In our last blog post we outlined the case of Ian Paterson, the jailed breast surgeon, whose actions have prompted a new government inquiry – currently underway. At inQuisit we have experience that’s relevant. And have identified five issues we think are paramount. Last time we looked at the patient perspective, which always needs to be held uppermost. Today we explore two other key issues: consent; and communication.
Informed consent
This is another issue that comes up again and again in the Kennedy Review. As it does in our work at inQuisit. ‘Women were giving their consent to a mastectomy. But, on occasions, a variation of a mastectomy was being carried out… This was not a recognised procedure. Women did not consent to it in any properly informed way.’
‘Treatment without consent is a criminal assault’, writes Dr Alexandra Mullock in this interesting post over on the University of Manchester’s Policy Blog. ‘Paterson’s victims signed consent forms, however, the consent was based on inaccurate information.’
How do hospitals redress the inevitable power imbalance between a surgeon and a patient? How is a patient to know whether a procedure being proposed is experimental unless the doctor tells them? There may not be easy answers, but there are steps that can be taken to better safeguard patients.
Documentation and information
The Association of Independent Healthcare Organisations (AIHO) states in Consent and Capacity Key Principles, July 2017: ‘it is important to have in mind that consent is a process which must be precisely documented’. But in our experience at inQuisit, we’ve often seen poor documentation around consent. Indeed, this has been a recurrent theme of complaints we’ve been asked to adjudicate on – with sometimes as little as two lines written to capture a twenty-minute consultation.
As one step, we think patients could be invited to sign off notes of a surgical consultation. This would mean them confirming their understanding of what’s been said, as well as securing a reliable record. Within this, we also think there’s a need for more, better, written patient information. The consultation around consent could focus on a discussion of how risks apply, in any patient’s specific case, with their surgeon directing them to best sources of reliable information, especially online. This would help ensure patients: get good information regarding risks and complications; and aren’t solely reliant on the word of one surgeon.
Communication and patient confidentiality
Our second issue this time concerns communication – which often proved difficult around Ian Paterson’s conduct in the Heart of England NHS Foundation Trust, according to the review. Confidentiality turned into a double-edged sword, used misguidedly as a means to contain the crisis. Other doctors and staff had concerns that weren’t heard in any fruitful way. ‘Their desire to do the best for the patient in front of them prevailed over making a stand.’
There’s a lot to understand, of course. Many of the problems were human. ‘Good news was preferred to true news’, for instance, to quote again from Kennedy. And ‘Rather than confront him, they preferred to work around him.’ These are natural ways for humans to deal with difficulties, and each other, in any group. But humans we all are. Our systems need to mitigate against these very circumstances.
Dr Mullock is in no doubt that the issues in this case have wider implications. ‘Paterson’s crimes are an anomaly, but the reasons he was not stopped sooner are the same or similar to the reasons that many patients are failed in other less dramatic ways.’ And recent research from the Care Quality Commission (CQC) into private hospitals, reported here on BBC News, would seem to back this up. ‘Chief inspector of hospitals Prof Ted Baker described the approach to consultants as “old-fashioned” as it relied on informal systems and people knowing each other’, says the BBC.
Medical advisory committees
At inQuisit, we agree. We think, among other things, that medical advisory committees could be key here: in demonstrating real leadership, and providing a safe environment for clinicians to raise concerns about colleagues. Why do we currently hear so little of them when they’re comprised of clinicians at the most senior level, whose combined expertise is – or surely should be – a real resource in this area?
We’d like to see medical advisory committees:
- Exercise proper oversight into how consultants within a hospital are performing
- Be actively aware of patient feedback relating to the surgeons working there
- And, crucially, support managers in addressing any concerns raised about specific individuals. Time and again, we hear, particularly in private hospitals, that managers struggle to ‘manage’ consultants with practising privileges
We all need to be able to rely on these committees to explore any concerns – whether raised by patients, managers and/ or other healthcare staff – fairly, rigorously and openly.
In our next and final post on the aftermath of the Paterson case, we pick up two last principal concerns: governance, especially in relation to new techniques; and, pivotally for us at inQuisit, the effective handling of patient complaints.