and which operated in a climate of poor governance.
Whistleblowing is in need of being supported and strengthened as, in many cases, it is only the concerns of co-workers which will identify poor practice before the point at which damaged patients make complaints to the GMC, as was the case here. Ensuring that appraisals are carried out which enable 360 degree opinions by colleagues in confidence, with concerns investigated, may be a way forward in identifying problems at an early stage. Importantly, there is also need for consultant outcomes publications to become established practice in the private sector. PHIN (Private Healthcare Information Network) has published on 3rd May 2017 the first performance data on private hospitals, with fuller results promised in time. The Centre for Health and Public Interest Report 2014 “Patient Safety in Private Hospitals” makes a number of recommendations to protect patients.
With Spire valuing its consultants and its patients on an equally important basis and HEFT seemingly virtually inactive in this episode of patient safety, this case serves as yet another example where the patient has not been put at the centre of care.
Recommendations for patients
Patients were not sufficiently protected either by the NHS or the private hospital in this instance. It is essential that the patient surgeon relationship is founded on trust, and this must also include the treatment hospital.
Patients should not hesitate to ask questions of their surgeons. Surgeons who put patients at the centre of their practice welcome ensuring that the patient has genuine informed consent for a procedure, and should not be offended if the patient asks for a second opinion. Patients should not feel uncomfortable asking for a second opinion
Patients should ask their surgeons how many times they have undertaken the procedure they are offered, and their outcomes or results.
Private patients should note that the facilities available in the private sector, including equipment and staffing numbers, differ from the NHS and patients may like to ask their surgeon, not only about the risks of a certain procedure, but also whether there might be additional risks in having the treatment at the private hospital rather than at their local NHS hospital.
Consultant Outcome information is available on the ACPGBI website, together with an explanation for Patients.
PHIN (Private Healthcare Information Network) https://www.phin.org.uk has published on 3rd May 2017 the first performance data on private hospitals and more detailed information will be rolled out in the future.
There are other sources of information on performance at some NHS trust sites.
If patients have any concerns about their treatment or are unsure how to proceed with a particular treatment, they should not hesitate to ask for a second opinion, and can contact the Patient Liaison Service (PALS) at their local hospital, who will be able to give guidance on this process.
Mr P S Rooney DM FRCS
Chair Clinical Governance Board
Chair ACPGBI Patient Liaison Group